Pain Management, Multi-Systems Trauma

[zippyRN]

What if you are a BLS car and all you can administer for pain is Entonox?

Would I be wrong to attempt to have dispatch page out the ALS crew to come and administer pain medication if I felt that my patient would benefit from stronger pain medication which I don't carry on car?

The town I work and live in we can be at the hospital within 10-20 code 3. Would it benefit my patient or just delay transport time if I paged out ALS to administer pain meds.?

firstly is the patient actually using the entonox properly , it is very effective if taken properly and kept 'topped up' ?

if entonox isn't enough you have to consider requesting back-up you also have to balance running hot to hospital and it;s increased risks with the extra time it will take to get that backup ...

[Paramagic]

On the first patient how minor of a depression would you consider acceptable? Even had her pit bull eaten my B/P cuff, I'm confident from her altered mentation, pulse quality, (What I know it must have been. Not pretending to remember now) that perfusion pressure is already critical, how much more critical is acceptable in order to manage her pain? What will you do to correct the current issues as well as overcome the minor depression?

Ok, to both of you, do me this favor. And this is in the spirit of learning not a "So you think so, do you!!" moment. You've convinced me that I 'may' be off in the ditch on this issue. I'm hoping you can convince me that I am...

Define the first patients injuries, her presentation and history and then your treatment to include all interventions, drugs, dosages. This will assume, as in reality, a 15 minute transport time to a level 3 trauma center.

And for the record, I didn't know exactly what the injury was when I treated her. I followed up on her at the ER and was informed there. Only that she was altered, seemed in terrible pain from an undiagnosed pelvic injury after falling from her bed, and that I was confident by her physiological markers that she was losing, if not into her pelvic cavity as I believed, a bunch of blood somewhere internally.

I didn't medicate her pain, and still feel that that was the prudent decision, but I'm miles away from knowing even what I'd like to, much less knowing everything...give 'er hell!

Dwayne

I can only go by what you have told me. I assume she is hypotensive secondary to blood loss from her pelvis. Coarse basal crackles in a bed-bound COPD patient do not worry me that greatly, but they obviously need watching. IV access, some fluid, TKVO at this stage, although it may be appropriate to give some small boluses depending on what happens with her blood pressure. 0.5mg/kg of ketamine, slow IV push, repeat as needed. No effect on BP, no effect on respirations, fantastic effect on pain.

If ketamine is not an option, then fentanyl, probably starting around 25mcgs every minute or two, and keeping an eye on blood pressure, although obviously there is less histamine release with fentanyl than morphine, so that shouldn't be a major issue (although some people report a terribly itchy nose with fentanyl)

If fentanyl isn't an option then an antihistamine to begin with to mediate the adverse effects (hypotension) of morphine that are primarily histamine mediated, then small boluses of morphine as with fentanyl.

Further fluid may be required, but we are obviously going to be cautious due to a CHF history and the desire not to replace lots of red stuff with clear stuff.

I agree that small doses of analgesia are not always optimal, but I fail to follow the reasoning of: small doses aren't great, so I'll give none. Something is better than nothing, and some explanation of why you are treating them they way you are, along with a bit of diversion if possible, should make them realize that you are acting in their best interests.

[Bieber]

Vorenus, she's hypotensive so I'm going to stay away from CPAP for now, but anecdotally I've gotten good results with resolving pulmonary edema with just sitting them up and high flow O2. I suppose we could assist ventilations with a BVM too, though if CPAP is contraindicated with hypotension I wonder if all PPV would have a similarly negative effect on their blood pressure... I'm guessing so, anybody think I'm looking at that wrong? The problem is PPV is gonna increase the vascular resistance for the right ventricle, which could further exacerbate her hypotension, but with that fluid in her lungs we don't want to risk drowning her with fluids and dopamine is contraindicated until we've replenished her volume (if we've identified this correctly as a fluid problem as opposed to a pump problem by now). Ideas?

I agree with Paramagic that a small fluid challenge might be appropriate, assuming we're getting good oxygen exchange to begin with otherwise we'll just be throwing more problems onto the ones we already have.

[DwayneEMTP]

I agree that sitting patients with pulmonary edema up is normally a good option, but would you sit her up on her damaged pelvis?

[Bieber]

...ahem... well... no...

So... guessing that means we do know that she's got a pelvic fracture, unlike what you knew at the time... so... yeah, like I said, maybe we won't sit her up...

Titrate fluid and fentanyl starting at 0.25 mcg/kg as tolerated by the patient! And let's strap a KED around her waist upside down.

[DwayneEMTP]

Yeah Beiber, I hear you. I knew she has something going on in the pelvic region that was causing her pain and had suspicions that it was also responsible for her hypertension, but didn't know exactly what until after she was diagnosed in the ER.

Her legs were together when I arrived, no shortening or rotation. I simply tied them together and tented them over pillows on the cot. I chose not to use spinal precautions simply because any touch or movement of the area seemed to cause great pain and I couldn't fathom laying her on a spine board, even with a quartered blanket on it. Yeah, I know, I'm a bad medic as I couldn't clear her via NEXUS but her writhing on the floor convinced me that there was little likelihood of gross damage...Probably the wrong path, but it was the one I chose.

I think you guys are just braver than I am maybe. Her perfusion pressures are already obviously in the toilet, my priority at this point, and bringing them up with fluids is, in my opinion, very dangerous due to her current assessment combined with her medical history.

I guess the issue that I'm having is with the term 'titrate' in this situation. It's going to take several minutes minimum to get even a micro trend of her condition and titrating fluids takes time, relatively speaking. The term titrate seems to be being used as if it's a predefined delivered volume, when in fact the fluids need to be delivered slowly, over time, and and reassessments conducted. The reassessments in this case revolve around physiological markers that can be tough to precisely quantify, lung sounds, B/P, pulse quality and mentation levels.

I guess my point is that it seems that to risk retarding her pulmonary/cardiac/hemodynamic status further, to any degree, would be irresponsible, yet to verify that you are not retarding those values takes more time than available before hand off at the ER. Unless you might choose to stay on scene to provide these interventions?

Thanks for the discussion. You guys are awesome.

Dwayne

[Paramagic]

There's no bravery at all. Ketamine has no effect on blood pressure or respirations, so I don't have to be worried about either of those things. The coarse basal crackles don't bother me much at all, I would not be surprised if that is her baseline finding. Even fentanyl would be relatively safe.

[ERDoc]

There's no bravery at all. Ketamine has no effect on blood pressure or respirations, so I don't have to be worried about either of those things. The coarse basal crackles don't bother me much at all, I would not be surprised if that is her baseline finding. Even fentanyl would be relatively safe.

Are you a sales rep for Ketamine? I'd have to disagree with you on this. From Micromedex:

Common adverse effects:

• Cardiovascular: Hypertension, Tachycardia
  
• Neurologic: Emergence from anesthesia, Psychiatric sign or symptom (12% to 50%)
  
  Serious adverse effects:
  
• Cardiovascular: Bradyarrhythmia, Cardiac dysrhythmia, Hypotension
  
• Immunologic: Anaphylaxis
  
• Respiratory: Apnea, Laryngeal spasm, Pulmonary edema, Respiratory depression
  

Not exactly the benign medication you are trying to make it out to be. Ever seen an emergence reaction? They are not pretty. Where do you practice that you are able to use ketamine?

[Paramagic]

A sales rep for a drug that is out of patent and extraordinarily cheap? Try again.

Yep, it can raise BP and heart rate slightly. Which is worse in this patient, dropping the BP or raising it slightly? We are not talking gross hypertension here. The serious effects, particularly apnea and laryngeal spasm are typically related to the speed at which the drug is pushed, hence my comment above about administering it slow IV push. The serious adverse effects are rare, and when we are considering a hemodynamically unstable patient, it is a clear choice between a histamine releasing opiate and ketamine.

Yes I have seen emergence phenomena, which are more common when using larger doses for procedural sedation or anaesthesia, and are usually attenuated with a small dose of a benzodiazepine. However in my experience they are rare when using ketamine in analgesic doses.

I'm not trying to make ketamine out to be anything other than what it is: a safe and very effective analgesic agent for the type of patient we are discussing.

[Bieber]

Dwayne, if your goal was to minimize spinal movement, I'm not sure how forcing someone onto a hard board that'll just make them writhe more would accomplish that. I think you did the right thing to withhold immobilization.

As far as pain management goes, I can't say for sure what I would do without having been there, but I understand your hesitance and share it. Titrating to me means initiating therapy at a lower level than typical and cautiously trying to find the balance between benefit/risk.

Good discussion man.

-Bieber