For 'newer' medics and students... abdominal pain management

[RRTMedic]

What are your thoughts on administering analgesics to patients experiencing abdominal pain? Is there evidence to support withholding narcotics to someone in obvious pain? How has technology changed this? I know my answer, but I'm curious what they're teaching in school nowadays.

 

[RocKetamine]

Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.

 

[VentMonkey]

Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.

...

 

[StCEMT]

I would give it assuming I didn't find anything that contraindicated it or made me question it. I don't buy the "they can't assess in the ER" deal. Otherwise, heck yea I will give some pain meds. Now I have heard that while I was in medic school, but that is a belief I chose to disregard once I was no longer under a preceptors oversight. Actually, one of the some kind of chiefs where I did my school advocated us not being stingy and treating pain appropriately if the patient is hurting. So I would say it still exists, but the idea is changing.

 

[medichopeful]

I'm still in medic school, but once I finish and start functioning as a paramedic, unless my protocols forbid it, I see no reason to withhold analgesia for abdominal pain.

Honestly, I don't remember what they taught me in medic school (maybe I just ignored that part if I didn't agree with it). But through my experience working in the hospital, I can say that analgesics are not going to effect imaging results, or lab results. Dulling the pain but not snowing the patient will also allow an assessment to continue. Or, better yet, just do the assessment well then give the pain meds.

TL;DR: no reason to withhold them except for outdated practices and laziness.

 

[Tigger]

The whole "interfering with the ED's assessment thing" seems to be pretty debunked. I'm not going to intentionally snow someone, but if you're hurting, I am going to try and put a dent in that. I might hold off on the Ketamine if I don't think I can adequately coach you, but really there are few contraindications to fentanyl and morphine here. Maybe be vary of opioid induced constipation, but aside from that...

 

[DesertMedic66]

My medic school stressed if they are in pain then medicate them. We viewed pain as an additional vital sign.

My company does not care how much pain meds we give or what we give it for.

Our company limits us to just isolated extremity trauma. We have to contact the base hospital for non-extremity pain or non traumatic pain. It really depends on the Doctor on duty that day. Some will let us while others won't.

 

[harold1981]

The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.

 

[ParamedicStudent]

Can someone please explain to me why abd pain is a contraindication for analgesics?

 

[RRTMedic]

Can someone please explain to me why abd pain is a contraindication for analgesics?

Hey so there is a adage traditional in the EMS world that patient's with abdominal pain should not receive analgesia because it may "mask" the assessment made by the physician. I.e. once the patient gets to the hospital they are no longer in any pain, soooo lets send them home. Not a good idea, right?

Although this practice may have had some merit back in the day, there is a number of pieces of literature that state there is no evidence for withholding analgesia in patients with abdominal pain.

A lot of this change in practice is due to the fact that our imaging technology has become some diagnostic and advanced. The use of ultrasound guided assessment has truly changed emergency medicine and done away with ideas such as withholding analgesia for the sake of a physical assessment.

 

[RRTMedic]

The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.

I'm always worried when we consider ketamine solely for pain management... call me what you may, it just seems like there are a number of mental side effects that are unnecessary that go along with ketamine.

My experience with ketamine has been with patient's not tolerating bipap in the ER... give some ketamine and viola, you can ventilate them.

Anyone have more anecdotal evidence or success with ketamine solely as an analgesic? Did it impair the patient's ability to answer questions and interview well?

 

[RRTMedic]

Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.

**sigh** Just another example of how EMS education is 20 years behind...

 

[EpiEMS]

So the initial idea of not providing analgesia for the acute abdominal pain patient (apparently) dates back to 1921, courtesy of Dr. Zachary Cope, who harangued against it. Now, that may have been reasonable then, but even as late as 1987, a later edition of Dr. Cope's book said "though it may appear crude, it is really prudent to withhold morphine until a reasonable diagnosis has been made and a plan of action formulated".

Now, we know (much) better and have better diagnostic modalities...thus we can fairly comfortably say things like: "The use of opioid analgesics in the therapeutic diagnosis of patients with [Acute Abdominal Pain] does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment."

 

[DrParasite]

A lot of this change in practice is due to the fact that our imaging technology has become some diagnostic and advanced. The use of ultrasound guided assessment has truly changed emergency medicine and done away with ideas such as withholding analgesia for the sake of a physical assessment.

so now the ER doctors aren't performing a subjective assessment to treat the patient (like EMS does), they are performing imaging and lab values to objectively identiy any issues.... an interesting change in assessment and treatment strategies

 

[medichopeful]

The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.

I'm reading this on my phone and read this as "1G of IV Fentanyl" because of the way the lines were laid out. That would fix the issue!

On a more serious note, what country do you work in that you're doing those meds for pain?

 

[NysEms2117]

if it helps at all when i went to the hospital recently (within the past month), with severe debilitating left sided abdominal/radiating to lower back pain, i got pain meds. fentanyl to be exact, idk the dose, seemed low, just enough to take the "debilitating" factor out.

 

[medichopeful]

I'm always worried when we consider ketamine solely for pain management... call me what you may, it just seems like there are a number of mental side effects that are unnecessary that go along with ketamine.

My experience with ketamine has been with patient's not tolerating bipap in the ER... give some ketamine and viola, you can ventilate them.

Anyone have more anecdotal evidence or success with ketamine solely as an analgesic? Did it impair the patient's ability to answer questions and interview well?

I've given low doses of Ketamine in the past (around 10mg if I remember correctly) for migraines and it hasn't had much of an effect on their mental status.

 

[EpiEMS]

Our company limits us to just isolated extremity trauma. We have to contact the base hospital for non-extremity pain or non traumatic pain.

Is this a California quirk or a company decision?

 

[SpecialK]

So tell me, is there any contraindication to treating pain? No! There may be contraindications to specific medicines, but not to pain in general.

Have you ever tried to examine somebody who is in writhing agony? I have, and it's pretty bloody hard let me tell you. That's just examining them, let alone getting them onto the bed and down to the ambulance and drive them to hospital.

When I first started it was entonox and morphine, and ketamine had just come out; so pretty limited. I can remember morphine plus midazolam because not everybody had ketamine. I don't even think there was paracetamol. Now there's almost no reason pain can't be treated between entonox, methoxyflurane, paracetamol, ibuprofen, tramadol, morphine, fentanyl, ketamine, and lignocaine blocks.

"Don't treat abdominal pain" is a relic from the decades before high-tech imaging such as CT scanning when surgeons had to rely more upon physical examination. As an aside, my ability to examine abdomens is absolutely terrible. I can inspect, auscultate and have a push in the 9 quadrants and have a general idea of what is in each but I'm really not very good. Most patients with abdominal pain "bad" enough to ring ambo gets taken to ED where they'll probably get thrown through the CT scanner (maybe) so nothing I really do is going to be clinically significant in terms of a diagnosis.

 

[RRTMedic]

so now the ER doctors aren't performing a subjective assessment to treat the patient (like EMS does), they are performing imaging and lab values to objectively identiy any issues.... an interesting change in assessment and treatment strategies

Sadly, it seems that a blanket of lab values and radiology trumps patient history and interview