Pain Management in the ED

Elise O. Lovell, MD

Pitfalls in Pain Management

Oligoanalgesia (too little)

Withholding analgesics until definitive diagnosis is made (too late)

Inappropriate route of administration

Inappropriate dosing schedule

Waiting for the patient to ask

Inappropriate discharge analgesic

Some specific analgesics

Ketorolac (Toradol)Cox-2 InhibitorsTramadol (Ultram)Propoxyphene (Darvon)Codeine/Hydrocodone/OxycodoneMeperidine (Demerol)Fentanyl (Sublimaze)MorphineHydromorphone (Dilaudid)

Case 1

28 yo male, MVC, isolated right leg pain.

PMH: neg, no allergies

VS: 140/80, 90, 18

Case 1

Case 2

30 yo female, left flank pain, hematuria, vomiting

PMH: neg, no allergies

Case 2

Case 3

19 yo male, RLQ pain, fever, anorexia

PMH: neg, no allergies

Surgeon calls and says: Don’t give him any pain medication, it will mess up my exam !!

Case 4

50 yo female, distal radius fracture, no reduction needed, in splint, ready for discharge.

PMH: negative, no allergy

Case 5

Ketorolac (Toradol)

Cyclooxygenase inhibition

Same GI side effects as all NSAIDS

Similar efficacy to Ibuprofen

Effective in renal and biliary colic

Obstructed kidney uses vasodilation to preserve perfusion (prostaglandin mediated effect), ketorolac -> ATN

COX-2 Inhibitors

Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)Efficacy similar to other NSAIDSImproved GI profile (maybe)Increased risk of MI and CVAAll NSAIDS with Renal, BP,GI effects, edema

COX-2 Inhibitors

Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)

Efficacy similar to other NSAIDS

Improved GI profile (maybe)

Increased risk of MI and CVA

Codeine/Hydrocodone/Oxycodone

Multiple strengths

Often mixed with ASA/tylenol

Tramadol (Ultram)

Binds to mu opioid receptors, also inhibits norepi/serotonin reuptake

Similar analgesic potency to codeine

Seizure risk

Nausea, dizziness, sedation, constipation

Serotonin syndrome with SSRI

Propoxyphene (Darvon)

Synthetic narcotic

In OD, expect seizures, also can cause cardiac toxicity (blocks), requires high doses of narcan to reverse

Fentanyl (Sublimaze)

Stable hemodynamic profile

Minimal histamine release

High dose rapid push --> “rigid chest syndrome”. Treat with naloxone and muscle relaxants

Large dose -->possible apnea

Small doses frequently (1-2 mic/kg, duration 30-60 minutes)

Also transdermal patch, lozenge,

inhaled

Morphine

Analgesic dose 0.1 mg/kg

Dosing ceiling from side effects, not from arbitrary number of mg

Hydromorphone (Dilaudid)

High potency (1 mg equals 7 mg morphine)

Meperidine (Demerol)

Not available (except for shivering)

Risk of seizures from Normeperidine in high dose (sickle cell anemia) and in renal failure

Serotonin syndrome with MAOI

Procedural Sedation

Fentanyl/Versed

Ketamine

Methohexital (Brevital)

Propofol (Diprivan)

Etomidate

Ketamine

Derivative of PCP

Use in kids (age 1-10 years) for short painful procedures

Onset 5 minutes, lasts approx. 30 minutes

Dissociative state-eyes open, no one home

Midazolam helps nausea, likely does NOT decrease emergence phenomena

Atropine no longer recommended

Ketamine, continued

Normal or increased muscle tone

Preserved airway reflexes

Analgesia, amnesia

Stable or increased BP and Pulse

Bronchodilator

Ketamine, the downside

Increases ICP and IOP

Apnea in children < 1 year

Increased secretions ->laryngospasm (bag through it)

Emergence phenomena (older kids)

Complete recovery -> 1 hour (concern of head positioning)

Emesis

Propofol (Diprivan)

Sedative hypnotic-NOT analgesicOnset 40 seconds, off in 5-10 minutesSide effects: Hypotension, Apnea, InfectionDecreases ICP, anti-emetic, anti-epilepticDecreased side effects with infusion rather than bolusDifferent dosing for induction vs. procedural sedation vs. maintenance

Propofol (Diprivan) Dosing

May add low dose fentanyl (1 mic/kg IV) as analgesic, and use lower propofol dosePediatrics- use 1 mg/kg IV“propofol syndrome” in kids seen in PICU-longer duration sedation (acidosis, hypotension, organ failure)

Let’s mix them together: “Ketofol”

1:1 mixture in same syringe

Usual dose required approximately 1.0 mg/kg

Best of both worlds (less hypotension, less resp. sedation, less vomiting, less emergence)

Methohexital (Brevital)

Not currently available

Ultra short acting barbiturate

1-1.5 mg/kg IV push

Not an analgesic

Can cause apnea, decreased BP, also possible laryngospasm, myoclonus, bronchospasm, N/V

Etomidate

Sedative hypnotic, NOT analgesicInduction dose 0.3 mg/kg IV push, use 0.15 mg/kg for procedural sedation Onset within one minute, off in about 10 minutesDecreases ICP and IOP Stable CV effectsCan cause myoclonus (not seizures), vomiting, respiratory depressionAdrenal suppression-consider alternative in sepsis

Take home points

Dose analgesics to effectiveness, not an arbitrary number of mgDose early, dose oftenBe proactive about offering analgesicsRemember the potency of DilaudidKetorolac is expensive Ibuprofen Etomidate and Propofol are NOT Analgesics

Propofol (Diprivan) dosing

Procedural sedation: usually slow push 1-1.5 mg/kg with repeated dosing of 0.5 mg/kg, duration 8-10 minutesInduction: 2-2.5 mg/kg, usually give 40 mg every 10 seconds (elderly 20 mg every 10 seconds)ICU sedation: 5 mic/kg/min (0.3 mg/kg/hr) increase by 10 mic/kg/min (0.6 mg/kg/hr) every 5-10 minutes