Pain Management Flashcards
1
Q
general principles of pain management
A
- 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
2
Q
Assessing pain
A
- Useful? Err on the side of believing the patient. Assess anxiety too
- Tx the pain, discuss rationale for what you are using w/ pt
3
Q
pain management routes
A
- 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
4
Q
Acetaminophen, NSAIDs
A
- 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
5
Q
Ketorolac, Gabapentin, Tramadol
A
- 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
6
Q
medications: opiates
A
- 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
7
Q
Parenteral opiates
A
- Morphine
- Hydromorphone (dilaudid)
- Fentanyl (Duragesic)
- Meperidine (Demerol)
- Methadone
8
Q
Morphine
A
- 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
9
Q
Hydromorphone (dilaudid)
A
- 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
10
Q
Fentanyl (Duragesic)
A
- 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
11
Q
Meperidine (demerol)
A
- Removed from most ED’s: safety, abuse potential
-
Contraindicated w/ MAOI’s: Serotonin Syndrome
- Libby Zion Law
12
Q
Methadone
A
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
13
Q
Oral opiates
A
- 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
14
Q
Adjuncts with opiates
A
- 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
15
Q
dissociatives
A
- 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
