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

[Nova1300]

If anyone ever happens to pick me up and I neeed pre-hospital analgesia, there are only 2 things I want you to give me:

1. Ketamine in 20 mg increments until I'm comfortable.
Or...
2. A penthrox inhaler


Unfortunately, those are both hard to come by in the US EMS world.
.

 

[ERDoc]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070812/

 

[StCEMT]

If anyone ever happens to pick me up and I neeed pre-hospital analgesia, there are only 2 things I want you to give me:

1. Ketamine in 20 mg increments until I'm comfortable.
Or...
2. A penthrox inhaler


Unfortunately, those are both hard to come by in the US EMS world.
.

Come to St. Louis, I'll get ya that special k.

 

[SpecialK]

Penthrox (penthrane) aka methoxyflurane is very common in Australia so much so they've withdrawn entonox. We still have entonox but also have MOF for an alternate when you can't give somebody entonox such as suspected bowel obstruction.

I haven't used it, truth be told I can't even remember how to do it, it's fiddly and painful to put together.

And in case you are wondering' "methoxyflurane" is a combination of parts of the IUPAC name: 2,2-dichloro-1,1-difluoro-1-methoxyethane.

 

[VentMonkey]

Penthrox (penthrane) aka methoxyflurane is very common in Australia so much so they've withdrawn entonox. We still have entonox but also have MOF for an alternate when you can't give somebody entonox such as suspected bowel obstruction.

I haven't used it, truth be told I can't even remember how to do it, it's fiddly and painful to put together.

And in case you are wondering' "methoxyflurane" is a combination of parts of the IUPAC name: 2,2-dichloro-1,1-difluoro-1-methoxyethane.

Or as my wife envious-restricted-American-paramedic self likes to call it..."The Magic Whistle".

 

[SpecialK]

Yes it's also referred to as "the green whistle" because the little inlet at the top can be covered with a finger is stronger analgesia is required; i.e. you are not also inspiring oxygen with the MOF.

I have never used it as I said, but we use entonox like it's going out of fashion and having MOF means even for people who can't have entonox (for whatever reason) they still have something to breathe for pain relief if they a) do not need IV pain relief, or b) the ambulance doesn't have a Paramedic or ICP onboard.

As an aside, now that oral tramadol has been introduced for EMTs the combination of paracetamol, ibuprofen and tramadol in addition to entonox or MOF means not only better pain relief options for EMTs (and the patient at the end of the day!) but also I would imagine sometimes no longer need to call for backup which is great because most ambulances with only an EMT (and either an FR/EMA or another EMT) are out in the country where backup can be a decent while away.

 

[EpiEMS]

Having entonox would be a huge, easy value add for us...but we've got nothing. Isolated extremity fracture hurts? Well, I either have to call a medic or drive - that's all I've got for ya (plus splinting, cryotherapy...).

 

[SpecialK]

So get entonox?

 

[EpiEMS]

So get entonox?

Would if I could - it's not the kind of thing that's going to be quickly implemented in my neck of the woods, especially with our profusion of medics and conservative administrations.

 

[Handsome Robb]

So get entonox?

The reason a lot of places stopped using nitronox here is because no one was manufacturing a mixer that was FDA approved for a long time.

My old service had it but we couldn't ever get parts to fix our equipment.


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[NomadicMedic]

So get entonox?

Curious how you track potential abuse?

 

[MackTheKnife]

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.

You give analgesics for pain. Even in Abdominal Compartment Syndrome.

 

[RocketMedic]

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.

I've noticed a lot of that. It's very disappointing- especially how people think that these people think that everyone with abdominal pain is "faking it" due to assumptions based on locale and demographics...

 

[SpecialK]

Curious how you track potential abuse?

We don't. Honestly, the idea somebody would mischievously huff entonox is pretty far out there no?

I can't think of a way you could do but I can't see why you'd need to.

Morphine, fentanyl, and ketamine are tracked and audited but nothing else because don't need to.

 

[MackTheKnife]

Another point- analgesics do not necessarily mask an evaluation by the ER provider. A dose of opiods is not going to totally shut down peristalsis ot abdominal sounds. Think of the various abdominal etiologies and their associated bowel sounds (hyopactive, hyperactive, etc.) And someone with rebound tenderness with a hot appy ain't gonna change the dx if they got some joy juice.

 

[SpecialK]

I remember being taught to stop testing for "rebound tenderness" years ago no? .....

 

[StCEMT]

I remember being taught to stop testing for "rebound tenderness" years ago no? .....

I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.

 

[Handsome Robb]

I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.

Or markle's sign. That's an easy one too.


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[NomadicMedic]

Or markle's sign. That's an easy one too.


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I was just going to say that! Or, the hop test.

 

[StCEMT]

Or markle's sign. That's an easy one too.


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Huh, I just learned something new. Good to know.