Pain Management, Multi-Systems Trauma

[medicgirl05]

You're local ERs suck.

No argument there. Most of the ER docs are rent a docs. When we fly out multi system trauma pain management is one of the first things dealt with. If we don't medicate the flight crew will so we figure why wait for their arrival. Only pain med we currently carry is Morphine. We had been using Nubain but it got removed after multiple ass chewings from ER docs. We are currently rewriting protocols to carry Toradol. Unfortunately my supervisor is more of the opinion that less intervention is better, so we don't carry many pain meds..

[ERDoc]

I'd have to say you are dealing to docs who are not EM residency trained nor EM board certified. Unfortunately, a large portion of the physicians who staff smaller, more rural hospitals tend to be trained in internal medicine or family medicine and sometimes surgery. As for what you have and what you might get, I would try to get your medical director to reconsider. Morphine is good, but as stated before, if you have a trauma pt, how will you know if they are dropping their pressure because of the morphine or because they are bleeding out? I realize this does not affect a large portion of calls but I think it would be nice to have fentanyl as a backup. Toradol is great, except it increases bleeding (like most NSAIDs), so you probably wouldn't want it for a trauma pt. We also have a phenomenon here where the urologists won't do procedures on kidney stones if they have had any NSAID. It comes from a lawsuit that they faced and inappropriately lost. This probably isn't an issue in most areas.

[island emt]

Personally, I love fentanyl in a trauma situation. As previously mentioned, it has the least effect on vitals. I'll start with that and once they have time to be observed , I'll switch to morphine or dilaudid.

As a side question to this: What do you feel the appropriate dosing levels for Fentanyl are?

The reason I ask is from personal experience when I dislocated my shoulder in January, They gave me an initial dose of 50 MCG followed 5 min later with 50 MCG more. The effect of 100 MCG was at best a reduction from 8/10 to 6/10 in pain level. Pain started raising again within 30 minutes,

so the ER Doc gave me 2 vicoden po which had a much greater effect in pain relief.

[Just Plain Ruff]

I'll bet that any doctor who uses the mantra that narcotics masks abdominal pain would change their tune quickly if they either had appendicitis or some other form of abdominal pain and were faced with their antiquated line of thinking.

As a side question to this: What do you feel the appropriate dosing levels for Fentanyl are?

The reason I ask is from personal experience when I dislocated my shoulder in January, They gave me an initial dose of 50 MCG followed 5 min later with 50 MCG more. The effect of 100 MCG was at best a reduction from 8/10 to 6/10 in pain level. Pain started raising again within 30 minutes,

so the ER Doc gave me 2 vicoden po which had a much greater effect in pain relief.

Some people do much better with PO pain meds than IV. I found that for my migraines that I get very very seldomly, that IV narcs kick the headache but they don't last long enough to completely get rid of them and I'm usually needing a 2nd dose.

Many years ago I had a headache that was so bad the doc gave me 2mg of nubain first, that didn't fix it so they moved to IV Demerol with minimal response, and then upped it to 5mg Morphine wiht minimal response and finally after 9 hours in the ER with the headache, 2 CT's and and MRI, and a near lumbar puncture, I was given 2mg Dilaudid and that finally did it but 2 hours later the headache was back and I got 2 vicodin's and that finally relieved the headache.

Have never had a headache that bad since.

[ERDoc]

Island, I quickly titrate the fentanyl, usually 25mcg q 5min. We try to avoid PO stuff until we know if they will need any procedures. Fentanyl does have a short half life, which is why I like it. If it does cause some BP issues or changes in mental status it wears off pretty quick.

Ruff, narcotics as horrible for migraines. They usually lead to rebound migraines that are even worse. The American Academy of Neurologists is recommending them as a last resort now. I usually start with 1L NS, 50mg Benadryl, 30mg Toradol, 10mg Compazine and 0.5mg Ativan. If that doesn't work I give another 50mg Benadryl, 12.5mg Phenergan, 125mg Solu-medrol. No improvement still? Then it's more phenergan and 1mg of DHE.

[JakeEMTP]

We also have a phenomenon here where the urologists won't do procedures on kidney stones if they have had any NSAID. It comes from a lawsuit that they faced and inappropriately lost. This probably isn't an issue in most areas.

ERDoc, our Medical Director recommends 30mg Toradol and start with 50mcg of Fentanyl Kidney Stones. I ask why both and he explained that the Toradol helped reduce the inflammation of the urinary tract, thus making it somewhat easier to pass the stone, and Fentanyl to ease the pain.

Island, I guess everybody has a different level of Fentanyl "tolerance" for lack of a better term. I once snowed a pt. with a dislocated shoulder with 50mcg. I mean snoring. Others, we start at 75mcg and can give up to 200mcg, although I've never had a need to give that much to manage a pt.'s pain level. I am glad though that the right medication and route was found to help you!

[Paramagic]

I treat multi-system trauma aggressively with analgesia. Ketamine is my preferred agent, but fentanyl is great too. It doesn't matter if they are altered or not, injuries hurt. Even if they don't recall or can't tell you about the pain, all those fractures still cause a physiological pain response that is detrimental to the injured patient.

There's never a good reason to withhold pain relief.

[DwayneEMTP]

...There's never a good reason to withhold pain relief.

Really?

[ERDoc]

ERDoc, our Medical Director recommends 30mg Toradol and start with 50mcg of Fentanyl Kidney Stones. I ask why both and he explained that the Toradol helped reduce the inflammation of the urinary tract, thus making it somewhat easier to pass the stone, and Fentanyl to ease the pain.

I love toradol for stones also. Like I said, the urologists won't touch a pt that has had it so they are getting a longer hospital stay. I won't go into the details but they got successfully sued after a pt died during a procedure that received toradol. It was a BS suit but this is America so sometimes you get your winning lottery ticket.

I treat multi-system trauma aggressively with analgesia. Ketamine is my preferred agent, but fentanyl is great too. It doesn't matter if they are altered or not, injuries hurt. Even if they don't recall or can't tell you about the pain, all those fractures still cause a physiological pain response that is detrimental to the injured patient.

There's never a good reason to withhold pain relief.

Ketamine? That is a little crazy. I can't even use that in the ER without it becoming a procedural sedation, regardless of the dose. I also like to keep track of my pt's mental status until they get their CT. I'd say there are much better options. As for the last comment, never say never. There are no absolutes in medicine.

[usalsfyre]

The only time I've found analgesia to really be an issue is in the strongly sympathetically-dependent shock patients, i.e. anyone that has an extremely tight vascular bed to maintain perfusion. I've had two of these patients take a crap on me after fentanyl, one post-ROSC that was chewing on the tube and one patient with severe internal hemmohrage that was still conscious. Other than that I've had no issues medicating really any patient experiencing pain.

On a personal note I have been a "multi-trauma" after an MVC/possible ejection (I was outside the car when found, no idea how I got there) and revived no analgesia till PO at discharge. By the grace of God I only had deep contusions, a couple of lacerations and abrasions and a kick ass concussion, but I still remember the pain associated with those injuries clearly even if everything else is extremely fuzzy. Anyone who's not medicating their patients for pain is doing them a disservice, and if your service doesn't have protocols for it, you should be screaming at the top of your lungs to get it written into them.

Edited September 21, 2011 by usalsfyre