acute pain management

[joeDO2]

As an update to this topic, some may find the article by Jennings et al in this months annals of EM interesting. It compares prehospital pain management by paramedics with morphine only or morphine + ketamine. As you would suspect, the morphine + ketamine group had significantly greater pain reduction. There was also increased side effects with that group, however they were minor in nature. Both groups started with 5mg morphine (and sometimes methoxyflurane also) and then received additional medication titrated to pain. The morphine group got an average of 14mg and the ketamine group 40mg. It seems both treatment arms were more aggressive than typically allowed prehospital, with redosing at 5min and 3min intervals respectively.

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[docB]

As an update to this topic, some may find the article by Jennings et al in this months annals of EM interesting. It compares prehospital pain management by paramedics with morphine only or morphine + ketamine. As you would suspect, the morphine + ketamine group had significantly greater pain reduction. There was also increased side effects with that group, however they were minor in nature. Both groups started with 5mg morphine (and sometimes methoxyflurane also) and then received additional medication titrated to pain. The morphine group got an average of 14mg and the ketamine group 40mg. It seems both treatment arms were more aggressive than typically allowed prehospital, with redosing at 5min and 3min intervals respectively.

That's why I think we should dial back our thinking a bit on this. Introducing ketamine is a big mental hurdle for most medical directors and regulatory boards. Maybe we should be looking at maximizing the analgesics we have now beyond the usual 5 at first 5 at the back door routine. I personally support prehospital ketamine and these other advances but I'm in a district where we still don't have RSI prehospital. Ketamine is not even on the radar.

 

[proman]

Interesting article. Methoxyflurane is a volatile anesthetic and its use in the study should have been controlled or just not used. I think the protocol for the ketamine was too aggressive. Initial bolus of 10 or 20 mg is fine (I would have gone with 20mg fixed dose) but an additional 10mg q 3 min is just too much too often. I don't redose analgesic ketamine more often that 10 min. The result is that the max dose of ketamine was 120mg which is damn near an induction dose. No wonder the most frequent complication was disorientation followed by emergence phenomenon.

 

[joeDO2]

Interesting article. Methoxyflurane is a volatile anesthetic and its use in the study should have been controlled or just not used. I think the protocol for the ketamine was too aggressive. Initial bolus of 10 or 20 mg is fine (I would have gone with 20mg fixed dose) but an additional 10mg q 3 min is just too much too often. I don't redose analgesic ketamine more often that 10 min. The result is that the max dose of ketamine was 120mg which is damn near an induction dose. No wonder the most frequent complication was disorientation followed by emergence phenomenon.

yes, I agree, it was a bit aggressive. they suggested in the article that the medics had the option of treating the emergence phenomenon with benzos. although to my recollection that was not needed, you could potentially have now methoxyflurane + opiate + ketamine + benzo? seems a little dicey for the field to me it is good to see there is some interest and research going into this issue though. I'd like to see a study done with a dosing protocol more similar to what you describe.