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Flashcards in pain Deck (134)
1

Oligoanesthesia- who is at risk

under-treatment of pain

• Peds, elderly, cognitive delay, psych pt’s, altered

2

Know three rule

• Know three drugs for each class and route

3 CCB for HTN
3 Medicines parenteral for pain
3 NSAIDS
3 Long Acting insulin

not everybody is the correct profile. the third medicine should always be "what if they are pregnant"

3

pain treatment is separate in what dx

• Pain treatment is separated in cancer and non-cancer pain

Cancer pain – don’t worry about addiction (just treat their pain which generally terrible pain)

4

Symptomatic vs. Mechanism approach

Treating the mechanism of pain is treating the nerve pathways/physiology of pain

5

Parenteral includes

IM SQ IV

6

onset of IM

easy, onset 10-20 min, lasts longer; stick is involved, not titrateable, results are unpredictable. Can give someone 8mg of morphine IM and they may not feel anything and want more.

7

IV advantages

what situations are pest

Fast onset, titrateable; stick, shorter duration, more side effects.

Good if: moderate/severe, NPO, or local pain control not possible. Best overall

8

advantages and disadvantages of PO

i. Easy, long duration; delayed onset, can’t give if vomiting, NPO or significant pain

9

Local infiltration/blocks advantages

i. Fast onset, lasts 1-4hrs*, good duration for procedures – lacs, abscess, foreign body, digital block, ring block, dental blocks

10

when would acetaminophen be used

• IV: 1g excellent; Oral: 1gm; Rectal in kids
• Great antipyretic, good analgesia
• Combine w/ NSAID’s, opiates - anything
• Good for most elderly/pregnant pt’s

11

when is acetaminophen CI

Avoid: liver FAILURE, big etoh

NOT liver disease

12

• NSAIDs are CI in

Over 65yo (but if youre going to give it, give the lowest dose), renal or GI issues, on ASA/coumadin, bleeding issues, pregnant, breastfeeding. Avoid Cox-2’s

13

NSAID dose

• Oral: Ibuprofen 600-800mg, Naprosyn 500mg, etc

800 NO significant benefit

14

can use NSAIDS with

Combo: APAP/NASIDs to treat acute pain

15

Ketorolac (Toradol®) what kind of drug is it

how is it administered

IM/IV 15-30mg (you will see 30 and 60 mg)

NSAIDS

16

Ketorolac (Toradol®) is best for

NSAIDS
Great: back pain, renal colic, muscles, burns, etc

17

Ketorolac (Toradol®) should be avoided in

Avoid:
Over 65yo (but if youre going to give it, give the lowest dose)
renal or GI issues
on ASA/coumadin
bleeding issues
pregnant
breastfeeding. Avoid Cox-2’s

18

what are the limitations with ketorolac

More not better. Give 1-2x max in ED. 5 days inpatient max

19

Benefits of Ketoralc over NSAIDs

sometimes better for acute pain
better for placebo of IM

20

Gabapentin (Neurontin®)

what are the other drugsin this class
dosed

nerve pain medication

Oral dosing only

Pregabalin, Duloxetine

21

Gabapentin can be used with

Gabapentin

combo with

NSAIDs/APAP for acute pain

but CAN'T DRIVEAFTER

22

Gabapentin typically given for

Neuropathic pain –
DM, fibromyalgia, post herpetic neuralgia, back pain

23

Tramadol (Ultram®)

• Synthetic, opiate-like activity

• Addiction/abuse potential
• . Not often used in ED for acute pain, not often rx’d

24

opiates are schedule

what are the indications

Opium-derived drugs: alkaloids, semisynthetic
. Parenteral are Schedule IV – pt specific order

iv. Indications: moderate – severe pain

25

Biggest ADE’s/concerns with opiates

i. Respiratory depression: all
ii. Hypotension; esp w/ Morphine
iii. Altered mental status, dizzy
iv. Nausea/vomiting common
v. ADE: flushing, rash, itching
vi. Constipation
vii. Tolerance/dependence/addiction

26

opiatesa are given with (3)

IV-pump up your blood pressure

antiemetics-keep you from barfing

antihistamines -reduce rash and flush

27

dosing or morphine

Dose 4-10mg IM/IV common

comes in 2's be mindful of this
order 2, 4, 6, 8 or 10

really don't use 2 or 10
because it comes in 2s DO NOT ORDER 5

8 is high
usually we giver 4 or 6

10mg is .1 fentanyl and 1.5 hydromorphone

onset is 10-15 minutes

28

morphine is CI in

hypotensive

USE ANOTHER DRUG

• AMS common; careful in resp dz, elderly, kids

29

Hydromorphone (Dilaudid®) dosing

Dose 0.5-1mg IV (0.5 novice, 1mg severe pain)

PO dose 1-2mg – good if no IV, can take PO

IM NOT so good
very slow onset

30

CI with dilaudid

Hypotension less – but still a concern; AMS

really high abuse potential

31

IV onset of dilaudid

• IV onset <10min, lasts ~2hrs unless tolerance

32

fentanyl compared to morphine

Powerful analgesic: 80-100x more potent than Morphine

33

fentanyl order

IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)

34

bigget benefit of fentanyl

Biggest benefit is NO hypotension – great choice in these pt’s

35

SE of fentanyl

Respiratory depression, GI effects common – give O2, antiemetic too

36

CI of fentanyl

Contraindicated if pt takes MAOI’s

37

why is fentanyl good choice for kids

Good in kids – intranasal/IM/IV – double check dose

38

duration of fentanyl

Short duration of effect: +/- 1hr; re-dosing common


IM/IV 1-2mcg/kg (25-100mcg) (that’s micrograms)

39

Meperidine (Demerol®) CI with

• Contraindicated w/ MAOI’s:

• Removed from most ED’s: safety, abuse potential

40

methadone works for addiction by

• Blocks the “high”, reduces cravings and withdrawal sx’s

41

methadone can be used for pain associated with

Effective for cancer pain, not first-line in non-cancer pain

Emerging usefulness in ED as oral alternative if using opiates – very long effect

42

Common Rx for moderate pain in ED if can take PO

Vicodin/Norco/Lortab (Hydrocodone + APAP)

Tylenol w/ Codeine

AVOID Oxycodone and Percocet

43

dosing of vicodin and norco

Vicodin 5/500 (5 hydrocodone and 500 Tylenol)

Norco 5/325 – avoid higher doses in ED

44

vicodin given for outpatient

As outpatient, short term Rx (#8-10 MAX)

2 tablets every 6 hours treats three days worth of pain

45

concerns with Vicodin rx

4. Constipation – Rx with Senna, Colace
5. Goal is to avoid opiates altogether!
6. Most ED’s do not refill oral opiates – check policy

46

why would Tylenol w/ Codeine be preferred in kids

2. Tylenol #3 (30/300), less potent than Vicodin/Norco
3. Elixir 12/120mg per 5ml: useful in kids (adjust dose); or if can’t swallow pills

47

Common ADE’s of opiates include:

i. Hypotension
ii. Nausea/vomiting
iii. Histamine release

48

f. Antiemetics that can be administered for opiate RX

Zofran 4-8mg IV/IM/SL

Metoclopramide 5-10mg IV/IM

Phenergan 12.5-25mg IV/IM/PR

Compazine 5-10mg IV/IM/PR

49

Anxiolytics (Benzos), name three

Lorazepam (Ativan®) 0.5-1mg IM/IV

Midazolam (Versed®) 2-4mg IM/IV: very short acting, very sedating

Benzos: offer no analgesia but will lower blood pressure

50

antihistamines given wiht opiates

i. Benadryl 25-50mg IM/IV

51

Ketamine

Trance-like” state; analgesia, amnestic

52

ketamine used to be used for

Was mostly for procedural sedation, until now. “The first 500”

iii. Low doses for acute pain in adults (LDK = low dose ketamine)

53

dosing for ketamine

1. IM 0.5-1mg/kg, IV 0.1-0.6mg/kg, IN 0.5mg/kg

54

why would ketamine be useful

Particularly useful in opiate tolerant pt’s; alternative to opiates

Great in kids >1yo, best if NPO x4hrs

Intranasal kids – great, if you have it and are comfortable

55

Emergence phenomenon

happens in adults and children – having a nightmare that you can’t get out of

1. Can give benzos for it

56

a. LET or EMLA cream

good for kids
i. Apply prior to local anesthesia, cover

57

a. LET or EMLA cream application

and onset

Apply to surrounding skin, +/- in open wound

Slow onset: 15-60min

58

b. Propericaine

topical anesthesia drops for eyes Burns x10sec, lasts 30min.

59

Propericaine watch out of theis

i. Do not Rx for home – can cause corneal scarring

60

– topical for open tissue wounds/mucosa. Road rash, hemorrhoids

c. Viscous Lidocaine

61

helps stop nosebleed, everybody happy. NOT IN KIDS

d. Topical cocaine

62

– topical for ear canal, otitis externa

e. Auralgan

63

topical Bladder spasm UTI

Phenazopyridine (Pyridium®)

64

Phenazopyridine (Pyridium®) dosing

100-200mg TID x2 days

65

Lidocaine

onset
what i's good for

(Amide) 1% or 2%
• Good general use
• Fast onset, lasts 1-3hrs


e. Addition of Bicarb
i. Reduces pain
ii. 4ml Lido + 1 ml bicarb

66

Bupivicaine

local
Amide) 0.25% or 0.5%
• Slower onset (10-15min)
• Lasts 2-5hrs (good for students...)

67

Epi good for

• Epi good for high vascular areas, bleeding; hurts

68

never use Epi on

• Never on: fingers, toes, penis, nose b/c you lose circulation in those areas and it can become necrotic

69

bicarb plus lidocaine can be used for

• Can add Bicarb: reduce pain
• 4ml lido + 1ml bicarb

70

max dose of lidocaine -adult

• 4mg/kg plain lidocaine = 28 cc of 1% for 70 kg

71

max dose of lidocaine-kid

• 7 mg/kg lidocaine w/ epi
• 2 mg/kg bupivicaine

72

how to do a lidocaine block

• Pull back on syringe as you enter to avoid giving it IV - to avoid injecting in the circulation

73

Large lacs/big areas want to consider

• Consider an ultrasound guided regional nerve block

74

Digital block

dosing
Adults: 7-8cc in finger, 8-10 in toes

75

before administering a block

ii. Kids: use half that or less
iii. Check neuro status before block!

76

i. Intra-articular can be used for

1. Pre-reduction, arthritis
2. US guided

Bupivicaine; +/- steroids but usually leave this up to orthopedics

77

Hematoma block-what is it and what would you use

"fantastic old-school"

1. Inject distal Fx sites (right into the crunchy part
2. Pre-reduction; not for minor/huge fx’s
3. Bupivicaine (long lasting)

10ccs pre reduction

Medium Fx only

78

Regional nerve block

1. Facial, ear, dental, feet

2. Bupivicaine

3. US guided arm, leg

79

US guided can be used with

a. Radial, medial, ulnar
b. Brachial plexus/axillary
c. Femoral, etc, etc

80

block over lidocaine

because you don't want to distort the skin with the lidocaine

81

indication for procedural sedation

brief procedure, pt would benefit from short-term sedation/amnesia. Drugs are titratable

Common: reductions, large abscesses, tricky procedures; procedures in kids or developmental delay/agitated

82

Minimal sedation

(PO opiates, benzos)

83

Moderate sedation

(IV benzos, low-dose ketamine)

84

Deep sedation

(sedation dose ketamine, propofol, brevitol, etc)

85

advantages of sedation

c. Advantages: pt does not recall procedure, controlled setting

86

disadvantages of sedation

abor/time intensive, staff (4 minimum), NPO status, recovery period, airway/circulation risk, drug risk

87

best pain control for kids

i. IV is best sedation overall: can titrate, control
1. But: painful, need monitoring, staff, time, recovery time
2. Quicker, safe options for minor procedures exist

88

IV Lidocaine

what would you use it for and what is the dose

Best studied in renal colic – emerging alternative

1.5mg/kg IV. Check does twice (or three times...)

89

for inflammatory pain making a comeback!
i. Can also give for back pain

c. Steroids

90

Bridge if patient interested in opiate cessation

d. Buphenerone

91

Documentation and Discharge

a. Pain does not have to be gone – but tolerable, better
b. Vitals must be normal
c. When will meds wear off?
d. Are they driving? Ask and document!. Tailor treatment if yes
e. Take meds at beginning of pain onset

f. Expectations for complete pain relief - discuss

Local care – splint, ice/heat, elevation, CAM, relaxation, music, etc – cannot be overestimated!

92

how do we classify chronic pain

a. Classified as: cancer pain and non-cancer pain

93

chronic main is commonly seen with these disorders

Very common:
dependence,
elderly,
fibromyalgia,
CRPS/RSD,
chronic low back pain,
post-herpetic,
post-traumatic pain, etc

94

addiction

2. Withdrawal sx’s if do not use
a. Its not that they do it for the high, they do it to avoid the withdrawal symptoms

95

physical/psychological – euphoria. Withdrawal if stops

Dependence and Tolerance

96

Patient who obtains Rx drugs for resale

Diversion

97

clues to drug seeking behavior

• Spilled the bottle, lost/stolen Rx
• Multi drug “allergies”
• Names drugs, gives doses, only “this” works
• Travelling, elaborate sad tales
• Demand drugs before Hx/PE
• Doctor died, on vacation
• No PMD, f/u, records
• Present late in day
• Demanding, hostile if needs not met or, conversely, overly nice

98


47yo female with Hx migraine headaches c/o typical migraine for past 5 hours. She c/o nausea, vomiting and photophobia. VS: 130/88 88 16 98.5 99%ra

Migraine “cocktail” – avoids opiates

Establish IV, give 1L bolus NS (vomiting)

Ketorolac 30mg IV

Metoclopromide (Reglan®) 10mg IV

Benadryl 50mg IV

99

reassessing hte pt with a migraine

can give triptan, steroids (Dexamethazone 8-10mg IV). Home w/ NSAIDs, antiemetic

100

A 12yo female presents with left arm pain/deformity after a fall at the climbing gym. Otherwise well. Neurovascularly intact. VSS

internasal versed, fentanyl or ketamine and then a hematoma block for reduction

101

for reduction in the child with pain after falling

Hematoma block for reduction – LET/EMLA to skin first

102

what would you do for the pt with reduction need

for discharge

5. Reduction, splint, sling

Home with weight adjusted NSAIDS, self care instructions

103

35yo male, IVDU, presents with a large abscess to his left deltoid. He is verbally abusive to staff when an IV is difficult to obtain, demanding meds for pain. He is otherwise stable. Options?

Low dose Ketamine IM now

US guided IV access now an option

Can give IV Ketamine, Ketorolac/APAP now

104

best management of IVDU with abscess

Best!

USG axillary nerve block – gets deltoid.
Also interscalene block great

or IM ketamine

105

what would you do if IV, NPO, refuses block if

Procedural sedation if IV, NPO, refuses block

106

If no IV, not NPO in IVDU with abscess

consider redose IM Ketamine, then ring block, I&D

107

discharge with abscess dude

Home with NSAIDS, APAP

108

50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)

Fentanyl best choice for pain in hypotension. Begin 50mcg IV

IV fluids to raise BP
IV ketorolac/Tylenol for fever and pain

Wait for better BP before anxiolytics; tx the problem in the meantime

109

50yo female presents with left sided pleuritic chest pain, SOB. Looks uncomfortable and anxious. (pt has a pleural effusion)

thoracentesis would locally block • Bupivicaine

Consider Ketamine, Ketorolac IV. Consider Dilaudid if pain persists, BP ok

110

55yo male with hx renal colic, same sx’s. Otherwise well. 158/92 100 20 98.9 98%ra

what would the rescue meds be


IV 1L bolus, Ketorolac 30mg IV, Zofran 4mg IV, IV Tylenol 1000mg

May add Morhpine 4-8mg IV or Dilaudid 0.5-1mg IV

maybeee IV lidocaine

111

28yo female with RLQ abdominal pain, vomiting. Upreg neg

febrile

IV 1L bolus,
Zofran 4mg IV,
Tylenol 1g IV

Ketoralac and IV fluids

Morphine 4-8mg IV or Dilaudid 0.5-1mg IV
Lower doses if opiate naive, Benadryl 25-50mg IV

112

if breasfeeding or pregnant

opiates category C
third trimester is really not good

call OB

would pump and dump if breasfeedings

113

28yo male tripped on sidewalk. Chin lac. Otherwise well. Options?

Local infiltration with Lidocaine or Bupivicaine (with student esp) with Epi (face bleeds a lot)

114

18mo male hit coffee table while running. Otherwise well. Options?

LET/EMLA to area for 30min – recheck
EMLA cream (eutectic mixture of local anesthetics) with that of LET solution (lidocaine, epinephrine, tetracaine
Consider IM/IN Midazolam (Versed®) or

Fentanyl; IM low dose or intranasal Ketamine as an option

Local infiltration of wound or regional block

Consider “papoose”, must be quick! INSURANCE for if a kid wakes up during a procedure

115

30yo male dropped car transmission on left ring finger. Otherwise stable. Options?

Digital block with Bupivicaine after neurovascular check

can do XRAY after

Splint, NSAID’s Rx

opiates no more than 3 days

Discharge both home on NSAIDS, Tylenol. Adult: +/- Vicodin #8

116

2yo male, brother shut fingers in car door. Otherwise stable. Screaming on exam. Options?

Need sedation prior to xray, digital block

+/- LET/EMLA at base of finger for block...finger, toes, penis, nose...

Versed, Fentanyl or Ketamine IM or IN

Discharge both home on NSAIDS, Tylenol. Adult: +/- Vicodin #8

117

A 30yo male presents after falling off a step stool. He is otherwise stable.
ii. VS: 108/82 105 16 98.5 98%ra

posterior dislocation

IM/IV Ketamine or Fentanyl 50mcg (lowish BP), consider oral Benzo’s before reduction

Or...Intra-articular injection of 8-10ml Bupivicaine: local tx is always good

Better: Brachial plexus US guided regional block. No IV/IM, monitoring, ADE’s...magic!

last choice sedation

after reduction NSAIDS muscle relaxers sling

118

Other than IM/IV ketamine or intra-articular bupivicane what can you do for should dislocation

Interscalene brachial plexus US guided regional block. No IV/IM, monitoring, ADE’s...magic!

119

last choice with dislocation

Last choice: procedural sedation to reduce

120

78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110

2. IV fluids, O2, Monitor

Fentanyl 25mcg IV to start
US guided femoral nerve block now!! (not a ton of opiates)
CONSULT Ortho, discuss block

Pt will not feel compartment syndrome!

121

i. 41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra

The size, mechanism and location make this wound special – will need xray, tons of irrigation, exploration


US guided radial nerve block: 8-10cc Bupivicaine – after neurovascular exam

Can add bupivicaine locally if anesthesia not complete
5. No US? Bupivicaine local

Discharge w/ NSAIDS, Abx and splint

122

what would you use for a minor laceration in a child

ii. Topical meds for minor lacs first

123

what would you use in young kids for procedures/imaging/cosmetic concerns/dental

name 3

iv. Analgesia/sedation/amnesia

1. Midazolam (Versed®) intranasal, IM, IV
2. Ketamine intranasal, IM, IV
3. Fentanyl IM, intranasal, oral, IM, IV

124

78yo female, trips and falls on porch steps. She c/o severe L hip pain, is screaming in pain. BP 100/60, HR 110

IV fluids, O2, Monitor
Fentanyl 25mcg IV to start
US guided femoral nerve block now!!
Consult Ortho, discuss block
Caution! Pt will not feel compartment syndrome after femoral block!

125

41yo male bit by police dog to left hand while resisting arrest. Otherwise stable. VS: 144/90 92 14 98.4 98%ra

US guided radial nerve block: 8-10cc Bupivicaine – after neurovascular exam

126

29yo male with acute low back pain, no red flags

NSAID (oral or Ketorolac IM),
Tylenol 1g PO.
Either Valium 5mg PO,
Gabapentin 600mg PO

127

29yo male with acute low back pain, no red flags discharge


D/C with NSAIDS, Tylenol, muscle relaxant (Baclofen®, Flexeril®)
Consider trigger point injection Bupicicaine 5-7ml

128

40yo female, closed, non-displaced distal fibula fx.

Ketorolac 15mg IM, Tylenol 1g PO. Splint, D/C home w/ NSAID, Tylenol, RICE. May add #8-10 Vicodin/Norco

129

30yo male with flu/mild pneumonia, stable, pleuritic chest pain.

Ketorolc IM/IV + Tylenol 1g PO/IV.

D/C with NSAID, Tylenol, Tessalon Pearls (Benzonatate), not cough syrup*

130

50yo with dental abscess.

Dental block w/ Bupivicaine – local tx of pain good

Oral NSAID, Tylenol 1g; oral steroid (dexamethazone 8-10mg po)??.

D/C w/ NSAID, Tylenol
Tx related to time to dentist – may add #8-10 Vicodin/Norco

131

25yo female with large burn to right thigh.

25yo female with large burn to right thigh.

132

58yo male with gout left great toe.

NSAID PO/IM – Ibuprofen as good as Indomethacin
Colchicine (1.2mg po) + steroids if severe (can give in ED)

133

68yo with chronic knee pain from osteoarthritis.

Intra-articular injection Bupivicaine (Intra-articular steroids??)

Or oral NSAID** (no Ketorolac d/t age, renal risk)

Short course NSAIDS**, Tylenol, self-care, Ortho f/u

134

23yo with strep throat, pain with swallowing.

NSAID plus Tylenol with Codeine Elixir 15ml in ED

Steroid IM: 6-10mg Dexamethazone + Abx

Home w/ NSAIDS/APAP