Pain Control

[Smash]

How is "what if" poor medicine? You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking. You have to ask yourself what if it is this and I do this. We can't make a 100% diagnosis in the field we aren't doctors.

If you can't form a good working diagnosis, you should probably fall back to treating symptoms. Like pain.

What benefit does unrelieved pain provide?

 

[johnrsemt]

My question is how many doctors that are not sure what the Abd or Head pain is from; don't do Emergent CT's? And how does taking pain away affect a CT? In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.

 

[zmedic]

All of my pub med and google search this eveing on it turned up stuff that basically said it demonstratively caused contraction.

Here is the original pubmed study I found and the rest were listed from it.

http://www.ncbi.nlm.nih.gov/pubmed/11316181

Did you read the abstract you cited?

"Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis."

So you can use morphine in this case.

The take home for you pre-hospital people is that you should use narcotic pain control for patient's with abdominal pain. Even if you think they have pacreatitis.

 

[usalsfyre]

My question is how many doctors that are not sure what the Abd or Head pain is from; don't do Emergent CT's? And how does taking pain away affect a CT? In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.

The problem is your typical physician knows why the patient is having abdominal pain well before the CT based on history and physical exam. They still order a CT due to medicolegal concerns, but usually could do without it. How many paramedics can say the same? For that matter, how many of you work with medics that can't locate the major abdominal organs?

 

[Veneficus]

Did you read the abstract you cited?

"Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.".

Yes, I did read the abstract, including the service that performed it.

But biliary tree obstruction has multiple causes, not just acute pancreatitis.

I also read a handful of others, and most of them refered to the context of ERCP where sphincter contraction was measured by manometry.

2 of them also listed medications, nalaxone and another one I don't remember off hand as it has been a busy day for me, that specifically relieve the effects of morphine, as was stated by an earlier poster.

 

[Veneficus]

My question is how many doctors that are not sure what the Abd or Head pain is from;

Hopefully only a few.

Ultrasound is also considerably cheaper.

don't do Emergent CT's?

CTing every is a waste of resources. Especially money.

And how does taking pain away affect a CT? In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.

It doesn't but many physicians I have met around the world don't advocate simply imaging everyone for everything.

CT is also not failsafe. It has limitations.

 

[rhan101277]

We only use toradol for abdominal pain. I am sure it is not as effective against pain as morphine. It is labeled as a NSAID with non-opioid analgesic properties. I have never tried to ask for morphine due to it not being in the protocol for abdominal pain.

 

[usalsfyre]

I have never tried to ask for morphine due to it not being in the protocol for abdominal pain.

Why?

 

[marineman]

Question for those of you carrying and using Toradol, do you have to verbally screen pregnancy first with females or can you just give it? In the hospital all but 1 doc make us wait until we have a neg preg test before we can give it. Granted in the field you don't have access to the tests but is a verbal screening mandatory?

 

[Aidey]

We used toradol when I worked in primary care, and we didn't do pregnancy tests first. I don't carry it now, but it is a pregnancy category C, which a number of medications are. I'm not seeing why toradol would be treated any differently.

 

[marineman]

I'm not sure what their big stink about it is either, hydromorphone is also pregnancy category C and they will give it all the time without a second thought.

 

[rhan101277]

Scenario:

GSW victim, small caliber, two wounds.

One would is located on the left leg, above knee, proximal to pelvis. It is through and through, PMS intact.

Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found. Large hematoma is noted on the lateral aspect of knee. You suspect popliteal artery has been nicked or damaged in some way.

Pt is AAOx3, GCS 15.

B/P 157/83; pulse 85; pt reports pain 20/10.

Under your protocols, can you give pain medication for this scenario with standing orders?

 

[Akulahawk]

Scenario:

GSW victim, small caliber, two wounds.

One would is located on the left leg, above knee, proximal to pelvis. It is through and through, PMS intact.

Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found. Large hematoma is noted on the lateral aspect of knee. You suspect popliteal artery has been nicked or damaged in some way.

Pt is AAOx3, GCS 15.

B/P 157/83; pulse 85; pt reports pain 20/10.

Under your protocols, can you give pain medication for this scenario with standing orders?

Sacramento County? In short: No. Now if the small caliber bullets were to have fractured the femur... then I could probably finagle the existing pain control in the "Trauma" protocol to do it... However, under standing orders as presented... I'd have to get a BHP order for the pain control.

 

[NomadicMedic]

Scenario:

GSW victim, small caliber, two wounds.

One would is located on the left leg, above knee, proximal to pelvis. It is through and through, PMS intact.

Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found. Large hematoma is noted on the lateral aspect of knee. You suspect popliteal artery has been nicked or damaged in some way.

Pt is AAOx3, GCS 15.

B/P 157/83; pulse 85; pt reports pain 20/10.

Under your protocols, can you give pain medication for this scenario with standing orders?

Yes. Up to 40mg of morphine or 500mcg of Fentanyl. And we do a LOT of GSWs over here.

However, in the city I'm close to the trauma center and usually don't have time to get pain meds on board before we're pulling up to the doors...

 

[rhan101277]

Yes. Up to 40mg of morphine or 500mcg of Fentanyl. And we do a LOT of GSWs over here.

However, in the city I'm close to the trauma center and usually don't have time to get pain meds on board before we're pulling up to the doors...

Yeah I called in for orders on this one. It was a 25 minute drive.

 

[MrBrown]

What can we give? Unlimited morphine + ketamine

 

[ah2388]

we use fentanyl in 50-100mcg increments titrated to relief of pain..and morphine up to 20mg...

 

[Blessed187]

Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2.

For some reason it reminds me of how I've had certain dentists hesitate to give me nitrous. The stuff will wear off before I get out of your chair, it reduces anxiety and pain for me, and I'm paying for it. But Mr. Dentist (or ER doc in the EMS equivalent) will happily leave me a script for Vicodin with my discharge paperwork that I could theoretically go home and take 20 of and sell the rest? That's what I don't understand. Granted, it's not the medic writing the script, and I've heard of dentists/doctors that are less friendly with the carry-out opiods, but honestly, I've yet to meet one.

Am I the only one that's noticed this phenomenon? I'll tell you when I ended up in the ED a few months ago for severe abd pain, I only got IV Zofran and fluids while curled up on the bed wincing in pain, but left with an RX for Vicodin to fill at Walgreen's.

I'm truly suprised the doc didn't give at least 5mg morphine for your abd px! That's crazy! I was in the ED two weeks ago with a typical migrain that had gone on for over 24hrs. Line in 5mg morphine, he did an LP just to make sure it was not anything serious than a migrane then he ordered another 5 mgs and I declined. He can in and asked why. I said I would much rather have 10 IM than 5 IV. As we all know the half life is all of 15 min of decent pain mgt. He agreed with me and ordered it along with 25 10/325 to go home with!!! Not even 5/325! I couldn't belive it. Even thou LP's cause REALLY bad head aches for up to two weeks afterwards. No wonder all the drug seekers are going into the ER every week!!!