Pain Management + unresponsive patient

[Akulahawk]

here's my question for you (or anyone else for that matter)

What would you with a combative trauma pt with low-ish bp that is combative? Morphine or valium?

I would see if I can find an underlying reason for the patient being combative and attempt to medicate for that instead of simply sedating because the patient is combative.

I wouldn't limit my choices to just those 2 agents, if I had any choice in the matter. In particular, I would expect that some of the agents that are already listed in this thread would be somewhat decent choices for use in that particular situation, that being attempting to control a combative patient with a low-ish blood pressure who is in severe pain.

If I had to limit my choices to morphine and/or Valium, I would possibly consider using Benadryl along with the morphine in an attempt to limit the hypotension that morphine can cause because it does result in a histamine release. I would then consider probably using some small amount of Valium, as it would be potentiated by the morphine and thus hopefully requiring only smaller amounts of it to provide the desired results without too much drop in blood pressure.

Otherwise, I would very much expect that there are better agents than those two that could be used to medicate a patient that is in great pain happens to be also combative. Of course your other ultimate option would be to RSI the patient… That, of course, has its own risks… Some very serious ones, and I would not consider performing at RSI on a patient simply because he or she is combative.

 

[Carlos Danger]

Why do you say opiates rather than benzos?

Because you want to treat the cause of the combativeness to the best of your ability.

If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.

here's my question for you (or anyone else for that matter)

What would you with a combative trauma pt with low-ish bp that is combative? Morphine or valium?

What do you mean by "combative"? Trying to beat you with a d-tank and jump out of a moving ambulance, or just anxious and not as cooperative as you'd like?

Do you mean after intubation? Or as a sedative for acute delirium secondary to a head injury or hypoxia?

For the former, a benzo should always be chosen over an opiate for sedation, and valium would probably have less effect on BP anyway. You can give some valium and some IVF and then work in a some morphine once their BP is stabilized some.

For the latter scenario, both morphine and valium are poor choices because of their long onset and propensity for hypotension in large doses. I would try to avoid either. If you absolutely had to give something because the patient was seriously endangering himself and others, I'd do probably 20 of diazepam IV or IM. The best drug for this scenario is probably ketamine. Etomidate works well, too. Something with some neuroleptic effects like haloperidol or promethazine mixed with some midazolam is an excellent combo to dart a combative patient.

protocols deny us use of opiates if pt has head trauma (all we got is morphine, unfortunatly).

It sounds like your protocols are in need of some serious updating. There is no reason to withold analgesia from a patient with head trauma. In fact, prior to RSI, fentanyl is a great pre-treatment.

Also, there are much better drugs than morphine and valium for prehospital use. Fentanyl and midazolam both have faster onset and shorter duration, and fentanyl has fewer hemodynamic effects than morphine. Ketamine is great to have, as well.

 

[Wheel]

Because you want to treat the cause of the combativeness to the best of your ability.

If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.



What do you mean by "combative"? Trying to beat you with a d-tank and jump out of a moving ambulance, or just anxious and not as cooperative as you'd like?

Do you mean after intubation? Or as a sedative for acute delirium secondary to a head injury or hypoxia?

For the former, a benzo should always be chosen over an opiate for sedation, and valium would probably have less effect on BP anyway. You can give some valium and some IVF and then work in a some morphine once their BP is stabilized some.

For the latter scenario, both morphine and valium are poor choices because of their long onset and propensity for hypotension in large doses. I would try to avoid either. If you absolutely had to give something because the patient was seriously endangering himself and others, I'd do probably 20 of diazepam IV or IM. The best drug for this scenario is probably ketamine. Etomidate works well, too. Something with some neuroleptic effects like haloperidol or promethazine mixed with some midazolam is an excellent combo to dart a combative patient.



It sounds like your protocols are in need of some serious updating. There is no reason to withold analgesia from a patient with head trauma. In fact, prior to RSI, fentanyl is a great pre-treatment.

Also, there are much better drugs than morphine and valium for prehospital use. Fentanyl and midazolam both have faster onset and shorter duration, and fentanyl has fewer hemodynamic effects than morphine. Ketamine is great to have, as well.

This is true, but there are many uneducated providers running around scared of fentanyl. I rarely see it used in my service, despite a better side effect profile. Everyone considers it "the big guns," as if equivalent doses don't exist.

 

[Carlos Danger]

This is true, but there are many uneducated providers running around scared of fentanyl. I rarely see it used in my service, despite a better side effect profile. Everyone considers it "the big guns," as if equivalent doses don't exist.

In a patient who is very stable and just in a lot of pain from an isolated extremity fracture or something like that, morphine is a good drug, especially when used in conjunction with non-opioids.

But in a sick patient with actual or potential hemodynamic compromise, I'm a lot more comfortable giving moderate to large doses of fentanyl than I am equivalent doses of morphine. Fentanyl can also be used as an adjunct in various ways that morphine cannot, or at least not as easily.

IMO, fentanyl is more useful, more predictable, easier to give, and for those reasons safer and more appropriate for prehospital use than morphine. Especially by those who don't necessarily know a lot about the drugs they are giving.

 

[jwk]

No perception of pain = no pain management. And if you have a comatose patient, there is also no need to treat them for "pain" simply because some protocol says you should because they have an ETT in place.

 

[Trashtruck]

No perception of pain = no pain management. And if you have a comatose patient, there is also no need to treat them for "pain" simply because some protocol says you should because they have an ETT in place.

Perfectly stated.
Succinct with no jargon.

 

[Akulahawk]

Because you want to treat the cause of the combativeness to the best of your ability.

If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.



What do you mean by "combative"? Trying to beat you with a d-tank and jump out of a moving ambulance, or just anxious and not as cooperative as you'd like?

Do you mean after intubation? Or as a sedative for acute delirium secondary to a head injury or hypoxia?

For the former, a benzo should always be chosen over an opiate for sedation, and valium would probably have less effect on BP anyway. You can give some valium and some IVF and then work in a some morphine once their BP is stabilized some.

For the latter scenario, both morphine and valium are poor choices because of their long onset and propensity for hypotension in large doses. I would try to avoid either. If you absolutely had to give something because the patient was seriously endangering himself and others, I'd do probably 20 of diazepam IV or IM. The best drug for this scenario is probably ketamine. Etomidate works well, too. Something with some neuroleptic effects like haloperidol or promethazine mixed with some midazolam is an excellent combo to dart a combative patient.



It sounds like your protocols are in need of some serious updating. There is no reason to withold analgesia from a patient with head trauma. In fact, prior to RSI, fentanyl is a great pre-treatment.

Also, there are much better drugs than morphine and valium for prehospital use. Fentanyl and midazolam both have faster onset and shorter duration, and fentanyl has fewer hemodynamic effects than morphine. Ketamine is great to have, as well.

This is actually closer to the answer that I wanted to give but didn't have a whole lot of time to write it. Morphine and Valium wouldn't be my first choice of drugs to use...because as you said, there are better drugs. It's too bad we never had access to them out here, and probably won't any time soon.

 

[Melclin]

Can't a bloke have a beer without getting drawn into a conversation about sedating head injured patients?

here's my question for you (or anyone else for that matter)

What would you with a combative trauma pt with low-ish bp that is combative? Morphine or valium?

My reasoning in regards to the opiates over benzos is, as others have correctly stated, that in general its a good idea to treat the actual problem rather than cover it up.

The idea is that you're actually treating their pain rather than just sedating them beyond the point of being able to experience it. For a perfectly compliant patient with an isolated femur fracture, we don't sit there and give midaz until they are so unconscious that they are no longer capable of experiencing pain. That would be absurd and dangerous. We treat their pain directly, such that they can be sitting there talking to us but still be relatively comfortable. This means they get relatively less of the drug in question which hopefully equals less of an affect on conscious state, haemodynamics etc. Why should it be significantly different for a pt who also has a head injury. I would argue that it is more important for a patient with a head injury given the deleterious affects of hypotension, hypoventilation & hypoxia.

I would argue because it is more likely to actually treat the cause (or part there of) of their agitation and because we really can't say for sure that their head injury makes them incapable of experiencing pain, that the lower doses involved, relatively speaking, make this both a safer and more humane way of treating these patients. A much better way to effectively sedate to facilitate assessment/treatment/pre-oxygenation for RSI.

I have applied, and seen others apply, the same logic to combative ROSC patients, combative intellectually disabled patients (pain or frustration is almost always the cause of their combativeness in my experience), and also children who have had too much red cordial. A little fentanyl and they're happy to sit there and stare at you with a stupid grin while you prepare for whatever torturous procedure you have in mind.

If not fentanyl, I would still prefer morphine over diaz or midaz. The risk of hypotension is ridiculously overstated with opiates. The vast majority of patients I see have a return to normal BP (either up or down). That said, it is the kinds of patients we're talking about who are most at risk...the hypovolaemic kind. The problem is similar with benzos though and for the reasons stated, I'd still argue you're ganna get more bang for your buck (and therefore, less adverse reactions) with an opiate.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.

Absolutely....and RSI may shortly follow if appropriate. However, I don't know that I agree that the combativeness is rarely because of pain. Sure their head injury is a problem and they can be combative from that alone, but I strongly believe their is a subset of multi-trauma pt whose combativeness can be quelled with analgesia. My admittedly limited experience with even small amounts of morph or fent in these patients has been convincing and the idea overall is not mine alone...I was taught it by other far more senior Intensive Care paramedics who have considerable experience in the matter. I believe based on experience, the idea is even tentatively supported from an official point of view to facilitate preparation for RSI.

 

[Carlos Danger]

Absolutely....and RSI may shortly follow if appropriate. However, I don't know that I agree that the combativeness is rarely because of pain. Sure their head injury is a problem and they can be combative from that alone, but I strongly believe their is a subset of multi-trauma pt whose combativeness can be quelled with analgesia. My admittedly limited experience with even small amounts of morph or fent in these patients has been convincing and the idea overall is not mine alone...I was taught it by other far more senior Intensive Care paramedics who have considerable experience in the matter. I believe based on experience, the idea is even tentatively supported from an official point of view to facilitate preparation for RSI.

I wonder if our differing views aren't due to differing opinions on what constitutes "combativeness"?

Many, many times I've seen patients who were agitated, anxious, and somewhat uncooperative due to to pain. These patients often calm with analgesia.

But, I rarely (if ever) have encountered someone who was actually combative - violent and irrational - because of pain alone.

I certainly haven't seen everything, so perhaps it is more common than I realize. But it seems to me that a safer assumption is that increased ICP or some other organic problem is the cause of combativeness in a trauma patient.

 

[Melclin]

I wonder if our differing views aren't due to differing opinions on what constitutes "combativeness"?

Many, many times I've seen patients who were agitated, anxious, and somewhat uncooperative due to to pain. These patients often calm with analgesia.

But, I rarely (if ever) have encountered someone who was actually combative - violent and irrational - because of pain alone.

I certainly haven't seen everything, so perhaps it is more common than I realize. But it seems to me that a safer assumption is that increased ICP or some other organic problem is the cause of combativeness in a trauma patient.

Probably a slightly different picture of combativeness, yes. I was talking more along the lines of the first. The patient who pulls away from you when you try to take a BP, maybe groans some slurred obscenities at you, makes general, uncoordinated attempts to pull their IV, etc.

Why the safer assumption? I'm not saying we have to make a choice between elevated ICP and pain as the cause of agitation in a head injured multi-trauma patient. What I'm saying is that its worth considering the idea that it might be both. We assume its purely the head injury, but I'm saying its a good idea to consider that in the setting of that head injury and in their irrational state, the pain of their other traumatic injuries may exacerbate their combativeness. If you treat their pain, they may become more easy to deal with prior to RSI/transport to facility that can RSI them.

 

[jefftherealmccoy]

Because you want to treat the cause of the combativeness to the best of your ability.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.

What do you mean by "combative"? Trying to beat you with a d-tank and jump out of a moving ambulance, or just anxious and not as cooperative as you'd like?

Do you mean after intubation? Or as a sedative for acute delirium secondary to a head injury or hypoxia?

For the former, a benzo should always be chosen over an opiate for sedation, and valium would probably have less effect on BP anyway. You can give some valium and some IVF and then work in a some morphine once their BP is stabilized some.

For the latter scenario, both morphine and valium are poor choices because of their long onset and propensity for hypotension in large doses. I would try to avoid either. If you absolutely had to give something because the patient was seriously endangering himself and others, I'd do probably 20 of diazepam IV or IM. The best drug for this scenario is probably ketamine. Etomidate works well, too. Something with some neuroleptic effects like haloperidol or promethazine mixed with some midazolam is an excellent combo to dart a combative patient.

It sounds like your protocols are in need of some serious updating. There is no reason to withold analgesia from a patient with head trauma. In fact, prior to RSI, fentanyl is a great pre-treatment.

Also, there are much better drugs than morphine and valium for prehospital use. Fentanyl and midazolam both have faster onset and shorter duration, and fentanyl has fewer hemodynamic effects than morphine. Ketamine is great to have, as well.

Yes, our protocols need to be redone. I eagerly await the day that happens. We only carry valium and morphine. I wish to high hell that we carried fentanyl. I came from an agency that had it and I miss it so.

I had a pt that was bleeding out from a large head lac and his LOC went from helpful and hurting to swinging at us and trying to jump off the cot as his blood pressure dropped (no brain bleed on CT). We figured the feeling of impending doom set in and he just wanted to get out of there. We ended up pushing valium instead of fentanyl because of the contraindication of head injury (we even tried calling the ED and asking for fentanyl, which the doc denied).

The risk of hypotension is ridiculously overstated with opiates.
.

From what I've heard from the ED staff is that they prefer opiates over benzos because they can reverse the opiates with narcan. I've yet to see when benzos (valium and versed) have tanked a blood pressure, but I've seen a few times in my short career where opiates have. I know it's a possiblility with both, but is it truly more likely with benzos than opiates?

 

[Carlos Danger]

The risk of hypotension is ridiculously overstated with opiates.

From what I've heard from the ED staff is that they prefer opiates over benzos because they can reverse the opiates with narcan. I've yet to see when benzos (valium and versed) have tanked a blood pressure, but I've seen a few times in my short career where opiates have. I know it's a possiblility with both, but is it truly more likely with benzos than opiates?

I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression.

It won't happen with the 2-5 mg doses that are commonly used in EMS, but once you get very far north of 10mg or so - which is the kind of dose you need to have any real sedating affect on an agitated patient - you can drop the BP pretty significantly.

Versed can drop pressure too, if they are volume depleted and SNS-dependent.

I suppose if I had to reverse something, I'd rather reverse an opioid OD than a benzo OD, but I think it's best to use drugs the way they are meant. Sedative meds are for sedation, pain meds are for pain.

You'd need to give an awful lot of either drug to require reversal......

 

[MountainMedic]

EMCrit has some good stuff on this.

Delirium Tremens is perhaps best treated with repeated boluses of Valium, at 10 mg each dose (IVP). Striking, huh?

In my short career I've seen Fentanyl tank a pressure a few times, but every time the pt had something very clearly wrong with them that explained the tanking. We also tend to simplify how fentanyl acts on BP - it doesn't really work directly. Rather, it acts as a sympatholytic, and simply unwinds all those compensatory mechanisms that are hiding what's really going on. Since in most cases of exsanguinating trauma the benchmark MAP for survival is 65-80 (LOW), you're really unlikely to do any harm administering small doses of fentanyl. My 2 cents.

I've also seen MDs give it in cases of clear head injury (confirmed SAH), citing that its sympatholytic effects will drop ICP more than its opioidergic effects will raise it.

 

[jefftherealmccoy]

I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression.

I agree. I've seen opiates tank a blood pressure. I dropped a pt's BP substantially with just 2mg morphine. I have yet to see benzos tank a blood pressure. I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine. Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.

We use morphine specifically for hypertensive crisis, we don't use benzos. I took this as the drug that is more likely to cause a drop in BP to be morphine. Am I wrong?

 

[VFlutter]

I agree. I've seen opiates tank a blood pressure. I dropped a pt's BP substantially with just 2mg morphine. I have yet to see benzos tank a blood pressure. I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine. Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.

We use morphine specifically for hypertensive crisis, we don't use benzos. I took this as the drug that is more likely to cause a drop in BP to be morphine. Am I wrong?

:blink: What do you use morphine for during a hypertensive crisis? Headache?

Theoretically any drug with anxiolytic properties has the propensity to lower blood pressure.

 

[jefftherealmccoy]

We use morphine and nitro specifically for the hypotensive side effects. We also use it for pulmonary edema.

 

[VFlutter]

We use morphine and nitro specifically for the hypotensive side effects. We also use it for pulmonary edema.

no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.

 

[jefftherealmccoy]

no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.

True, but none in use in high-dee-hoe.

 

[jefftherealmccoy]

Or utah for that matter.

 

[Handsome Robb]

We use morphine and nitro specifically for the hypotensive side effects. We also use it for pulmonary edema.

Ever heard of rebound/reflex hypertension with nitro? Or seen it?

A little counterproductive for those patients in a hypertensive crisis.

We carry metoprolol but have no protocol for it except for STEMI patients who meet certain parameters. Medics call for orders for it though all the time and get them.