Pain relief and Alcohol intoxication

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philslat

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Thoughts and experience with managing pain in a drunk patient with severe pain from a traumatic injury.
Morphine contraindicated in acute alcohol intoxication. Is IN fentanyl ok
This patient in question has a dislocated shoulder and a head laceration from a fall from standing, GCS 15 and vital signs all within normal limits.
There was an LOC
 
philslat said:
Thoughts and experience with managing pain in a drunk patient with severe pain from a traumatic injury.
Morphine contraindicated in acute alcohol intoxication. Is IN fentanyl ok
This patient in question has a dislocated shoulder and a head laceration from a fall from standing, GCS 15 and vital signs all within normal limits.
There was an LOC
Click to expand...

Any CNS depressant, opiate or otherwise, will act synergistically with alcohol (think Jimi Hendrix). There really isn't anyway to predict how a patient like this will respond to any narcotic. Not knowing any of the critical particulars, I'd proceed with extreme caution in terms of narcotic if at all.
 
Just be cautious with your dosing. We give opiates to people with ETOH on board all the time.


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I like small doses of Ketamine for this situation exactly.
 
If I felt the patient was reasonably calm and directable, I would move right to Ketamine. If not I'd try small doses of fent.

Had a very drunk patient of large stature stick his fingers into a running lawn mower this summer. The first 100 of fent did nothing, the second 200 nearly resulted in the use of a BVM. Silly intern me should have just used Ketamine.
 
Depends on how drunk. Basically i'd consider opiates but definitely smaller doses cautiously. Ketamine if needed.
 
An alternative is Ketoralac. It's not a CNS depressant and your primary concern is kidney function, not liver impairment.
 
Unless youre in the states where entonox isn't an option and hardly anyone has ketorolac ;) I do wish I had those options though
 
I wouldn't do IN fentynal in this situation. I would want a line in case I needed it. IV only
 
CWATT said:
An alternative is Ketoralac. It's not a CNS depressant and your primary concern is kidney function, not liver impairment.
Click to expand...
Ketoralac isn't an alternative to IV narcs. If you are looking at someone with a dislocated shoulder, one of the most painful isolated injuries out there (at least for the first time), and thinking "I know... this person could use some Advil!" Well... crap! Because Toradol is no more effective than 800mg of ibuprofen!

If your patient needs powerful analgesics in an emergency situation, don't piss in the wind with an NSAID. Do hook them up with 800mg ibuprofen after the reduction.

And I agree with @Parameduck no IN. IN is too unpredictable and we need to titrate in a patient like this if giving opiates and that means IV and fentanyl is the call for the short halflife (unless you are finding Vit K suitable). Just be ready to bag, and I'd throw EtCO2 on them for sure because that is your early warning radar.
 
Summit said:
Ketoralac isn't an alternative to IV narcs. If you are looking at someone with a dislocated shoulder, one of the most painful isolated injuries out there (at least for the first time), and thinking "I know... this person could use some Advil!" Well... crap! Because Toradol is no more effective than 800mg of ibuprofen!
Click to expand...
Source?
 
I'd agree with the others in that Ketamine would likely be your best option if you're worried about further respiratory depression. If the patient's vitals and mental status are within normal limits I'd likely try an opiate first.

Maybe it's your agency policy but per the FDA morphine is only contraindicated in patients with "respiratory depression in the absence of resuscitative equipment".
 
Summit said:
Ketoralac isn't an alternative to IV narcs. If you are looking at someone with a dislocated shoulder, one of the most painful isolated injuries out there (at least for the first time), and thinking "I know... this person could use some Advil!" Well... crap! Because Toradol is no more effective than 800mg of ibuprofen!
Click to expand...

I've made this point before when people bring up ketorolac as an option for prehospital analgesia. Ketorolac's only role in severe pain is as an adjunct to more potent drugs. And in the EMS setting, where movement and anxiety are often a component, a little more opioid probably works better than ketorolac. If the pain is mild-to moderate, PO is just as good, and cheaper, and doesn't require a parenteral injection.

Another thing to keep in mind is that ketorolac has many precautions and relative contraindications. In almost any sick patient you can probably find at least one reason to think twice about using ketorolac.

So, there are reasons why ketorolac has never really caught on in EMS.
 
I think thjnl the only reason I have given toradol in the prehospital setting was if they were stable and had a positive Murphy's sign. It was my first line for those patients along with zofran followed up by Dilaudid or fentanyl if they still were coming off the cot.

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We use it almost exclusively for renal calculi. I've never used it for anything else prehospital, but almost everyone got a slug at the Urgent care.
 
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