What’s Pain Got To Do With It? PAD Launch Day March 30, 2015 Daniel Ovakim, MD MSc FRCPC Critical Care Medicine, Royal Jubilee and Victoria General Hospitals Island Health Authority Medical Toxicology, BC Drug and Poison Information Centre Clinical Assistant Professor, Department of Medicine, UBC [email protected]
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What’s pain got to do with it? Disclosures None Toxicologic Antidotes Outline 1.Case based review of the assessment and treatment of pain in the adult.
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What’s Pain Got To Do With It?
PAD Launch DayMarch 30, 2015
Daniel Ovakim, MD MSc FRCPCCritical Care Medicine, Royal Jubilee and Victoria General HospitalsIsland Health AuthorityMedical Toxicology, BC Drug and Poison Information CentreClinical Assistant Professor, Department of Medicine, [email protected]
What’s pain got to do with it?
Disclosures
None
Toxicologic Antidotes
Outline
1. Case based review of the assessment and treatment of pain in the adult ICU
2. Review the presentation and management of excited delirium
What’s pain got to do with it?
Toxicologic Antidotes
Outline
1. Case based review of the assessment and treatment of pain in the adult ICU
2. Review the presentation and management of excited delirium
What’s pain got to do with it?
Mr. VE• 37M, multiple gun shot wounds• History of• Polysubstance abuse• Chronic opioid use
• Injuries• Brachial artery laceration • Right rib/lung/diaphragm injuries• Penetrating liver and bowel injury
Toxicologic AntidotesWhat’s pain got to do with it?
Mr. VE• Multiple (?8) trips to operating room• Multiple complications• Severe sepsis• Rhabomyolysis (PRIS?)• Acute kidney injury requiring dialysis
• High narcotic and sedative requirements
Toxicologic AntidotesWhat’s pain got to do with it?
Mr. VE (3 weeks later)• Acute issues resolved• Escalating analgesic requirements• Hydromorphone 7 mg po q4h scheduled• Hydromorphone 1-2 mg IV q1h PRN
Toxicologic AntidotesWhat’s pain got to do with it?
Questions on rounds
1. How can we reliably assess this patient’s pain?2. Can we use his vital signs as an indication?3. Are there other therapeutic options?4. What about his mood?
Toxicologic AntidotesWhat’s pain got to do with it?
The Ideal Pain Assessment• Reproducible across disciplines• Enables monitoring over time• Assesses adequacy of interventions• Easily implemented and monitored
Back to Case 1• 37M, multiple gun shot wounds• Persistent 10/10 abdominal pain• “Unresponsive” to narcotics• What worked for him?• Scaled back regular hydromorphone to 2 mg q4h• Stopped routine bowel care• Aggressive mobilization• Dramatic response to trial of methylphenidate
(Ritalin®)
Pain in the ICU
Toxicologic Antidotes
Outline
1. Case based review of the assessment and treatment of pain in the adult ICU
2. Review the presentation and management of excited delirium
What’s pain got to do with it?
Mr. WF• 41M, suicide attempt after romantic crisis• Voluntary ingestion of 6500 mg bupropion XL,
and self-injection of 3 epi-pens• Acutely agitated, disoriented, aggressive• Midazolam x 50 mg in ER and infusion in ICU• Remained extremely agitated• Physically restrained
Toxicologic AntidotesWhat’s pain got to do with it?