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Emergency Medicine > pain > Flashcards

pain Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Oligoanesthesia- who is at risk

A

under-treatment of pain

• Peds, elderly, cognitive delay, psych pt’s, altered

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2
Q

Know three rule

A

• 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”

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3
Q

pain treatment is separate in what dx

A

• 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)

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4
Q

Symptomatic vs. Mechanism approach

A

Treating the mechanism of pain is treating the nerve pathways/physiology of pain

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5
Q

Parenteral includes

A

IM SQ IV

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6
Q

onset of IM

A

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.

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7
Q

IV advantages

what situations are pest

A

Fast onset, titrateable; stick, shorter duration, more side effects.

Good if: moderate/severe, NPO, or local pain control not possible. Best overall

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8
Q

advantages and disadvantages of PO

A

i. Easy, long duration; delayed onset, can’t give if vomiting, NPO or significant pain

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9
Q

Local infiltration/blocks advantages

A

i. Fast onset, lasts 1-4hrs*, good duration for procedures – lacs, abscess, foreign body, digital block, ring block, dental blocks

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10
Q

when would acetaminophen be used

A
  • 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
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11
Q

when is acetaminophen CI

A

Avoid: liver FAILURE, big etoh

NOT liver disease

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12
Q

• NSAIDs are CI in

A

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

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13
Q

NSAID dose

A

• Oral: Ibuprofen 600-800mg, Naprosyn 500mg, etc

800 NO significant benefit

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14
Q

can use NSAIDS with

A

Combo: APAP/NASIDs to treat acute pain

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15
Q

Ketorolac (Toradol®) what kind of drug is it

how is it administered

A

IM/IV 15-30mg (you will see 30 and 60 mg)

NSAIDS

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16
Q

Ketorolac (Toradol®) is best for

A

NSAIDS

Great: back pain, renal colic, muscles, burns, etc

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17
Q

Ketorolac (Toradol®) should be avoided in

A 
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
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18
Q

what are the limitations with ketorolac

A

More not better. Give 1-2x max in ED. 5 days inpatient max

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19
Q

Benefits of Ketoralc over NSAIDs

A

sometimes better for acute pain

better for placebo of IM

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20
Q

Gabapentin (Neurontin®)

what are the other drugsin this class 
dosed
A

nerve pain medication

Oral dosing only

Pregabalin, Duloxetine

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21
Q

Gabapentin can be used with

A

Gabapentin

combo with

NSAIDs/APAP for acute pain

but CAN’T DRIVEAFTER

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22
Q

Gabapentin typically given for

A

Neuropathic pain –

DM, fibromyalgia, post herpetic neuralgia, back pain

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23
Q

Tramadol (Ultram®)

A

• Synthetic, opiate-like activity

  • Addiction/abuse potential
  • . Not often used in ED for acute pain, not often rx’d
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24
Q

opiates are schedule

what are the indications

A

Opium-derived drugs: alkaloids, semisynthetic
. Parenteral are Schedule IV – pt specific order

iv. Indications: moderate – severe pain

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25
Q

Biggest ADE’s/concerns with opiates

A

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

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26
Q

opiatesa are given with (3)

A

IV-pump up your blood pressure

antiemetics-keep you from barfing

antihistamines -reduce rash and flush

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27
Q

dosing or morphine

A

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

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28
Q

morphine is CI in

A

hypotensive

USE ANOTHER DRUG

• AMS common; careful in resp dz, elderly, kids

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29
Q

Hydromorphone (Dilaudid®) dosing

A

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

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30
Q

CI with dilaudid

A

Hypotension less – but still a concern; AMS

really high abuse potential

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31
Q

IV onset of dilaudid

A

• IV onset <10min, lasts ~2hrs unless tolerance

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32
Q

fentanyl compared to morphine

A

Powerful analgesic: 80-100x more potent than Morphine

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33
Q

fentanyl order

A

IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)

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34
Q

bigget benefit of fentanyl

A

Biggest benefit is NO hypotension – great choice in these pt’s

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35
Q

SE of fentanyl

A

Respiratory depression, GI effects common – give O2, antiemetic too

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36
Q

CI of fentanyl

A

Contraindicated if pt takes MAOI’s

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37
Q

why is fentanyl good choice for kids

A

Good in kids – intranasal/IM/IV – double check dose

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38
Q

duration of fentanyl

A

Short duration of effect: +/- 1hr; re-dosing common

IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)
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39
Q

Meperidine (Demerol®) CI with

A
  • Contraindicated w/ MAOI’s:

* Removed from most ED’s: safety, abuse potential

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40
Q

methadone works for addiction by

A

• Blocks the “high”, reduces cravings and withdrawal sx’s

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41
Q

methadone can be used for pain associated with

A

Effective for cancer pain, not first-line in non-cancer pain

Emerging usefulness in ED as oral alternative if using opiates – very long effect

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42
Q

Common Rx for moderate pain in ED if can take PO

A

Vicodin/Norco/Lortab (Hydrocodone + APAP)

Tylenol w/ Codeine

AVOID Oxycodone and Percocet

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43
Q

dosing of vicodin and norco

A

Vicodin 5/500 (5 hydrocodone and 500 Tylenol)

Norco 5/325 – avoid higher doses in ED

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44
Q

vicodin given for outpatient

A

As outpatient, short term Rx (#8-10 MAX)

2 tablets every 6 hours treats three days worth of pain

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45
Q

concerns with Vicodin rx

A
  1. Constipation – Rx with Senna, Colace
  2. Goal is to avoid opiates altogether!
  3. Most ED’s do not refill oral opiates – check policy
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46
Q

why would Tylenol w/ Codeine be preferred in kids

A
  1. 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

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47
Q

Common ADE’s of opiates include:

A

i. Hypotension
ii. Nausea/vomiting
iii. Histamine release

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48
Q

f. Antiemetics that can be administered for opiate RX

A

Zofran 4-8mg IV/IM/SL

Metoclopramide 5-10mg IV/IM

Phenergan 12.5-25mg IV/IM/PR

Compazine 5-10mg IV/IM/PR

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49
Q

Anxiolytics (Benzos), name three

A

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

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50
Q

antihistamines given wiht opiates

A

i. Benadryl 25-50mg IM/IV

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51
Q

Ketamine

A

Trance-like” state; analgesia, amnestic

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52
Q

ketamine used to be used for

A

Was mostly for procedural sedation, until now. “The first 500”

iii. Low doses for acute pain in adults (LDK = low dose ketamine)

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53
Q

dosing for ketamine

A
  1. IM 0.5-1mg/kg, IV 0.1-0.6mg/kg, IN 0.5mg/kg
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54
Q

why would ketamine be useful

A

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

55
Q

Emergence phenomenon

A

happens in adults and children – having a nightmare that you can’t get out of

  1. Can give benzos for it
56
Q

a. LET or EMLA cream

A

good for kids

i. Apply prior to local anesthesia, cover

57
Q

a. LET or EMLA cream application

and onset

A

Apply to surrounding skin, +/- in open wound

Slow onset: 15-60min

58
Q

b. Propericaine

A

topical anesthesia drops for eyes Burns x10sec, lasts 30min.

59
Q

Propericaine watch out of theis

A

i. Do not Rx for home – can cause corneal scarring

60
Q

– topical for open tissue wounds/mucosa. Road rash, hemorrhoids

A

c. Viscous Lidocaine

61
Q

helps stop nosebleed, everybody happy. NOT IN KIDS

A

d. Topical cocaine

62
Q

– topical for ear canal, otitis externa

A

e. Auralgan

63
Q

topical Bladder spasm UTI

A

Phenazopyridine (Pyridium®)

64
Q

Phenazopyridine (Pyridium®) dosing

A

100-200mg TID x2 days

65
Q

Lidocaine

onset
what i’s good for

A

(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

66
Q

Bupivicaine

A

local
Amide) 0.25% or 0.5%
• Slower onset (10-15min)
• Lasts 2-5hrs (good for students…)

67
Q

Epi good for

A

• Epi good for high vascular areas, bleeding; hurts

68
Q

never use Epi on

A

• Never on: fingers, toes, penis, nose b/c you lose circulation in those areas and it can become necrotic

69
Q

bicarb plus lidocaine can be used for

A
  • Can add Bicarb: reduce pain

* 4ml lido + 1ml bicarb

70
Q

max dose of lidocaine -adult

A

• 4mg/kg plain lidocaine = 28 cc of 1% for 70 kg

71
Q

max dose of lidocaine-kid

A
  • 7 mg/kg lidocaine w/ epi

* 2 mg/kg bupivicaine

72
Q

how to do a lidocaine block

A

• Pull back on syringe as you enter to avoid giving it IV - to avoid injecting in the circulation

73
Q

Large lacs/big areas want to consider

A

• Consider an ultrasound guided regional nerve block

74
Q

Digital block

A

dosing

Adults: 7-8cc in finger, 8-10 in toes

75
Q

before administering a block

A

ii. Kids: use half that or less

iii. Check neuro status before block!

76
Q

i. Intra-articular can be used for

A
  1. Pre-reduction, arthritis
  2. US guided

Bupivicaine; +/- steroids but usually leave this up to orthopedics

77
Q

Hematoma block-what is it and what would you use

A

“fantastic old-school”

  1. Inject distal Fx sites (right into the crunchy part
  2. Pre-reduction; not for minor/huge fx’s
  3. Bupivicaine (long lasting)

10ccs pre reduction

Medium Fx only

78
Q

Regional nerve block

A
  1. Facial, ear, dental, feet
  2. Bupivicaine
  3. US guided arm, leg
79
Q

US guided can be used with

A

a. Radial, medial, ulnar
b. Brachial plexus/axillary
c. Femoral, etc, etc

80
Q

block over lidocaine

A

because you don’t want to distort the skin with the lidocaine

81
Q

indication for procedural sedation

A

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

82
Q

Minimal sedation

A

(PO opiates, benzos)

83
Q

Moderate sedation

A

(IV benzos, low-dose ketamine)

84
Q

Deep sedation

A

(sedation dose ketamine, propofol, brevitol, etc)

85
Q

advantages of sedation

A

c. Advantages: pt does not recall procedure, controlled setting

86
Q

disadvantages of sedation

A

abor/time intensive, staff (4 minimum), NPO status, recovery period, airway/circulation risk, drug risk

87
Q

best pain control for kids

A

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

88
Q

IV Lidocaine

what would you use it for and what is the dose

A

Best studied in renal colic – emerging alternative

1.5mg/kg IV. Check does twice (or three times...)
89
Q

for inflammatory pain making a comeback!

i. Can also give for back pain

A

c. Steroids

90
Q

Bridge if patient interested in opiate cessation

A

d. Buphenerone

91
Q

Documentation and Discharge

A

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!
92
Q

how do we classify chronic pain

A

a. Classified as: cancer pain and non-cancer pain

93
Q

chronic main is commonly seen with these disorders

A 
Very common: 
dependence, 
elderly,
 fibromyalgia,
 CRPS/RSD, 
chronic low back pain, 
post-herpetic, 
post-traumatic pain, etc
94
Q

addiction

A
  1. 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

95
Q

physical/psychological – euphoria. Withdrawal if stops

A

Dependence and Tolerance

96
Q

Patient who obtains Rx drugs for resale

A

Diversion

97
Q

clues to drug seeking behavior

A
  • 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
98
Q

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

A

Migraine “cocktail” – avoids opiates

Establish IV, give 1L bolus NS (vomiting)

Ketorolac 30mg IV

Metoclopromide (Reglan®) 10mg IV

Benadryl 50mg IV

99
Q

reassessing hte pt with a migraine

A

can give triptan, steroids (Dexamethazone 8-10mg IV). Home w/ NSAIDs, antiemetic

100
Q

A 12yo female presents with left arm pain/deformity after a fall at the climbing gym. Otherwise well. Neurovascularly intact. VSS

A

internasal versed, fentanyl or ketamine and then a hematoma block for reduction

101
Q

for reduction in the child with pain after falling

A

Hematoma block for reduction – LET/EMLA to skin first

102
Q

what would you do for the pt with reduction need

for discharge

A
  1. Reduction, splint, sling

Home with weight adjusted NSAIDS, self care instructions

103
Q

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?

A

Low dose Ketamine IM now

US guided IV access now an option

Can give IV Ketamine, Ketorolac/APAP now

104
Q

best management of IVDU with abscess

A

Best!

USG axillary nerve block – gets deltoid.
Also interscalene block great

or IM ketamine

105
Q

what would you do if IV, NPO, refuses block if

A

Procedural sedation if IV, NPO, refuses block

106
Q

If no IV, not NPO in IVDU with abscess

A

consider redose IM Ketamine, then ring block, I&D

107
Q

discharge with abscess dude

A

Home with NSAIDS, APAP

108
Q

50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)

A

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

109
Q

50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)

A

thoracentesis would locally block • Bupivicaine

Consider Ketamine, Ketorolac IV. Consider Dilaudid if pain persists, BP ok

110
Q

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

A

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

111
Q

28yo female with RLQ abdominal pain, vomiting. Upreg neg

febrile

A

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

112
Q

if breasfeeding or pregnant

A

opiates category C
third trimester is really not good

call OB

would pump and dump if breasfeedings

113
Q

28yo male tripped on sidewalk. Chin lac. Otherwise well. Options?

A

Local infiltration with Lidocaine or Bupivicaine (with student esp) with Epi (face bleeds a lot)

114
Q

18mo male hit coffee table while running. Otherwise well. Options?

A

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

115
Q

30yo male dropped car transmission on left ring finger. Otherwise stable. Options?

A

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

116
Q

2yo male, brother shut fingers in car door. Otherwise stable. Screaming on exam. Options?

A

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

117
Q

A 30yo male presents after falling off a step stool. He is otherwise stable.
ii. VS: 108/82 105 16 98.5 98%ra

A

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

118
Q

Other than IM/IV ketamine or intra-articular bupivicane what can you do for should dislocation

A

Interscalene brachial plexus US guided regional block. No IV/IM, monitoring, ADE’s…magic!

119
Q

last choice with dislocation

A

Last choice: procedural sedation to reduce

120
Q

78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110

A
  1. 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!

121
Q

i. 41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra

A

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

122
Q

what would you use for a minor laceration in a child

A

ii. Topical meds for minor lacs first

123
Q

what would you use in young kids for procedures/imaging/cosmetic concerns/dental

name 3

A

iv. Analgesia/sedation/amnesia

  1. Midazolam (Versed®) intranasal, IM, IV
  2. Ketamine intranasal, IM, IV
  3. Fentanyl IM, intranasal, oral, IM, IV
124
Q

78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110

A 
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!
125
Q

41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra

A

US guided radial nerve block: 8-10cc Bupivicaine – after neurovascular exam

126
Q

29yo male with acute low back pain, no red flags

A

NSAID (oral or Ketorolac IM),
Tylenol 1g PO.
Either Valium 5mg PO,
Gabapentin 600mg PO

127
Q

29yo male with acute low back pain, no red flags discharge

A

D/C with NSAIDS, Tylenol, muscle relaxant (Baclofen®, Flexeril®)
Consider trigger point injection Bupicicaine 5-7ml

128
Q

40yo female, closed, non-displaced distal fibula fx.

A

Ketorolac 15mg IM, Tylenol 1g PO. Splint, D/C home w/ NSAID, Tylenol, RICE. May add #8-10 Vicodin/Norco

129
Q

30yo male with flu/mild pneumonia, stable, pleuritic chest pain.

A

Ketorolc IM/IV + Tylenol 1g PO/IV.

D/C with NSAID, Tylenol, Tessalon Pearls (Benzonatate), not cough syrup*

130
Q

50yo with dental abscess.

A

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

131
Q

25yo female with large burn to right thigh.

A

25yo female with large burn to right thigh.

132
Q

58yo male with gout left great toe.

A

NSAID PO/IM – Ibuprofen as good as Indomethacin

Colchicine (1.2mg po) + steroids if severe (can give in ED)

133
Q

68yo with chronic knee pain from osteoarthritis.

A

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

134
Q

23yo with strep throat, pain with swallowing.

A

NSAID plus Tylenol with Codeine Elixir 15ml in ED

Steroid IM: 6-10mg Dexamethazone + Abx

Home w/ NSAIDS/APAP

Emergency Medicine (28 decks)

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