acute pain mx pgy1&2 2013
TRANSCRIPT
Chris Cresswell
Emergency Physician
Whanganui
New Zealand
2013
Chris Cresswell
Emergency Physician
Whanganui
New Zealand
2013
Acute Pain Management
PGY 1+2
Acute Pain Management
PGY 1+2
AnalgesiaAnalgesia
Do the basics well
Reassurance
Do the basics well
Reassurance
SplintageSplintage
Immobilise broken bits early
Sling
Cardboard splint
Immobilise broken bits early
Sling
Cardboard splint
Polypharmacy is Cool!Polypharmacy is Cool!
Paracetamol
Loading dose: 2g PO or 1g IV or 20mg/kgPO or 15mg/kg IV
Maintenance dose: PO 15mg/kg q4h or max 8g/day for adults
NASIDs eg Ibuprofen 10mg/kg tds
Highly effective
Be careful in the elderly, CCF, renal impairment
Codeine – effective when used with paracetamol– easier for nurses to dispense than other opioids
Non-metabolisers and fast metabolisers.
Paracetamol
Loading dose: 2g PO or 1g IV or 20mg/kgPO or 15mg/kg IV
Maintenance dose: PO 15mg/kg q4h or max 8g/day for adults
NASIDs eg Ibuprofen 10mg/kg tds
Highly effective
Be careful in the elderly, CCF, renal impairment
Codeine – effective when used with paracetamol– easier for nurses to dispense than other opioids
Non-metabolisers and fast metabolisers.
Consider paracetamol toxicity in someone who has had difficult to control pain in the community - typically toothache
> 20 tab in 24 hours or > 24 tab in 48 hours
-> N-acetylcysteine and ask questions later.
Consider paracetamol toxicity in someone who has had difficult to control pain in the community - typically toothache
> 20 tab in 24 hours or > 24 tab in 48 hours
-> N-acetylcysteine and ask questions later.
Can’t take pain relief orally?Can’t take pain relief orally?
Paracetamol IV (usually only 1g) or PR
Parenteral NSAID eg Diclofenac IV (75mg in 100ml N Saline)
Almost never use IM analgesia in ED
Slow
Painful
Paracetamol IV (usually only 1g) or PR
Parenteral NSAID eg Diclofenac IV (75mg in 100ml N Saline)
Almost never use IM analgesia in ED
Slow
Painful
1µg/kg IV q3min, 3µg/kg IN prn q5min
Use half the dose in elderly or drugged (eg ethanol or morphine)
IV dose can be repeated in a few minutes PRN
Doesn’t make people puke, itch, hypotensive or as sedated as as morphine
Shorter acting than morphine.
Use morphine once patient analgesed if long acting analgesia needed.
1µg/kg IV q3min, 3µg/kg IN prn q5min
Use half the dose in elderly or drugged (eg ethanol or morphine)
IV dose can be repeated in a few minutes PRN
Doesn’t make people puke, itch, hypotensive or as sedated as as morphine
Shorter acting than morphine.
Use morphine once patient analgesed if long acting analgesia needed.
FentanylFentanyl
Nitrous oxideNitrous oxide
50:50 nitrous oxide : oxygen “Entonox”
Moderate analgesic
Very safe
Theoretical risks of diffusing into and expanding closed spaces eg pneumothorax, bowel obstruction, hernias
Requires patient to suck to activate valve -> children under 5 usually unable to use
Use it for catheters or IV access in needlephobes
50:50 nitrous oxide : oxygen “Entonox”
Moderate analgesic
Very safe
Theoretical risks of diffusing into and expanding closed spaces eg pneumothorax, bowel obstruction, hernias
Requires patient to suck to activate valve -> children under 5 usually unable to use
Use it for catheters or IV access in needlephobes
70% Nitrous Oxide70% Nitrous Oxide
70% Nitrous oxide : 30% oxygen
Strong analgesic and sedative
Can often suture with this
Need an oxygen wash-out to prevent hypoxia
70% Nitrous oxide : 30% oxygen
Strong analgesic and sedative
Can often suture with this
Need an oxygen wash-out to prevent hypoxia
Nerve blocksNerve blocks
Do a neurovascular exam first!
Use a long acting local anaesthetic eg bupivocaine,
Lignocaine if you want sensation early, eg lips
Great for hips and femurs – femoral nerve or triple block.
Maximum doses?
Do a neurovascular exam first!
Use a long acting local anaesthetic eg bupivocaine,
Lignocaine if you want sensation early, eg lips
Great for hips and femurs – femoral nerve or triple block.
Maximum doses?
Local anaesthetic maximum dosesLocal anaesthetic maximum doses
Bupivacaine max dose 2mg/kg
Repeated doses up to 400mg/day can be used1
Lignocaine max
4.5mg/kg without adrenaline
7mg/kg with adrenaline
Adrenaline can be put into appendages.
1: http://www.medsafe.govt.nz/profs/datasheet/m/MarcainAndadrenalineinj.pdf
Bupivacaine max dose 2mg/kg
Repeated doses up to 400mg/day can be used1
Lignocaine max
4.5mg/kg without adrenaline
7mg/kg with adrenaline
Adrenaline can be put into appendages.
1: http://www.medsafe.govt.nz/profs/datasheet/m/MarcainAndadrenalineinj.pdf
Signs of local anaesthetic toxicity?Signs of local anaesthetic toxicity?
Signs of local anaesthetic toxicity.Signs of local anaesthetic toxicity.
Perioral tingling
Visual disturbance
Seizure
Coma
VT
Antidote?
Perioral tingling
Visual disturbance
Seizure
Coma
VT
Antidote?
Antidote for LA toxicityAntidote for LA toxicity
Fat emulsion eg Intralipid 1ml/kg prn q3minutes then infusion
Fat emulsion eg Intralipid 1ml/kg prn q3minutes then infusion
Fascia Iliaca Block AKA triple blockFascia Iliaca Block AKA triple block
Triple block (femoral, lateral cutaneous nerve of thigh, obtruator) by the double pop fascial puncture technique is fantastic, super safe analgesia for # NOF and # femur
Triple block (femoral, lateral cutaneous nerve of thigh, obtruator) by the double pop fascial puncture technique is fantastic, super safe analgesia for # NOF and # femur
1 fascia lata, 2 fascia iliaca, 3 N. femoralis, 4 N. cutaneus femoris lateralis, 5
V. and A. femoralis, 6 M. pectinale, 7 M. psoas
1 fascia lata, 2 fascia iliaca, 3 N. femoralis, 4 N. cutaneus femoris lateralis, 5
V. and A. femoralis, 6 M. pectinale, 7 M. psoas
Other blocksOther blocks
There are lots other great places you can stick local anaesthetic
Femoral nerve block
Digital nerves: Go into the dorsum of the webspace ~ 2ml of local on each side of the finger
# ribs 5 ml of local over the # site
Median, radial and ulnar nerve blocks at the wrist. 5ml per nerve
Haematoma blocks for # wrist 10ml into the #
Dental anaesthesia Inject 3ml of long acting local injected through the buccal sulcus into soft tissue adjacent to the gum at the effected tooth
Rarely a Inferior alveolar nerve block will be needed for a lower molar.
There are lots other great places you can stick local anaesthetic
Femoral nerve block
Digital nerves: Go into the dorsum of the webspace ~ 2ml of local on each side of the finger
# ribs 5 ml of local over the # site
Median, radial and ulnar nerve blocks at the wrist. 5ml per nerve
Haematoma blocks for # wrist 10ml into the #
Dental anaesthesia Inject 3ml of long acting local injected through the buccal sulcus into soft tissue adjacent to the gum at the effected tooth
Rarely a Inferior alveolar nerve block will be needed for a lower molar.
TramadolTramadol
Tramadol is for people who say it works well for or patients you don’t like
Old adage:
Works for 1/3
Useless for another 1/3
Makes 1/3 vomit or spin out
Crappy analagesic eg Oxford league table of analgesics in acute pain
Very good for people who you think are drug seeking. Tramadol is not “liked” by IVDU but they are often tolerant to it’s side effects and do get an analgesic effect.
Tramadol is for people who say it works well for or patients you don’t like
Old adage:
Works for 1/3
Useless for another 1/3
Makes 1/3 vomit or spin out
Crappy analagesic eg Oxford league table of analgesics in acute pain
Very good for people who you think are drug seeking. Tramadol is not “liked” by IVDU but they are often tolerant to it’s side effects and do get an analgesic effect.
BenzodiazepinesBenzodiazepines
No analgesic effect, no muscle relaxant effect at sub-anaesthetic doses
But may help patients tolerate pain
But usually better to use an analgesic than has sedative properties eg opioid, clonidine
Considered a harmful treatment for acute low back pain (as are opioids)
New Zealand acute low back pain guide, incorporating the guide to assessing psychosocial yellow flags in acute low back pain
http://www.acc.co.nz/
No analgesic effect, no muscle relaxant effect at sub-anaesthetic doses
But may help patients tolerate pain
But usually better to use an analgesic than has sedative properties eg opioid, clonidine
Considered a harmful treatment for acute low back pain (as are opioids)
New Zealand acute low back pain guide, incorporating the guide to assessing psychosocial yellow flags in acute low back pain
http://www.acc.co.nz/
Smooth muscle relaxantsSmooth muscle relaxants
eg buscopan
Little evidence of effect
Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial.
http://www.ncbi.nlm.nih.gov/pubmed/22307926
Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute renal colic. http://www.ncbi.nlm.nih.gov/pubmed/22487663
Is there a role for antimuscarinics in renal colic? A randomized controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/16006900
Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic. http://www.ncbi.nlm.nih.gov/pubmed/15230794
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic. http://www.ncbi.nlm.nih.gov/pubmed/12748151
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic.
eg buscopan
Little evidence of effect
Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial.
http://www.ncbi.nlm.nih.gov/pubmed/22307926
Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute renal colic. http://www.ncbi.nlm.nih.gov/pubmed/22487663
Is there a role for antimuscarinics in renal colic? A randomized controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/16006900
Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic. http://www.ncbi.nlm.nih.gov/pubmed/15230794
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic. http://www.ncbi.nlm.nih.gov/pubmed/12748151
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic.
Skeletal Muscle RelaxantsSkeletal Muscle Relaxants
eg orphendarine
Some evidence of benefit
But generally we prefer analgesics over muscle relaxants
Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American
College of Physicians clinical practice guideline. http://www.ncbi.nlm.nih.gov/pubmed/17909211
eg orphendarine
Some evidence of benefit
But generally we prefer analgesics over muscle relaxants
Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American
College of Physicians clinical practice guideline. http://www.ncbi.nlm.nih.gov/pubmed/17909211
Ketamine - analgesiaKetamine - analgesia
Low dose ketamine is an excellent analgesic
But some patients spin out – unpredictable which ones
Eg 0.1mg/kg prn q 5min IV. Advise patients that it is “trippy”. Sell it to them that it will be pleasant.
Maximum dose of ketamine for unsupervised RMO probably 30mg
If someone is nervous give eg 1mg of midazolam IV before hand
Talk them through it as it is “coming on”
Low dose ketamine is an excellent analgesic
But some patients spin out – unpredictable which ones
Eg 0.1mg/kg prn q 5min IV. Advise patients that it is “trippy”. Sell it to them that it will be pleasant.
Maximum dose of ketamine for unsupervised RMO probably 30mg
If someone is nervous give eg 1mg of midazolam IV before hand
Talk them through it as it is “coming on”
Ketamine - analgesiaKetamine - analgesia
Cautions
Elderly
Start with 5mg
Psych history, IHD, marked hypertension
Get senior advice
Cautions
Elderly
Start with 5mg
Psych history, IHD, marked hypertension
Get senior advice
Other agentsOther agents
Seldom used outside of theatre
Clonidine
Good analgesic and sedative
Beware of hypotension especially if other hypotensing agents on board eg spinal anaesthesia
Eg 15µg q 15min IV, 2.5mg/week patch
Seldom used outside of theatre
Clonidine
Good analgesic and sedative
Beware of hypotension especially if other hypotensing agents on board eg spinal anaesthesia
Eg 15µg q 15min IV, 2.5mg/week patch
Long acting analgesiaLong acting analgesia
Long acting opioidsLong acting opioids
Fentanyl patch
Ketamine infusion eg 0.3mg/kg/hour
PCA eg fentanyl
SC morphine eg palliative (NZ medical system resistant to use of SC fentanyl currently)
Fentanyl patch
Ketamine infusion eg 0.3mg/kg/hour
PCA eg fentanyl
SC morphine eg palliative (NZ medical system resistant to use of SC fentanyl currently)
Procedural anaesthesia Procedural anaesthesia
Current drug limits for RMOs is say 100 mcg fentanyl + 2 mg of midazolam
RMOs currently are not allowed to use propofol or more than 30mg ketamine unsupervised (even though probably safer than midazolam and morphine)
Pt who had 2 respiratory arrests in Xray after a shoulder reduction
Current drug limits for RMOs is say 100 mcg fentanyl + 2 mg of midazolam
RMOs currently are not allowed to use propofol or more than 30mg ketamine unsupervised (even though probably safer than midazolam and morphine)
Pt who had 2 respiratory arrests in Xray after a shoulder reduction
Procedural AnaesthesiaProcedural Anaesthesia
Ketamine + propofol = magic
Ketamine is a excellent analgesic and patients (if you give it right) maintain their ABCs
Downside:
“Bad trips” = “emergence reactions”
Vomiting
Add propofol
Anxiolytic
Antiemetic
= near perfect combo
Ketamine + propofol = magic
Ketamine is a excellent analgesic and patients (if you give it right) maintain their ABCs
Downside:
“Bad trips” = “emergence reactions”
Vomiting
Add propofol
Anxiolytic
Antiemetic
= near perfect combo
Procedural AnaesthesiaProcedural Anaesthesia
Still potential for ABC disaster and you need to have all your toys + drugs + skilled personnel for an RSI available
Still potential for ABC disaster and you need to have all your toys + drugs + skilled personnel for an RSI available
References References
Oxford league table of analgesics in acute pain
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html
Oxford league table of analgesics in acute pain
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html
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