Ooowweeyyy

Pain control: it'll preserve your hearing, along with your sanity.

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Now I know what you're thinking, we're just fueling the fire for all those with opioid dependency. However, pain is pain. It is a subjective matter and passing judgement on your patient does nothing other than hurt the patient-provider relationship. Besides, you'd be surprised who the bad ones really are…





So let's figure out what we can do to really help those in pain: Here are the players:
I.   acetaminophen (Tylenol®)

II.  non-steroid anti-inflammatory drugs
     A. Ibuprofen (Motrin®) 
     B. Ketorlac (Toradol®)

III.  hydrocodone/acetaminophen (Vicodin®, Norco®)

IV.  oxycodone/acetaminophen (Percocet®, Roxicet®)

V.    morphine (MS Contin®)

VI.  hydromorphone (Dilaudid®)
    A. 10mg inj morphine = roughly 1mg inj.hydromorphone

VII. oxycodone (oxyCONTIN®)

VIII. meperdine (Demerol®)

IX.  fentanyl (Sublimaze®)
    A. 100x stronger than morphine, but an rapid half-life

There’s a lot more, but I’m no pharmacist (I don’t think I could even play one on TV)…so let’s look at these patient populations:

MINIMUM dosing for morphine is 0.1mg/kg IV! (children and adults)
If you have a 300lb. female who presents with abdominal pain, 4 of morphine just isn’t going to cut it. In fact, 1mg of hydromorphone may not either…

300lb/2.2= 136kg x 0.1mg/kg= 13.6mg morphine

hydromorphone- 0.0125 mg/kg IV
300lb/2.2= 136kg x 0.0125mg/kg= 1.7 mg hydromorphone
Children
Acetaminophen- 15mg/kg PO
Ibuprofen- 10mg/kg PO
Intranasal fentanyl- 1-2mcg/kg 
Intranasal fentanyl is a great way to take the “edge off” if you need to do a procedure on a little kid. Give a lil’ spray in each nostril, stick a lollipop in their mouth, and call it a day (personally I'm 0/2).

Another option is intranasal midazolam (Versed) 0.5mcg/kg (maximum dose 10mg/kg)

Adults
Avoid Ibuprofen if concerns for GI bleed/diverticulitis/ulcers (think elderly)
Acetaminophen has concerns for hepatotoxicity in doses greater than 4g/day

RUQ pain
I added this section as a little reminder, there are concerns with giving morphine and spasm of the sphincter of Oddi. This MIGHT exacerbate pain for someone with biliary colic/gallbladder disease or pancreatitis. In the end it’s your clinical decision, and I’ve seen providers give morphine without problems. Try D/C home with ibuprofen 400mg PO for pain, Vicodin® for severe pain.

Alternatives:
Meperidine 50-150mg slow IV push (Beware: serotonin syndrome!)

Ketorlac (Toradol®)- 30-60mg IM

hydromorphone- 1-2mg IV

Don’t forget to make these patients NPO and hydrate!

Angina
morphine has been considered standard treatment for chest pain (remember M.O.N.A.?) for two reasons:

Step 1: Treating pain will decreased anxiety. Decreasing anxiety will calm patient down and reduce catecholamine secretion.
Step 2: Decreasing catecholamine secretion will lower heart rate and blood pressure. This will allow for improved blood flow and help maintain perfusion in a heart may have been damaged by infarction.

2-4mg IV q5-15 mins., can increase 2-8mg until pain relief.

Methadone
So anyone on methadone has been dealing with chronic pain for some time now, and hopefully pain management is following. Methadone has a long half-life.These people are going to be in pain! The standard algorithms for pain management DO NOT APPLY (I learned the hard way, my poor patient. it took 4mg dilaudid). Talk to your patient; how much methadone are they on? For how long?

You can give a 100lb. patient 2mg Dilaudid without breaking a sweat, but discuss this with your attending/supervising physician first!

Side effects:
Please don’t forget nausea/vomiting is a common complaint, especially for the opioid naive. Anti-emetics should routinely be dosed with narcotics:

Ondansetron (Zofran®) 4-8mg ODT (avoid in those with arrhythmia)

Metoclopramide (Reglan®) 10mg inj.(great for those with gastroparesis, constipation. Beware dystonia)

Promethazine (Phenergan®) 12.5-25mg inj. (Beware x 2! for dystonia)

Sedation, monitor your patients. Please don't turn them into respiratory depression...


Pain scale:

Ketorlac→  Morphine →   Hydromorphone → Lorazepam (Ativan®)

Allie Brosh

I hope this helps as you attempt to provide some pain relief for all your patients flooding in the ED:






There’s also the topics of conscious sedation, but that is beyond me and I would refer to your attending/supervising physician.


References:
 
http://www.med.umich.edu/1info/FHP/practiceguides/pain/dosing.pdf
UptoDate®
Cline, D.M., Ma, O.J., Cydulka, R.K., Meckler, G.D., Handel, D.A., & Thomas, S.H. (2012). Tintinalli's Emergency Medicine Manual (7th ed.) McGraw Hill Professional: Columbus, OH.