pain Flashcards
Oligoanesthesia- who is at risk
under-treatment of pain
• Peds, elderly, cognitive delay, psych pt’s, altered
Know three rule
• Know three drugs for each class and route
3 CCB for HTN
3 Medicines parenteral for pain
3 NSAIDS
3 Long Acting insulin
not everybody is the correct profile. the third medicine should always be “what if they are pregnant”
pain treatment is separate in what dx
• Pain treatment is separated in cancer and non-cancer pain
Cancer pain – don’t worry about addiction (just treat their pain which generally terrible pain)
Symptomatic vs. Mechanism approach
Treating the mechanism of pain is treating the nerve pathways/physiology of pain
Parenteral includes
IM SQ IV
onset of IM
easy, onset 10-20 min, lasts longer; stick is involved, not titrateable, results are unpredictable. Can give someone 8mg of morphine IM and they may not feel anything and want more.
IV advantages
what situations are pest
Fast onset, titrateable; stick, shorter duration, more side effects.
Good if: moderate/severe, NPO, or local pain control not possible. Best overall
advantages and disadvantages of PO
i. Easy, long duration; delayed onset, can’t give if vomiting, NPO or significant pain
Local infiltration/blocks advantages
i. Fast onset, lasts 1-4hrs*, good duration for procedures – lacs, abscess, foreign body, digital block, ring block, dental blocks
when would acetaminophen be used
- IV: 1g excellent; Oral: 1gm; Rectal in kids
- Great antipyretic, good analgesia
- Combine w/ NSAID’s, opiates - anything
- Good for most elderly/pregnant pt’s
when is acetaminophen CI
Avoid: liver FAILURE, big etoh
NOT liver disease
• NSAIDs are CI in
Over 65yo (but if youre going to give it, give the lowest dose), renal or GI issues, on ASA/coumadin, bleeding issues, pregnant, breastfeeding. Avoid Cox-2’s
NSAID dose
• Oral: Ibuprofen 600-800mg, Naprosyn 500mg, etc
800 NO significant benefit
can use NSAIDS with
Combo: APAP/NASIDs to treat acute pain
Ketorolac (Toradol®) what kind of drug is it
how is it administered
IM/IV 15-30mg (you will see 30 and 60 mg)
NSAIDS
Ketorolac (Toradol®) is best for
NSAIDS
Great: back pain, renal colic, muscles, burns, etc
Ketorolac (Toradol®) should be avoided in
Avoid: Over 65yo (but if youre going to give it, give the lowest dose) renal or GI issues on ASA/coumadin bleeding issues pregnant breastfeeding. Avoid Cox-2’s
what are the limitations with ketorolac
More not better. Give 1-2x max in ED. 5 days inpatient max
Benefits of Ketoralc over NSAIDs
sometimes better for acute pain
better for placebo of IM
Gabapentin (Neurontin®)
what are the other drugsin this class dosed
nerve pain medication
Oral dosing only
Pregabalin, Duloxetine
Gabapentin can be used with
Gabapentin
combo with
NSAIDs/APAP for acute pain
but CAN’T DRIVEAFTER
Gabapentin typically given for
Neuropathic pain –
DM, fibromyalgia, post herpetic neuralgia, back pain
Tramadol (Ultram®)
• Synthetic, opiate-like activity
- Addiction/abuse potential
- . Not often used in ED for acute pain, not often rx’d
opiates are schedule
what are the indications
Opium-derived drugs: alkaloids, semisynthetic
. Parenteral are Schedule IV – pt specific order
iv. Indications: moderate – severe pain
Biggest ADE’s/concerns with opiates
i. Respiratory depression: all
ii. Hypotension; esp w/ Morphine
iii. Altered mental status, dizzy
iv. Nausea/vomiting common
v. ADE: flushing, rash, itching
vi. Constipation
vii. Tolerance/dependence/addiction
opiatesa are given with (3)
IV-pump up your blood pressure
antiemetics-keep you from barfing
antihistamines -reduce rash and flush
dosing or morphine
Dose 4-10mg IM/IV common
comes in 2’s be mindful of this
order 2, 4, 6, 8 or 10
really don’t use 2 or 10
because it comes in 2s DO NOT ORDER 5
8 is high
usually we giver 4 or 6
10mg is .1 fentanyl and 1.5 hydromorphone
onset is 10-15 minutes
morphine is CI in
hypotensive
USE ANOTHER DRUG
• AMS common; careful in resp dz, elderly, kids
Hydromorphone (Dilaudid®) dosing
Dose 0.5-1mg IV (0.5 novice, 1mg severe pain)
PO dose 1-2mg – good if no IV, can take PO
IM NOT so good
very slow onset
CI with dilaudid
Hypotension less – but still a concern; AMS
really high abuse potential
IV onset of dilaudid
• IV onset <10min, lasts ~2hrs unless tolerance
fentanyl compared to morphine
Powerful analgesic: 80-100x more potent than Morphine
fentanyl order
IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)
bigget benefit of fentanyl
Biggest benefit is NO hypotension – great choice in these pt’s
SE of fentanyl
Respiratory depression, GI effects common – give O2, antiemetic too
CI of fentanyl
Contraindicated if pt takes MAOI’s
why is fentanyl good choice for kids
Good in kids – intranasal/IM/IV – double check dose
duration of fentanyl
Short duration of effect: +/- 1hr; re-dosing common
IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)
Meperidine (Demerol®) CI with
- Contraindicated w/ MAOI’s:
* Removed from most ED’s: safety, abuse potential
methadone works for addiction by
• Blocks the “high”, reduces cravings and withdrawal sx’s
methadone can be used for pain associated with
Effective for cancer pain, not first-line in non-cancer pain
Emerging usefulness in ED as oral alternative if using opiates – very long effect
Common Rx for moderate pain in ED if can take PO
Vicodin/Norco/Lortab (Hydrocodone + APAP)
Tylenol w/ Codeine
AVOID Oxycodone and Percocet
dosing of vicodin and norco
Vicodin 5/500 (5 hydrocodone and 500 Tylenol)
Norco 5/325 – avoid higher doses in ED
vicodin given for outpatient
As outpatient, short term Rx (#8-10 MAX)
2 tablets every 6 hours treats three days worth of pain
concerns with Vicodin rx
- Constipation – Rx with Senna, Colace
- Goal is to avoid opiates altogether!
- Most ED’s do not refill oral opiates – check policy
why would Tylenol w/ Codeine be preferred in kids
- Tylenol #3 (30/300), less potent than Vicodin/Norco
3. Elixir 12/120mg per 5ml: useful in kids (adjust dose); or if can’t swallow pills
Common ADE’s of opiates include:
i. Hypotension
ii. Nausea/vomiting
iii. Histamine release
f. Antiemetics that can be administered for opiate RX
Zofran 4-8mg IV/IM/SL
Metoclopramide 5-10mg IV/IM
Phenergan 12.5-25mg IV/IM/PR
Compazine 5-10mg IV/IM/PR
Anxiolytics (Benzos), name three
Lorazepam (Ativan®) 0.5-1mg IM/IV
Midazolam (Versed®) 2-4mg IM/IV: very short acting, very sedating
Benzos: offer no analgesia but will lower blood pressure
antihistamines given wiht opiates
i. Benadryl 25-50mg IM/IV
Ketamine
Trance-like” state; analgesia, amnestic
ketamine used to be used for
Was mostly for procedural sedation, until now. “The first 500”
iii. Low doses for acute pain in adults (LDK = low dose ketamine)
dosing for ketamine
- IM 0.5-1mg/kg, IV 0.1-0.6mg/kg, IN 0.5mg/kg
why would ketamine be useful
Particularly useful in opiate tolerant pt’s; alternative to opiates
Great in kids >1yo, best if NPO x4hrs
Intranasal kids – great, if you have it and are comfortable
Emergence phenomenon
happens in adults and children – having a nightmare that you can’t get out of
- Can give benzos for it
a. LET or EMLA cream
good for kids
i. Apply prior to local anesthesia, cover
a. LET or EMLA cream application
and onset
Apply to surrounding skin, +/- in open wound
Slow onset: 15-60min
b. Propericaine
topical anesthesia drops for eyes Burns x10sec, lasts 30min.
Propericaine watch out of theis
i. Do not Rx for home – can cause corneal scarring
– topical for open tissue wounds/mucosa. Road rash, hemorrhoids
c. Viscous Lidocaine
helps stop nosebleed, everybody happy. NOT IN KIDS
d. Topical cocaine
– topical for ear canal, otitis externa
e. Auralgan
topical Bladder spasm UTI
Phenazopyridine (Pyridium®)
Phenazopyridine (Pyridium®) dosing
100-200mg TID x2 days
Lidocaine
onset
what i’s good for
(Amide) 1% or 2%
• Good general use
• Fast onset, lasts 1-3hrs
e. Addition of Bicarb
i. Reduces pain
ii. 4ml Lido + 1 ml bicarb
Bupivicaine
local
Amide) 0.25% or 0.5%
• Slower onset (10-15min)
• Lasts 2-5hrs (good for students…)
Epi good for
• Epi good for high vascular areas, bleeding; hurts
never use Epi on
• Never on: fingers, toes, penis, nose b/c you lose circulation in those areas and it can become necrotic
bicarb plus lidocaine can be used for
- Can add Bicarb: reduce pain
* 4ml lido + 1ml bicarb
max dose of lidocaine -adult
• 4mg/kg plain lidocaine = 28 cc of 1% for 70 kg
max dose of lidocaine-kid
- 7 mg/kg lidocaine w/ epi
* 2 mg/kg bupivicaine
how to do a lidocaine block
• Pull back on syringe as you enter to avoid giving it IV - to avoid injecting in the circulation
Large lacs/big areas want to consider
• Consider an ultrasound guided regional nerve block
Digital block
dosing
Adults: 7-8cc in finger, 8-10 in toes
before administering a block
ii. Kids: use half that or less
iii. Check neuro status before block!
i. Intra-articular can be used for
- Pre-reduction, arthritis
- US guided
Bupivicaine; +/- steroids but usually leave this up to orthopedics
Hematoma block-what is it and what would you use
“fantastic old-school”
- Inject distal Fx sites (right into the crunchy part
- Pre-reduction; not for minor/huge fx’s
- Bupivicaine (long lasting)
10ccs pre reduction
Medium Fx only
Regional nerve block
- Facial, ear, dental, feet
- Bupivicaine
- US guided arm, leg
US guided can be used with
a. Radial, medial, ulnar
b. Brachial plexus/axillary
c. Femoral, etc, etc
block over lidocaine
because you don’t want to distort the skin with the lidocaine
indication for procedural sedation
brief procedure, pt would benefit from short-term sedation/amnesia. Drugs are titratable
Common: reductions, large abscesses, tricky procedures; procedures in kids or developmental delay/agitated
Minimal sedation
(PO opiates, benzos)
Moderate sedation
(IV benzos, low-dose ketamine)
Deep sedation
(sedation dose ketamine, propofol, brevitol, etc)
advantages of sedation
c. Advantages: pt does not recall procedure, controlled setting
disadvantages of sedation
abor/time intensive, staff (4 minimum), NPO status, recovery period, airway/circulation risk, drug risk
best pain control for kids
i. IV is best sedation overall: can titrate, control
1. But: painful, need monitoring, staff, time, recovery time
2. Quicker, safe options for minor procedures exist
IV Lidocaine
what would you use it for and what is the dose
Best studied in renal colic – emerging alternative
1.5mg/kg IV. Check does twice (or three times...)
for inflammatory pain making a comeback!
i. Can also give for back pain
c. Steroids
Bridge if patient interested in opiate cessation
d. Buphenerone
Documentation and Discharge
a. Pain does not have to be gone – but tolerable, better
b. Vitals must be normal
c. When will meds wear off?
d. Are they driving? Ask and document!. Tailor treatment if yes
e. Take meds at beginning of pain onset
f. Expectations for complete pain relief - discuss
Local care – splint, ice/heat, elevation, CAM, relaxation, music, etc – cannot be overestimated!
how do we classify chronic pain
a. Classified as: cancer pain and non-cancer pain
chronic main is commonly seen with these disorders
Very common: dependence, elderly, fibromyalgia, CRPS/RSD, chronic low back pain, post-herpetic, post-traumatic pain, etc
addiction
- Withdrawal sx’s if do not use
a. Its not that they do it for the high, they do it to avoid the withdrawal symptoms
physical/psychological – euphoria. Withdrawal if stops
Dependence and Tolerance
Patient who obtains Rx drugs for resale
Diversion
clues to drug seeking behavior
- Spilled the bottle, lost/stolen Rx
- Multi drug “allergies”
- Names drugs, gives doses, only “this” works
- Travelling, elaborate sad tales
- Demand drugs before Hx/PE
- Doctor died, on vacation
- No PMD, f/u, records
- Present late in day
- Demanding, hostile if needs not met or, conversely, overly nice
47yo female with Hx migraine headaches c/o typical migraine for past 5 hours. She c/o nausea, vomiting and photophobia. VS: 130/88 88 16 98.5 99%ra
Migraine “cocktail” – avoids opiates
Establish IV, give 1L bolus NS (vomiting)
Ketorolac 30mg IV
Metoclopromide (Reglan®) 10mg IV
Benadryl 50mg IV
reassessing hte pt with a migraine
can give triptan, steroids (Dexamethazone 8-10mg IV). Home w/ NSAIDs, antiemetic
A 12yo female presents with left arm pain/deformity after a fall at the climbing gym. Otherwise well. Neurovascularly intact. VSS
internasal versed, fentanyl or ketamine and then a hematoma block for reduction
for reduction in the child with pain after falling
Hematoma block for reduction – LET/EMLA to skin first
what would you do for the pt with reduction need
for discharge
- Reduction, splint, sling
Home with weight adjusted NSAIDS, self care instructions
35yo male, IVDU, presents with a large abscess to his left deltoid. He is verbally abusive to staff when an IV is difficult to obtain, demanding meds for pain. He is otherwise stable. Options?
Low dose Ketamine IM now
US guided IV access now an option
Can give IV Ketamine, Ketorolac/APAP now
best management of IVDU with abscess
Best!
USG axillary nerve block – gets deltoid.
Also interscalene block great
or IM ketamine
what would you do if IV, NPO, refuses block if
Procedural sedation if IV, NPO, refuses block
If no IV, not NPO in IVDU with abscess
consider redose IM Ketamine, then ring block, I&D
discharge with abscess dude
Home with NSAIDS, APAP
50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)
Fentanyl best choice for pain in hypotension. Begin 50mcg IV
IV fluids to raise BP
IV ketorolac/Tylenol for fever and pain
Wait for better BP before anxiolytics; tx the problem in the meantime
50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)
thoracentesis would locally block • Bupivicaine
Consider Ketamine, Ketorolac IV. Consider Dilaudid if pain persists, BP ok
55yo male with hx renal colic, same sx’s. Otherwise well. 158/92 100 20 98.9 98%ra
what would the rescue meds be
IV 1L bolus, Ketorolac 30mg IV, Zofran 4mg IV, IV Tylenol 1000mg
May add Morhpine 4-8mg IV or Dilaudid 0.5-1mg IV
maybeee IV lidocaine
28yo female with RLQ abdominal pain, vomiting. Upreg neg
febrile
IV 1L bolus,
Zofran 4mg IV,
Tylenol 1g IV
Ketoralac and IV fluids
Morphine 4-8mg IV or Dilaudid 0.5-1mg IV
Lower doses if opiate naive, Benadryl 25-50mg IV
if breasfeeding or pregnant
opiates category C
third trimester is really not good
call OB
would pump and dump if breasfeedings
28yo male tripped on sidewalk. Chin lac. Otherwise well. Options?
Local infiltration with Lidocaine or Bupivicaine (with student esp) with Epi (face bleeds a lot)
18mo male hit coffee table while running. Otherwise well. Options?
LET/EMLA to area for 30min – recheck
EMLA cream (eutectic mixture of local anesthetics) with that of LET solution (lidocaine, epinephrine, tetracaine
Consider IM/IN Midazolam (Versed®) or
Fentanyl; IM low dose or intranasal Ketamine as an option
Local infiltration of wound or regional block
Consider “papoose”, must be quick! INSURANCE for if a kid wakes up during a procedure
30yo male dropped car transmission on left ring finger. Otherwise stable. Options?
Digital block with Bupivicaine after neurovascular check
can do XRAY after
Splint, NSAID’s Rx
opiates no more than 3 days
Discharge both home on NSAIDS, Tylenol. Adult: +/- Vicodin #8
2yo male, brother shut fingers in car door. Otherwise stable. Screaming on exam. Options?
Need sedation prior to xray, digital block
+/- LET/EMLA at base of finger for block…finger, toes, penis, nose…
Versed, Fentanyl or Ketamine IM or IN
Discharge both home on NSAIDS, Tylenol. Adult: +/- Vicodin #8
A 30yo male presents after falling off a step stool. He is otherwise stable.
ii. VS: 108/82 105 16 98.5 98%ra
posterior dislocation
IM/IV Ketamine or Fentanyl 50mcg (lowish BP), consider oral Benzo’s before reduction
Or…Intra-articular injection of 8-10ml Bupivicaine: local tx is always good
Better: Brachial plexus US guided regional block. No IV/IM, monitoring, ADE’s…magic!
last choice sedation
after reduction NSAIDS muscle relaxers sling
Other than IM/IV ketamine or intra-articular bupivicane what can you do for should dislocation
Interscalene brachial plexus US guided regional block. No IV/IM, monitoring, ADE’s…magic!
last choice with dislocation
Last choice: procedural sedation to reduce
78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110
- IV fluids, O2, Monitor
Fentanyl 25mcg IV to start
US guided femoral nerve block now!! (not a ton of opiates)
CONSULT Ortho, discuss block
Pt will not feel compartment syndrome!
i. 41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra
The size, mechanism and location make this wound special – will need xray, tons of irrigation, exploration
US guided radial nerve block: 8-10cc Bupivicaine – after neurovascular exam
Can add bupivicaine locally if anesthesia not complete
5. No US? Bupivicaine local
Discharge w/ NSAIDS, Abx and splint
what would you use for a minor laceration in a child
ii. Topical meds for minor lacs first
what would you use in young kids for procedures/imaging/cosmetic concerns/dental
name 3
iv. Analgesia/sedation/amnesia
- Midazolam (Versed®) intranasal, IM, IV
- Ketamine intranasal, IM, IV
- Fentanyl IM, intranasal, oral, IM, IV
78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110
IV fluids, O2, Monitor Fentanyl 25mcg IV to start US guided femoral nerve block now!! Consult Ortho, discuss block Caution! Pt will not feel compartment syndrome after femoral block!
41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra
US guided radial nerve block: 8-10cc Bupivicaine – after neurovascular exam
29yo male with acute low back pain, no red flags
NSAID (oral or Ketorolac IM),
Tylenol 1g PO.
Either Valium 5mg PO,
Gabapentin 600mg PO
29yo male with acute low back pain, no red flags discharge
D/C with NSAIDS, Tylenol, muscle relaxant (Baclofen®, Flexeril®)
Consider trigger point injection Bupicicaine 5-7ml
40yo female, closed, non-displaced distal fibula fx.
Ketorolac 15mg IM, Tylenol 1g PO. Splint, D/C home w/ NSAID, Tylenol, RICE. May add #8-10 Vicodin/Norco
30yo male with flu/mild pneumonia, stable, pleuritic chest pain.
Ketorolc IM/IV + Tylenol 1g PO/IV.
D/C with NSAID, Tylenol, Tessalon Pearls (Benzonatate), not cough syrup*
50yo with dental abscess.
Dental block w/ Bupivicaine – local tx of pain good
Oral NSAID, Tylenol 1g; oral steroid (dexamethazone 8-10mg po)??.
D/C w/ NSAID, Tylenol
Tx related to time to dentist – may add #8-10 Vicodin/Norco
25yo female with large burn to right thigh.
25yo female with large burn to right thigh.
58yo male with gout left great toe.
NSAID PO/IM – Ibuprofen as good as Indomethacin
Colchicine (1.2mg po) + steroids if severe (can give in ED)
68yo with chronic knee pain from osteoarthritis.
Intra-articular injection Bupivicaine (Intra-articular steroids??)
Or oral NSAID** (no Ketorolac d/t age, renal risk)
Short course NSAIDS**, Tylenol, self-care, Ortho f/u
23yo with strep throat, pain with swallowing.
NSAID plus Tylenol with Codeine Elixir 15ml in ED
Steroid IM: 6-10mg Dexamethazone + Abx
Home w/ NSAIDS/APAP
