Another Pain Management Thread (Multi-System Trauma)

[MissMedicCMO]

interesting....didnt know that but im a newer medic too. thats how we were taught in class also. Even our flight medics in surrounding areas use it. But Im in Indiana and Ive heard that Indiana is behind the times as far as ems.

 

[rhan101277]

How about morphine administration. Say it is someone that has something like a dislocated knee. Who knows how long he will wait for pain meds at the ER. Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?

 

[triemal04]

How about morphine administration. Say it is someone that has something like a dislocated knee. Who knows how long he will wait for pain meds at the ER. Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?

Or you could just give it IVP and then reduce the dislocation. Much more easy and beneficial in that situation.

Otherwise, initially your goal is to reduce the pt's pain...that will be accomplished much faster if the drug is given intravenously vs IM. Your concern is valid, but, (and this will depend on your local hospitals) if you're giving morphine as your analgesic, then if you give a dose as you arrive at the hospital, they'll most likely be ok. But, if where you go has a history of extended waiting times for in-hospital care, then it might be more appropriate to give a final dose IM, as long as the pt needed it and could tolerate it.

 

[Melclin]

Woah, lignocaine for ICP management? Is that in the same textbook as leeches for a fever and per rectal tobacco smoke during cardiac arrest? I kid I kid, but that's some old stuff there.

 

[Scott33]

There are studies that show [Lidocaine] is of no use in decreasing ICP.

I have never heard of Lidocaine decreasing ICP - only minimizing any further increase in it.

 

[AKidd]

The biggest issue with ketamine, although uncommon in lower doses not used for sedation, is the "emergence reaction". This may well mask or skew neurological status assessment, but withholding all types of pain management in polytrauma is questionable in the best of situations.

Definitely an interesting thread.

 

[Akulahawk]

How about morphine administration. Say it is someone that has something like a dislocated knee. Who knows how long he will wait for pain meds at the ER. Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?

Or you could just give it IVP and then reduce the dislocation. Much more easy and beneficial in that situation.

Otherwise, initially your goal is to reduce the pt's pain...that will be accomplished much faster if the drug is given intravenously vs IM. Your concern is valid, but, (and this will depend on your local hospitals) if you're giving morphine as your analgesic, then if you give a dose as you arrive at the hospital, they'll most likely be ok. But, if where you go has a history of extended waiting times for in-hospital care, then it might be more appropriate to give a final dose IM, as long as the pt needed it and could tolerate it.

If you wait too long after the patella dislocates, you're going to have to give more than morphine to reduce it. Think muscle relaxant... Remember, the quads will contract in an attempt to splint the injury... Once that occurs, a pretty significant amount of force will be required to reduce that dislocation, as you'd generally have to push the patella back over the lateral femoral condyle, against some pretty heavily contracted quads.

In my experience, EMS doesn't arrive on scene quickly enough and isn't trained/authorized to reduce these dislocations.

 

[triemal04]

If you wait too long after the patella dislocates, you're going to have to give more than morphine to reduce it. Think muscle relaxant... Remember, the quads will contract in an attempt to splint the injury... Once that occurs, a pretty significant amount of force will be required to reduce that dislocation, as you'd generally have to push the patella back over the lateral femoral condyle, against some pretty heavily contracted quads.

In my experience, EMS doesn't arrive on scene quickly enough and isn't trained/authorized to reduce these dislocations.

Not necessarily and never that I've seen. I'm suppose it could be possible, but given the position that the leg end's up in with (lateral) patellar dislocations, that would take a long time, and it's not really necessary to move the upper leg to reduce it, though it does make it easier. A more likely issue would be swelling, but even that will take long enough that a field reduction is still usually possible.

The biggest complications that would prevent a field reduction are fractures of either the patella itself, or the epicondyles on the femur/tibia. Beyond that the risks are damage to the surrounding tissue/ligaments (which a reduction will help) and the small possibility of bone fragments being left in the knee.

Luckily for the people that this happens to it often self-reduces, and, as the knee isn't like most other joints in the body, a reduction in the field after appropriate pain meds is still very possible.

http://www.athleticadvisor.com/Injuries/LE/Knee/Patella/patella_dislocations.htm
http://emedicine.medscape.com/article/90068-overview
http://wildernessmedicinenewsletter.wordpress.com/2006/11/11/reducing-a-dislocated-patella/

 

[Akulahawk]

The athletic advisor site has some pretty good basic info about patellar dislocations. However, most of the patellar dislocations I've ever heard about occur because of an impact or a VERY high Q angle. Those dislocations that I've heard about from non-contact events would generally have a previous history of dislocations.

Many dislocations do spontaneously reduce. For those I'd have to reduce manually, I'd be more worried about reducing those that occurred due to an impact, as this increases the likelihood of a lateral condylar fracture. Reduction of the dislocation without pain meds is most possible within minutes after the dislocation. As swelling and muscle spasm begins, it will become more and more unlikely to reduce the dislocation without meds.

The emedscape article is actually pretty good for discussing the factors and some evaluation techniques. It should be noted that it does NOT get into evaluating patellar dislocation vs ACL/MCL/Medial Meniscus injuries, that can also occur with a similar mechanism stated in the first article.

The wilderness medicine article does state kind of how to do it, but it leaves out a step... and that is controlling the patella as it begins to reduce. You do NOT want it to pop back over the lateral condyle in an uncontrolled manner, if you can help it.

Once muscle spams get going, it's not going to be easy to straighten the leg and therefore, it won't be an easy reduction. It'll get worse once any significant swelling occurs as that won't allow the joint to completely straighten. Combine that with muscle spasming... and you might begin to see why medication assistance (muscle relaxers specifically) become useful in reducing these.

Patellar Dislocations are pretty far from multi-system trauma though. If, by chance, I found a trauma patient that also happened to have a patellar dislocation, chances are, I'm not going to worry about reducing it. I've got other things I need to get to first...

 

[LondonMedic]

I've used all sorts of things for analgesia from proper anaesthesia through to paracetamol but I've found that one of the easiest and most effective is good splinting/traction and good positioning for transport.

 

[FLEMTP]

Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside.

Personally.. for multisystem trauma pain management I like to use .3mg/kg of Etomidate, and then 2mg/kg of Succs I kid i kid...

Seriously though, we carry fentanyl and morphine for pain management. My personal drug of choice for pain, especially multisystem trauma type pain is Fentanyl. We can give as much as we see fit provided it doesnt cause the patient to become obtunded. Our protocol states 2mcg/kg but then again we can do pretty much anything we need to outside of the protocol provided we can justify it.

 

[BLSBoy]

Seriously though, we carry fentanyl and morphine for pain management. My personal drug of choice for pain, especially multisystem trauma type pain is Fentanyl. We can give as much as we see fit provided it doesnt cause the patient to become obtunded. Our protocol states 2mcg/kg but then again we can do pretty much anything we need to outside of the protocol provided we can justify it.

Um, are you hiring?

 

[FLEMTP]

haha i wish we were.. we just hired 12.. and when we do open up applications... we get approx 600 applications per open position.

You're welcome to look us up though!

http://www.lee-ems.com/ems/default.htm

 

[LondonMedic]

Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside.

London Ambulance carry and use quite a lot of it, it's also pretty popular in the ER setting over here for rapid-onset, short-duration analgesia for moderate to severe musculo-skeletal pain.

 

[MrBrown]

Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside.

Yes, we carry nox (and methyoxyflurane) as basic level inhalation analgesia and they work very well.

Considering it was Wells who first use N20 in 1844 wow, what, 160+ years later it seems the US hasn't caught on that its good for crews who are unable to give intravenous analgesia as upposed to what you have now which is um, nothing!

 

[LondonMedic]

Considering it was Wells who first use N20 in 1844 wow, what, 160+ years later it seems the US hasn't caught on that its good for crews who are unable to give intravenous analgesia as upposed to what you have now which is um, nothing!

I'd argue that it's also a good tool to be used instead of, or to complement, IV opioids and should be part of ALS kit.

 

[FLEMTP]

Seems to be more the norm to use NOX overseas.. not so common in the states...

 

[VentMedic]

Seems to be more the norm to use NOX overseas.. not so common in the states...

NOX? That just refers to a broad category of nitrogen oxides and is generally used in reference to Nitrogren Dioxide (NO2) by the EPA. NO2 is not a gas that is desirable. It is also one of the monitoring alarms when delivering NO (nitric oxide).


N2O is nitrous oxide.

NO is nitric oxide which you will see on specialty transport or with some home care patients who have pulmonary hyptension.

N2 is nitrogen which you may see on specialty transport doing subambient therapy for congenital heart defects.

And then you also have the many different diving mixtures which EMS providers along the coasts of Florida should be familiar with.

Thus, watch your terminology since I do know there are a lot of medical and dive gases used in your area. It is very easy to confuse the terms and confusing the gases might not be beneficial.

 

[FLEMTP]

NOX? That just refers to a broad category of nitrogen oxides and is generally used in reference to Nitrogren Dioxide (NO2) by the EPA. NO2 is not a gas that is desirable. It is also one of the monitoring alarms when delivering NO (nitric oxide).


N2O is nitrous oxide.

NO is nitric oxide which you will see on specialty transport or with some home care patients who have pulmonary hyptension.

N2 is nitrogen which you may see on specialty transport doing subambient therapy for congenital heart defects.

And then you also have the many different diving mixtures which EMS providers along the coasts of Florida should be familiar with.

Thus, watch your terminology since I do know there are a lot of medical and dive gases used in your area. It is very easy to confuse the terms and confusing the gases might not be beneficial.

yeah.... um.. ok.. cuz any of that matters in an online forum...Im well aware of the different gasses.. i was attempting to make a quick reply from my blackberry.. but hey.. if you get off on that kinda stuff..then hey.. have at it...

 

[VentMedic]

yeah.... um.. ok.. cuz any of that matters in an online forum...Im well aware of the different gasses.. i was attempting to make a quick reply from my blackberry.. but hey.. if you get off on that kinda stuff..then hey.. have at it...

Since some of the specialty trucks in Florida (and other states) can carry 4 or 5 different medical gases it would be wise to know the difference. There are also several members of this forum that are just starting out and may not be aware of some of these gases when they are asked to help transport a specialty team. If you also look around at some of the home care patients you come into contact with, you may find that tank a might look like "O2" but isn't Oxygen.

When you are working with medical gases, DO NOT EVER ASSUME you know what is in that tank especially if you do not know the terminology.

I guess we now know why some of the medical gases aren't widely used in EMS in the U.S.