Pain Management, Multi-Systems Trauma

[WelshMedic]

Interesting how many people have missed the point that providing adequate pain management is about providing humane management. To not provide through lack of equipment, skill set or protocol is inhumane at best and negligent at worst

Pain is pain

Just sayin

As for the K-juice, we trialled it here and it was an astounding drug. The stand out demo for me was a patient partialy ejected in a car v's tree, ended up with her mangled legs mashed in amongst the front drivers side suspension / sterring arms screaming her head off

Special K sorted her out real good.

Yep, it does that to a person. You take one panicked individual and turn them into a calm, serene, easy to work with person.

You trialled it? Do you still have it then? I'd hate to think of it being taken away.

WM

[Kiwiology]

As for the K-juice, we trialled it here and it was an astounding drug. The stand out demo for me was a patient partialy ejected in a car v's tree, ended up with her mangled legs mashed in amongst the front drivers side suspension / sterring arms screaming her head off

Special K sorted her out real good.

And it gave her 2/3 of her daily fibre requirement too y'know

[BushyFromOz]

And it gave her 2/3 of her daily fibre requirement too y'know

YEah, she had good legs and wore that red dress too!

And it gave her 2/3 of her daily fibre requirement too y'know

YEah, she had good legs and wore that red dress too!

[Krysteen]

Very relaxed protocols on pain management. I start with fentanyl for faster onset and will usually continue with morphine. Also we have abdominal pain management protocols. The old treatment of absolutely no pain control has been done away with here for quite some time. I refuse to let my patients suffer.

[krumel]

In my former service I could choose between Fentanyl, Morphine, Pethidine and (Normal)Ketamine....

I found the discussion about not giving pain meds for "diagnostic purpose" quite interesting as we have a completly other doctrine here...

ER Personal will get pretty mad if the patient is in pain and we don't have a really good excuse.

On the practical side I'm clearly in favor of ketamine in a multi-systems trauma....It provides quite a good pain reduction and brings (when combined with a benzo, i.e. Midazolam) to a very "calm and stable" state soon.

BP-Management is as well as never an issue as the BP will normally only go up in a 10-15mmHG range which only very rarely is a problem...

Emergence-Phenomen occour sometimes, most of the times in Patients with an preexisting mental or neurological deficit but can be controlled with Midazolam just fine. (By the way: Emergence can also occour with patients who seem asleep.... YOU can't see it..but the patient will remember it when you don't use a benzo...)

Back in Germany we used Esketamine a lot, the Racemic of Ketamine which does not bring that much side effect, i.e. almost no emergence and not that much hypertension....Quite good stuff...

But to bring up a new topic in the discussion: Experience about the combined use of Fentanyl and Ketamine anyone?

So long,

K

Edited November 2, 2011 by krumel

[Kiwiology]

But to bring up a new topic in the discussion: Experience about the combined use of Fentanyl and Ketamine anyone?

We have the option of using fentanyl (IV or IN) plus ketamine but I have not seen it used

[WelshMedic]

In my former service I could choose between Fentanyl, Morphine, Pethidine and (Normal)Ketamine....

I found the discussion about not giving pain meds for "diagnostic purpose" quite interesting as we have a completly other doctrine here...

ER Personal will get pretty mad if the patient is in pain and we don't have a really good excuse.

On the practical side I'm clearly in favor of ketamine in a multi-systems trauma....It provides quite a good pain reduction and brings (when combined with a benzo, i.e. Midazolam) to a very "calm and stable" state soon.

BP-Management is as well as never an issue as the BP will normally only go up in a 10-15mmHG range which only very rarely is a problem...

Emergence-Phenomen occour sometimes, most of the times in Patients with an preexisting mental or neurological deficit but can be controlled with Midazolam just fine. (By the way: Emergence can also occour with patients who seem asleep.... YOU can't see it..but the patient will remember it when you don't use a benzo...)

Back in Germany we used Esketamine a lot, the Racemic of Ketamine which does not bring that much side effect, i.e. almost no emergence and not that much hypertension....Quite good stuff...

But to bring up a new topic in the discussion: Experience about the combined use of Fentanyl and Ketamine anyone?

So long,

K

Krumel,

Whilst it isn't seen as a standard cocktail, I have used esketamine and fentanyl together in the past. The fentanyl hits the nocireceptors and deepens the dissiassocative effect of the esketamine by virtue of being an absolute (as opposed to relative) anesthetic drug.

I would personally only reserve it for polytrauma patients that have multi-system injuries and whereby I need to watch the haemodynamic status very closely. Having said that, for these patients, it is very effective indeed.

My initial bolus dose would be: midazolam 0.05mg/kg, esketamine 0.5mg/kg and fentanyl 0.15 mg/kg. I would titrate from there. The pain score would lead me further.

Carl.

Edited November 2, 2011 by WelshMedic

[Kiwiology]

Oh yes this deep talk of anaesthetic drugs is just so gosh darn sexy

[krumel]

I asked this question as most colleagues at my former service were pretty scared of mixing drugs. Personally I used this combination for dislocated shoulders as Fentanyl is working quite a bit longer than Ketamine.... Especially in situations were the main source of pain is movement or the "Reposition" of limbs it is a pretty good combo I think....

[Vorenus]

I asked this question as most colleagues at my former service were pretty scared of mixing drugs. Personally I used this combination for dislocated shoulders as Fentanyl is working quite a bit longer than Ketamine.... Especially in situations were the main source of pain is movement or the "Reposition" of limbs it is a pretty good combo I think....

With dislocated limbs we normally use Ketamin and Midazolam. I also find, that after the initial indication of analgesia to reposition and immobilize, most pat. don`t need extended analgesia anymore (at least not while keeping the limb still).

Edited November 2, 2011 by Vorenus