Rheumatoid arthritis

[Epi-do]

I recently transported a patient with rheumatoid arthritis that was having an acute flare-up with significant breakthrough pain. It was isolated to his L hip and was severe enough he was unable to bear weight on his L leg.

I realized that RA is primarily an disease of inflammation a ultimately he needs something that is going to address that, along with some steriods to treat the flare-up.

The only thing we carry for pain management is fentanyl. I opted to give it, although I wasn't really expecting it to do much. After a total of 200 mcg, I hadn't really made any sort of change in the poor guy's pain. (from 10/10 to 9/10) Yes, I realize that he was in such severe pain that I was playing catchup. That aside, has anyone had any success with treating RA breakthrough pain with fentanyl?

 

[Dutch-EMT]

Well, what about a coldpack or something the patiënt has in his freezer for cooling. Let the patient lie down on the stretcher with the painfull leg above.
This in combination with a pain-drug?

Isn't there any med in your kit like a NSAID? Paracetamol/Perfalgan?

 

[Epi-do]

I really wish we had more options for pain relief! Alas, all we have is fentanyl. Granted, it does work great for some things. This just isn't one of them.

We did position him in a position of least discomfort. Compounding that problem though, was the fact that he has a bad back and while some positions would make his hip feel slightly better, it would agitate his back.

I just hate it when I know there are things that can help, but I just don't have access to them here.

 

[LondonMedic]

This is something I find incredibly frustrating.

Despite working in an ED we have a very limited analgesic formulary, outiside of the traditional drugs. In minors, we're essentially limited to paracetamol, co-dydramol, ibuprofen, tramadol, PR diclofenac and diazepam but have no access to PO/IM diclofenac, amitriptyline, gabapentin or any of the more obscure (but occasionally very useful) agents.

 

[Dutch-EMT]

This is something I find incredibly frustrating.

Despite working in an ED we have a very limited analgesic formulary, outiside of the traditional drugs. In minors, we're essentially limited to paracetamol, co-dydramol, ibuprofen, tramadol, PR diclofenac and diazepam but have no access to PO/IM diclofenac, amitriptyline, gabapentin or any of the more obscure (but occasionally very useful) agents.

Diclofenac i.m. works perfect at a 75milligram dose. this in combination with paracetamol can help.

We always try oral meds in our hospital:
We mostly use paracetamol 1000mg and diclofenac 50mg mostly together.
This in combination with tramadol 50mg or oxycodon 10mg.

Well, in the Netherlands we can buy paracetamol 500mg, diclofenackalium 25mg, ibuprofen 400mg and naproxen 275/550mg without doctors prescripton in our local stores. Isn't that strange?
Also meds like esomeprazol 20mg, pantoprazol 20mg and anti-emetics like domperidon can we buy without prescription.

Problems like gastric perforation and ulcus pepticum caused by NSAID's are regular seen problems we see in our hospitals because people use it to much when having headache, backpain, fever, etc...

But talking about our ambulances: They did have diclofenac 75mg i.m. in their med-kits untill the new protocolls came in 2007.
Now there is left: morphine, fentanyl, esketamine (in combination with dormicum).