Pain Management, Multi-Systems Trauma

[rock_shoes]

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?

All true. These effects, with the exception of anaphylaxis, are all typically related to either very large doses or pushing the drug too quickly however. It's no different than any other drug in that the consequences of its use should be carefully considered. Ketamine has an unjustified bad rap in North America and is routinely used successfully throughout the rest of the world.

http://www.anesthesia-analgesia.org/content/99/2/482.full.pdf+html

[rock_shoes]

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.?

Do not delay transport waiting for ALS. If you have the opportunity to intercept with ALS enroute to the hospital or they're able to make it to the scene prior to your departure by all means do so.

As has already been mentioned, Entonox can be effective if used correctly. Your greatest benefit to patient's in pain may come from carefully reviewing how you instruct your patients to use the entonox.

[Vorenus]

Gotta say, I`m a big friend of Ketamine, too.

Only had good experiences with it, and I`ve seen it in use quite often.

Of course, we`re not allowed to push it ourselves (well, push yes, but Doc`s gotta give the order), but still....

[Bieber]

I've heard about ketamine, unfortunately we don't carry it and I don't know anyone around here that does.

[Vorenus]

We used to carry Ketamine, right now, we carry Ketamine S (Esketamine). Though since no one seems to be a hundred percent sure wether the hypnotical side-effects are really erased (or significantly reduced) or not, it`s a bit ridiculous in my eyes, since we still give it only with benzos (this is actually the second time we`ve got Esketamine, after some time we swapped again, then again,... can`t they just decide what they want ?)

[systemet]

On the pharmacology of ketamine: [Just for general information -- I'm aware that anyone with MD after their name is already aware of the following ]

* Ketamine itself is a negative inotrope.

* However, ketamine stimulates sympathetic discharge, so administering ketamine may increase CO / MAP, provided, the patient has a functional ability to increase their heart rate and constrict their peripheral vasculature. This may not always be the case, in which case ketamine may cause hypotension.

* It is not hemodynamically neutral. It just has less potential for hemodynamic compromise than benzodiazepines, and most opiates.

* Part of the hemodynamic effect of ketamine is to raise ICP. However it's also been trialed (unsuccessfully) as a neuroprotective. There is ongoing controvery as to its use in closed head injury.

* Ketmaine also has an intrinsic bronchodilator effect, making it beneficial in situations where bronchospasm is an issue, e.g. status asthmaticus.

Ketamine is beginning to find its way into prehospital care. For example this system -- which I don't work in, before anyone asks --- (http://www.albertahealthservices.ca/hp/if-hp-ems-mcp.pdf) allows ketamine for RSI or as a sole agent in the intubation of patients presenting with hypotension, airway burns, acute asthma or procedural sedation in hypotensive patients <80mmHg (e.g. pre-cardioversion, or for fracture realignment).

I think it's often finding use outside of the US in situations where US providers might opt to use etomidate.

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.?

As a medic, I'd happily come out to give pain control to anyone. I think it's one of the most tangible benefits of having an ALS response. It's something we actually know we're good at. Personally, I'd never have an issue with coming out to pain control someone. Or, in general, to back up BLS. I'd rather a BLS provider calls me, if they have a concern, and have it be a waste of time than have someone be too afraid to call, and have the patient suffer.

But this is going to depend on your system, and the availability of ALS resources.

I think that if you're close to the hospital, and can move the patient without undue pain, or you think that a critical life threat is present, then you probably shouldn't wait for ALS. In contrast, if you have someone with previously diagnosed renal colic, having symptoms suggestive of their prior renal colic, and they're a vomiting, diaphoretic mess on their bathroom floor, it might be better just to start an IV (if that's in your scope), and wait for someone who can give opiates.

[Kiwiology]

It's very simple - patients in pain get pain relief

Patients without significant shock get entonox and/or morphine to start with but if required get ketamine

Patients with significant shock get ketamine

There, that was easy. Now, who wants an omlette?

Edited September 26, 2011 by kiwimedic

[systemet]

There, that was easy. Now, who wants an omlette?

Well... how much vegemite is in that omelette?

[DwayneEMTP]

We used etonox in Afg...it was the friggin bomb! Easy set up, simple patient managed delivery. The only down side that I personally saw was that the filters didn't always work perfectly so when we had multiple patients using it in our hot, non ventilated plywood ambulances we'd get pretty stoned as well.

Where I worked there I think that they were thinking of taking it away though. If I remember correctly the problem was that everyone from the medics to finally delivery...wherever...wanted to use it for a quick fix and people were ending up well above safe dosages over time and getting kidney issues.

I'm not sure why, in an environment where that's unlikely, that everyone doesn't carry it...

Dwayne

[systemet]

I'm not sure why, in an environment where that's unlikely, that everyone doesn't carry it...

BLS in the area I used to work was able to use Entonox, and we used to carry it on the ALS trucks as well. However, we didn't use it that often. I think perhaps it was a little underused. A few problems come up with it, as you may have seen:

* The pain relief only lasts while the patient's inhaling the nitrous oxide, so once you arrive at a receiving facility, you either have to leave the bottle with the patient (impractical), or take it away (unethical). So usually you end up giving morphine (or another opiate) anyway.

* Some people just don't like it. There can be a lot of nausea / dizziness / dysphoria.

* There's a risk that the nitrous oxide migrates into air-filled spaces, making it dangerous in bowel obstruction, and you can't really use it in most major trauma, because it can worsen pneumothoraces (or other disease processes involving trapped air).

* It just isn't as effective as opiates in most patients. So if the pain is severe, again, you're adding opiates.

Now personally, I think that in combination with an opiate, it's a good analgesic for transport / extrication providing none of the issues above apply. It allows you to provide added analgesia to someone while you're moving them around and exposing them to vibration and stress during transport, which can then be d/c'd upon arrival, once these stressors are removed.

[For what's it's worth, I also prefer morphine over fentanyl in situations where hemodynamics aren't an issue, as I've had too many experiences where I've got the patient transferred to a bed, given report to an RN, and then had the fentanyl wear off, and been put in a situation where I feel an ethical obligation to provide further pain control, but know that if I do it in the ER, after transferring care, that I'm putting myself in a potentially risky position.]