Pain Management

Question 1

general principles of pain management

Answer 1

• Avoid delays in pain mgt: expeditious, adequate
  
  • Obtaining the Dx should not delay the treatment
  • Pain delays a good history; relief improves BP and pulse
• Consider best agent/dose/route for this pt
  
  • Treat the source, intensity. Treat locally whenever possible
  • Consider onset/duration/ease of administration
• Safety: in THIS pt. Age, condition, allergies, PMH
  
  • Side effect/adverse effect profile
• Oligoanesthesia – under-treatment of pain
  
  • Peds, elderly, cognitive delay, psych pt’s, altered
• Always acknowledge, assess, reassess, document
• Know three drugs for each class and route
• Pain treatment is separated into cancer and non-cancer pain
• Attempt to avoid opiates initially for acute pain, unless serious condition or cancer pain. Use as “rescue” tx
• Symptomatic vs. Mechanism approach
• The Opioid Epidemic
  
  • JACHO 2000, pain is “the 5th vital sign”; imperative to measure, fix pain to level of zero. Result: rise in opiate Rx’s to comply
  • In 2014 >2 million Americans abused/addicted to Rx opiates
  • 2014 >1000 ED visits daily in US were for opiate Rx misuse
  • Half who take opiates daily for 3mos are still taking them 5yrs later
  • 1999-2016: 197,000 people have died from Rx opioids (CDC)
  • Everything has changed – treatment, research, attitudes

Question 2

Assessing pain

Answer 2

• Useful? Err on the side of believing the patient. Assess anxiety too
• Tx the pain, discuss rationale for what you are using w/ pt

Question 3

pain management routes

Answer 3

• Oral
• Parenteral (IM, IV)
• Topical/mucosal
• Local infiltration/blocks
• US guided regional block
• Med choice is related to the route
• Oral: easy, long duration; delayed onset, not if vomiting*, NPO or significant pain
• IM: easy, onset 10-20min, lasts longer; stick, not titrateable (if you give too much, too bad), unpredictable
• IV: Fast onset, titrateable; stick, shorter duration, more side effects. Good if: moderate/severe, NPO, or local pain control not possible. Best overall
• Topical: fast onset, short duration. Includes on skin, intranasal, etc
• Local: fast onset, lasts 1-4hrs*, good duration for procedures – lacs, abscess, foreign body, digital block, ring block, dental blocks
• US guided regional blocks - fabulous
• If vomiting – antiemetic first – like sublingual Zofran
  • Takes about 30 mins for oral meds to kick in

Question 4

Acetaminophen, NSAIDs

Answer 4

• Acetaminophen (APAP)
  
  • IV: 1g excellent; Oral: 1gm; Rectal in kids
  • Great antipyretic, good analgesia
  • Combine w/ NSAID’s, opiates - anything
  • Avoid: bad liver failure, big etoh
  • Good for most elderly/pregnant pt’s
• NSAIDs:
  
  • Oral: : Ibuprofen 600mg, Naprosyn 500mg, etc
  • Great antipyretic, analgesia for mild/moderate pain
  • Avoid: Over 65yo, renal or GI issues, on ASA/coumadin, bleeding issues, pregnant, breastfeeding. Avoid Cox-2’s
  • Combo: APAP/NASIDs to treat acute pain - mainstay
  • Short-term NSAID use may be ok in elderly
• Kidneys or GI problems are what we worry about with NSAIDs
• When you get older you kidneys are much less able to handle the kidney tax of NSAIDs

Question 5

Ketorolac, Gabapentin, Tramadol

Answer 5

• Ketorolac (Toradol®): Parenteral NSAID: moderate to severe pain
  
  • IM/IV 15mg
  • Great: back pain, renal colic, muscles, burns, etc
  • Great choice to avoid opiates
  • Avoid: same as NSAIDs
  • More not better. Give 1-2x max in ED. 5 days inpatient max
  • Studies: same efficacy as oral NSAID
  • Oral Toradol $$$, not better than Ibuprofen
• Gabapentin (Neurontin®) Pregabalin (Lyrica®), Duloxetine (Cymbalta®)
  
  • Oral only, avoid if renal issues
  • Gabapentin: 300-600mg PO: combo with NSAIDs/APAP for acute pain
  • Neuropathic pain – Neuropathy, fibromyalgia, post herpetic neuralgia, back pain, etc
  • Lyrica/Cymbalta not as well studied for ED use
• Tramadol (Ultram®)
  
  • Synthetic, opiate-like activity
  • Addiction/abuse potential
  • Not often used in ED for acute pain, not often rx’d as outpt

Question 6

medications: opiates

Answer 6

• Opium-derived drugs: alkaloids, semisynthetic
• Parenteral are Schedule IV – pt specific order
• 1st/2nd trimester Pregnancy Category C (short-term use)
  
  • Passed into breast milk – pump/dump best
• Effective, fast, multi-route
• Know 3 parenteral, 3 oral
• Biggest ADE’s/concerns:
  
  • Respiratory depression: all
  • Hypotension; esp w/ Morphine
  • Altered mental status, dizzy
  • Nausea/vomiting common
  • ADE: flushing, rash, itching
  • Constipation
  • Tolerance/dependence/addiction
• Commonly give with IV fluids, antiemetic, +/- antihistamine
  
  • Iv fluids so you don’t become hypotensive, antihistamine so you don’t get a rash
• Remember that we measure everything compared to morphine
• 3rd trimester/long term use Pregnancy Category D
• People will NOT become addicted with one time use!!! Dependence and addiction happen over time with repeated exposure

Question 7

Parenteral opiates

Answer 7

• Morphine
• Hydromorphone (dilaudid)
• Fentanyl (Duragesic)
• Meperidine (Demerol)
• Methadone

Question 8

Morphine

Answer 8

• The classic opiate by which all others measured
• Dose 4-10mg IM/IV common
• Textbook 0.1mg/kg often inadequate – repeat dosing to achieve pain control
• IM onset 10-15min, lasts 2hrs
• IV onset <10min, lasts 1-2hrs
• Beware! Hypotensive? Use another drug
• AMS common; careful in resp dz, elderly, kids
• Extended release oral morphine 15mg PO
• PR not common in ED
• Kadian, Roxinol oral for cancer pain

Question 9

Hydromorphone (dilaudid)

Answer 9

• Very effective pain relief
• Dose 0.5-1mg IV (0.5 novice, 1mg severe pain)
• 2mg IV, if have tolerance, not unusual
• Textbook dose: .015mg/kg – may need repeat
• IV onset <10min, lasts ~2hrs unless tolerance
• Not good IM: slow onset, variable absorption
• PO dose 1-2mg – good if no IV, can take PO
• Hypotension less – but still a concern; AMS
• High abuse potential! Used less and less to avoid opiates

Question 10

Fentanyl (Duragesic)

Answer 10

• Powerful analgesic: 80-100x more potent than Morphine
• Combo of opiate and hypnotic properties
• Commonly used pre/post/during-surgery/procedures
• Short duration of effect: +/- 1hr; re-dosing common
• IM/IV 25-100mcg (that’s micrograms)
• Biggest benefit is NO hypotension – great choice in these pt’s
• Respiratory depression, GI effects common – give O2, antiemetic too
• Contraindicated if pt takes MAOI’s
• Good in kids – intranasal/IM/IV – double check dose

Question 11

Meperidine (demerol)

Answer 11

• Removed from most ED’s: safety, abuse potential
• Contraindicated w/ MAOI’s: Serotonin Syndrome
  
  • Libby Zion Law

Question 12

Methadone

Answer 12

For opiate addiction/use disorder

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

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

Missed “dose” not given in ED – encourages inappropriate use

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

Question 13

Oral opiates

Answer 13

• Vicodin/Norco/Lortab (Hydrocodone + APAP)
  
  • Common Rx for moderate pain in ED if can take PO
  • Vicodin 5/500; Norco 5/325 – avoid higher doses in ED
  • As outpatient, short term Rx (#8-10, 3 days max)
  • Constipation – Rx with Senna, Colace
  • Goal is to avoid opiates altogether!
  • Most ED’s do not refill oral opiates – check policy
• Tylenol w/ Codeine
  
  • Moderate pain, mostly as outpt, avoid higher doses
  • Tylenol #3 (30/300), less potent than Vicodin/Norco
  • Elixir 12/120mg per 5ml: useful in kids (adjust dose); or if can’t swallow pills
• Oxycodone, Percocet® (+ APAP)
  
  • Huge abuse potential; avoid use in ED, avoid Rx

Question 14

Adjuncts with opiates

Answer 14

• Common ADE’s of opiates include:
  
  • Hypotension
  • Nausea/vomiting
  • Histamine release
• Pain + anxiety common presentation
• Add adjuncts to pain order as indicated
• IV fluids useful for hypotension, n/v
• Minimize # of sticks
• Antiemetics:
  
  • 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)
  
  • Lorazepam (Ativan®) 0.5-1mg IM/IV
  • Midazolam (Versed®) 2-4mg IM/IV: very short acting, very sedating
  • Benzos: offer no analgesia and will lower blood pressure
• Antihistamine
  
  • Benadryl 25-50mg IM/IV

Question 15

dissociatives

Answer 15

• Ketamine
  
  • “Trance-like” state; analgesia, amnestic
  • Was mostly for procedural sedation, until now. “The first 500”
  • Low doses for acute pain in adults
    
    • IM 0.5-1mg/kg, IV 0.1-0.6mg/kg, IN 0.5mg/kg
  • Particularly useful in opiate tolerant pt’s
  • Minimal airway/respiratory compromise
  • Great in kids >1yo, best if NPO x4hrs
  • Intranasal kids – great, if you have it and are comfortable
  • Hallucinations, emergence phenomenon – warn the pt!
  • Gaining acceptance

Question 16

Medications: topical/misc

Answer 16

• LET or EMLA cream – good for kids
  
  • LET: lidocaine, epinephrine, tetracaine
  • EMLA: lidocaine, prilocaine
  • Apply prior to local anesthesia, cover
  • Apply to surrounding skin, +/- in open wound
  • Slow onset: 15-60min
• Ethyl Chloride spray: “freezes” skin to numb, prior to needle stick or small incision
• Proparicaine – topical anesthesia drops for eyes. Burns x10sec, lasts 30min. Do not Rx for home
• Viscous Lidocaine – topical for open tissue wounds/mucosa. Road rash, hemorrhoids
• Topical cocaine – helps stop nosebleed, everybody happy. Not in kids
• Auralgan – topical for ear canal, otitis externa
• Bladder spasm UTI – Phenazopyridine (Pyridium®) 100-200mg TID x2 days

Question 17

medications: local/regional

Answer 17

• Lidocaine (Amide) 1% or 2%
  
  • Good general use
  • Fast onset, lasts 1-3hrs
• Bupivicaine (Amide) 0.25% or 0.5%
  
  • Slower onset (10-15min)
  • Lasts 2-5hrs (good for students…)
• Addition to either with epinephrine
  
  • Epi good for high vascular areas, bleeding; hurts
  • Never on: fingers, toes, penis, nose – this is being challenged
• Can add Bicarb: reduce pain
  
  • 4ml lido + 1ml bicarb
• Not benign! Vasoactive!
• Max dose adults:
  
  • 4mg/kg plain lidocaine = 28 cc of 1% for 70 kg
• Max dose in kids:
  
  • 7 mg/kg lidocaine w/ epi
  • 2 mg/kg bupivicaine
• Pull back on syringe as you enter to avoid giving it IV
• Large lacs/big areas
  
  • Consider an ultrasound guided regional nerve block

Question 18

digital blocks

Answer 18

• Adults: 7-8cc in finger, 8-10 in toes
• Kids: use half that or less
• Check neuro status before block!

Question 19

Hematoma block

Answer 19

• Inject distal Fx sites
• Pre-reduction; not for minor/huge fx’s
• Bupivicaine

Question 20

intra-articular block

Answer 20

• Pre-reduction, arthritis
• US guided
• Bupivicaine; +/- steroids

Question 21

US guided nerve blocks

Answer 21

• Operator dependent: comfort level and skill
• Fabulous – will be ubiquitous in ED’s in a few years
• Common Types:
  
  • Forearm: Radial, Median, Ulnar Block
  • Femoral Nerve Block
  • Interscalene Brachial Plexus
  • Axillary Nerve Block
  • RAPTIR*
  • Posterior Tibial
  • Etc, etc
• RAPTIR = Retroclavicular Approach to the Infraclavicular Region

Question 22

procedural sedation

Answer 22

• Indication: brief procedure, pt would benefit from short-term sedation/amnesia. Drugs are titratable
  
  • Common: reductions, large abscesses, tricky procedures; procedures in kids, developmental delay, agitated, psych
• Levels of sedation:
  
  • Minimal (PO opiates, benzos)
  • Moderate (IV benzos, low-dose ketamine)
  • Deep (sedation dose ketamine, propofol, brevitol, etc)
• Advantages: pt does not recall procedure, controlled setting
• Disadvantages: labor/time intensive, staff (4 minimum), NPO status, recovery period, airway/circulation risk, drug risk

Question 23

Minor procedure in kids

Answer 23

• IV is best sedation overall: can titrate, control
  
  • But: painful, need monitoring, staff, time, recovery time
  • Quicker, safe options for minor procedures exist
• Topical meds for minor lacs first – then infiltrate
• Intranasal route great, careful dosing, atomizerà
• Analgesia/sedation/amnesia in young kids for procedures/imaging/cosmetic concerns/dental
  
  • Midazolam (Versed®) intranasal, IM, IV
  • Ketamine intranasal, IM, IV
  • Fentanyl IM, intranasal, oral, IM, IV
• Attending consult. Everybody has a favorite
• Infant sedation is tricky – talk it over with attending
• Infant sedation is VERY tricky
• nitric oxide is laughing gas

Question 24

New/Old alternatives for sedation in kids

Answer 24

• Nitrous Oxide
  
  • Old drug, inhaled. Switched mix from 50/50 N2O/O2 to 70/30
  • Analgesia and anxiolysis without deep sedation
  • Pre-procedure - useful
• IV Lidocaine
  
  • Best studied in renal colic – emerging alternative
  • 1.5mg/kg IV. Check does twice (or three times…)
• Steroids for inflammatory pain making a comeback!
• Buprenorphine
  
  • Bridge if patient interested in opiate cessation – stops withdrawal symptoms
  • Pt must be in opiate withdrawal, sublingual 1st dose

Question 25

Documentation and discharge

Answer 25

* Pain does not have to be gone – but tolerable, better * Vitals must be normal * When will meds wear off? * Are they driving? Ask and document! Tailor treatment if yes * Take meds at beginning of pain onset * Expectations for complete pain relief - discuss * Local care – splint, ice/heat, elevation, CAM, relaxation, music, etc – cannot be overestimated!

Question 26

Chronic pain in ED

Answer 26

* Classified as: cancer pain and non-cancer pain * Very common: dependence, elderly, fibromyalgia, CRPS/RSD, chronic low back pain, post-herpetic, post-traumatic pain, etc * Long-term opiates are not effective for most non-cancer pain * Goal is not to relieve pain entirely but to restore functional status of the patient * ED is a poor place to really care for these pt’s * Follow-up care, pain management, pain contracts w/ PMD * When in doubt – treat the patient * CRPS: Complex Regional Pain Syndrome, formerly RSD: Reflex Sympathetic Dystrophy. Most often post trauma, surgery. Chronic, burning pain, swelling. Difficult to treat

Question 27

Drug-seeking behavior

Answer 27

* Addiction * Craving, compulsive use of substance despite harm * Withdrawal sx’s if do not use * Tolerance does not equal addiction * Dependence and Tolerance * Physical/psychological – euphoria. Withdrawal if stops * Diversion * Patient who obtains Rx drugs for resale * ED is perfect setting: open 24hrs, some real pain, some dependent d/t medical condition/tx, some are professionals * Many ED’s have “we do not refill opiates/benzos” policies * Most of the people who obtain drugs for diversion purposes are because they have an expense to meet that they cannot meet

Question 28

Drug-seeking behavior clues

Answer 28

* 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

Question 29

how to manage drug seeking behavior

Answer 29

* Don’t get angry or want to “win” * Be professional, factual, calm, steady but firm, no negotiating * Check past visits, know ED policy * CURES data base – disclose you checked it * What needs to happen – f/u, PMD, pain contract, etc * You will treat acute pain, provide referrals * Say what you will do – say what you will not do – listen to pt and then repeat * Consult your attending if in doubt