ALTO....sounds like a muppet character

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Groove

Groove

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Anyone else using these ALTO guidelines for non opioid pain management in your ED? We have a non opioid pain policy with big banners in the ED informing patients and although physicians are technically free to order whatever they think is appropriate, we get emails with the names of physicians who are the biggest offenders with ordering narcotics in the ER so there is definitely pressure to not order them if you can help it. FMD is 100% behind the push for no opioids. At first, I was really excited about the policy and it has definitely made it easier to refuse drugs to the pill heads but incessant pressure to "never order them" has gotten to me recently. I always get rubbed the wrong way when I feel intense pressure to practice a certain way. Sometimes, I feel we're getting so obsessed with non narcotics that it's bordering on lunacy. I mean, check out the ALTO stuff for example:

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Headache guidelines? Ok, not so bad, though I don't think Haldol would be my first choice to cure someone's headache. How about extremity fracture or joint dislocation. Let's take a femur fracture for instance... Ketamine intranasal? Nitrous?! Are you serious? For the femur fracture and the pt writhing around in the bed in pain, why on earth would I have two techs grab his head and hold him still while I make him snort ketamine? And nitrous?! I can just see myself... "For God's sake, hold him still while I get this Nitrous set up!" For real? Man, give that guy some morphine dammit. I guess my point is that there are still plenty of times where I feel it's completely appropriate to give IV narcotics. Kidney stone? Oh c'mon, add some morphine with that toradol instead of bolusing him with IV lidocaine.

Sometimes, I feel like we've gone so far out into left field with the opioid crisis that we've lost sight of the forest for the trees. IV narcotics are still some of the best ways to manage pain. I'm talking true pain, not the supratentorial BS. I have this one doc who is obsessed with IV ketamine for anyone with pain over 2/10 and I keep thinking to myself...is IV ketamine becoming our "morphine 4mg IV push" of the future? If so, is this really a good idea? I mean...it's ketamine people. For starters, I really hate the dissociative jazz that these pt's go through as soon as you bolus them an "analgesic" dose. I've got patients that will start swaying, yelling, screaming, talking to dead relatives, it's all very annoying with the nurse looking at me nervously.

And what does everyone do with the SCPC? If you try 100% non-narcotic therapy, they will either sign out AMA and call the hospital complaint line or get admitted for pain control. Every time. Good luck getting them pain controlled and out the door without narcotics. What's more....I can't find any official recommendations for non narcotic therapy in SCD. All guidelines recommend IV narcotics. I also feel like such a dumb ass when I phone up medicine for a SCPC admission who hasn't received any narcotics at all because that's the first thing that gets ordered for them by the hospitalist and hematology. Don't get me wrong, I hate giving these guys IV narcs because we have such a huge population of SCD that has been turned into drug seekers but I still haven't found a great way to manage them in the ED in this "non narcotic world" we seem to have found ourselves in these days.

End rant.
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Groove said:
Anyone else using these ALTO guidelines for non opioid pain management in your ED? We have a non opioid pain policy with big banners in the ED informing patients and although physicians are technically free to order whatever they think is appropriate, we get emails with the names of physicians who are the biggest offenders with ordering narcotics in the ER so there is definitely pressure to not order them if you can help it. FMD is 100% behind the push for no opioids. At first, I was really excited about the policy and it has definitely made it easier to refuse drugs to the pill heads but incessant pressure to "never order them" has gotten to me recently. I always get rubbed the wrong way when I feel intense pressure to practice a certain way. Sometimes, I feel we're getting so obsessed with non narcotics that it's bordering on lunacy. I mean, check out the ALTO stuff for example:

View attachment 277049

Headache guidelines? Ok, not so bad, though I don't think Haldol would be my first choice to cure someone's headache. How about extremity fracture or joint dislocation. Let's take a femur fracture for instance... Ketamine intranasal? Nitrous?! Are you serious? For the femur fracture and the pt writhing around in the bed in pain, why on earth would I have two techs grab his head and hold him still while I make him snort ketamine? And nitrous?! I can just see myself... "For God's sake, hold him still while I get this Nitrous set up!" For real? Man, give that guy some morphine dammit. I guess my point is that there are still plenty of times where I feel it's completely appropriate to give IV narcotics. Kidney stone? Oh c'mon, add some morphine with that toradol instead of bolusing him with IV lidocaine.

Sometimes, I feel like we've gone so far out into left field with the opioid crisis that we've lost sight of the forest for the trees. IV narcotics are still some of the best ways to manage pain. I'm talking true pain, not the supratentorial BS. I have this one doc who is obsessed with IV ketamine for anyone with pain over 2/10 and I keep thinking to myself...is IV ketamine becoming our "morphine 4mg IV push" of the future? If so, is this really a good idea? I mean...it's ketamine people. For starters, I really hate the dissociative jazz that these pt's go through as soon as you bolus them an "analgesic" dose. I've got patients that will start swaying, yelling, screaming, talking to dead relatives, it's all very annoying with the nurse looking at me nervously.

And what does everyone do with the SCPC? If you try 100% non-narcotic therapy, they will either sign out AMA or get admitted for pain control. Every time. Good luck getting them pain controlled and out the door without narcotics. What's more....I can't find any official recommendations for non narcotic therapy in SCD. All guidelines recommend IV narcotics. I also feel like such a dumb ass when I phone up medicine for a SCPC admission who hasn't received any narcotics at all because that's the first thing that gets ordered for them by the hospitalist and hematology. Don't get me wrong, I hate giving these guys IV narcs because we have such a huge population of SCD that has been turned into drug seekers but I still haven't found a great way to manage them in the ED in this "non narcotic world" we seem to have found ourselves in these days.

End rant.
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Just do it? You're the physician. Why are you listening to some piece of paper algorithm? So what if your name is in the top list. Neat. The list should be who writes the most Rx for opiates at home, not who's adequately controlling pain in the ED (if the clipboard warriors must create some silly list in the first place).

Might as well fill the ED with NPs if any semblance of medical decision making is going to be removed because it's not just pain medications. There's these little algorithms for nearly everything in the ED. Anything beyond the scope of the piece of paper would get an Up To Date consult.
 
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Rekt said:
Just do it? You're the physician. Why are you listening to some piece of paper algorithm?

Might as well fill the ED with NPs if any semblance of medical decision making is going to be removed because it's not just pain medications. There's these little algorithms for nearly everything in the ED. Anything beyond the scope of the piece of paper would get an Up To Date consult.
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Well, the sad reality is that job security these days means "falling in line" with hospital and CMG policy. Everyone is all very nice to your face about how they don't want to influence how you practice medicine but meanwhile you'll get "report cards" from hospital or CMG brass showing how you measure up against your peers. Usually with a Tony Robbins quote attached about "maximizing your potential" and "identifying barriers to excellence" or any of the countless other quotes from an MBA psychology course on how to motivate your minions.
 
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Nurse: Hey your patient with the femur fracture is asking for something other than tylenol
Me: Give him nitrous oxide while I prepare the regional anesthesia

looooollllll

Also love the trigger point injection suggestion. I thought it was a cool technique when I learned it in residency and it seems to really work. The downside, however, is you have to spend more than 20 seconds in the room, something the neurologist that taught us this didn't factor in when he was wondering why we don't do it more often
 
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Well, the table is suggestions. And they are all good suggestions. But, yes there are times when you will go right to an opiate, like the example you gave of someone writhing in pain from actual serious pathology. Also nitrous is a good option temporarily. Actually, using it on someone with a femur fracture until you can get an IV is not a bad idea. If the person won't hold still for nitrous, they probably ain't gonna hold still for an IV.

Also, nerve blocks are great. But, yes, until it can be done, you'll usually need something IV. Also, they are not the easiest to learn on your own and can be time consuming to learn, so I understand why many don't bother.
 
carbonizedeyesockets said:
Well, the table is suggestions. And they are all good suggestions. But, yes there are times when you will go right to an opiate, like the example you gave of someone writhing in pain from actual serious pathology. Also nitrous is a good option temporarily. Actually, using it on someone with a femur fracture until you can get an IV is not a bad idea. If the person won't hold still for nitrous, they probably ain't gonna hold still for an IV.

Also, nerve blocks are great. But, yes, until it can be done, you'll usually need something IV. Also, they are not the easiest to learn on your own and can be time consuming to learn, so I understand why many don't bother.
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A femoral nerve block is not rocket science. Taking the 10 mins to set up, get the equipment, get semi-sterile, have someone hold them still while you're spear fishing on the US...all to avoid an IV dose of medication that would have given this guy instant relief is insanity.

Also, you've got nitrous in your ED? Man, I've never even SEEN nitrous in an ED. My dentists office...sure. ED? Never. I can't think routine nitrous would be very common.

Oh man...Ketamine intranasal for an extremity fracture, LOL. I'm just envisioning my writhing patient going from cursing to dissociative yelling and talking to dead presidents...but hey...morphine BAD! <slaps wrist> MORPHINE VERY BAD!

Slap slap!
 
Apollyon said:
Ah, got it. Nonstandard abbreviation, but, also, I only see one SC pt, and rarely (prisoner, retic-ing at 10%, prefers, and greatly at that, Toradol to Dilaudid), so it's not on my radar.
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Consider yourself lucky. TN/MS is like the sickle cell Mecca. I feel like have at least 1-2 each shift.
 
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Groove said:
A femoral nerve block is not rocket science. Taking the 10 mins to set up, get the equipment, get semi-sterile, have someone hold them still while you're spear fishing on the US...all to avoid an IV dose of medication that would have given this guy instant relief is insanity.

Also, you've got nitrous in your ED? Man, I've never even SEEN nitrous in an ED. My dentists office...sure. ED? Never. I can't think routine nitrous would be very common.

Oh man...Ketamine intranasal for an extremity fracture, LOL. I'm just envisioning my writhing patient going from cursing to dissociative yelling and talking to dead presidents...but hey...morphine BAD! <slaps wrist> MORPHINE VERY BAD!

Slap slap!
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Yep, had nitrous and we're getting it back (lapse due to the brand of canisters for our machine no longer made). I haven't used IN ketamine, but the few times I've used analgesic doses of ketamine, I haven't had any problems.
 
carbonizedeyesockets said:
Yep, had nitrous and we're getting it back (lapse due to the brand of canisters for our machine no longer made). I haven't used IN ketamine, but the few times I've used analgesic doses of ketamine, I haven't had any problems.
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What are you dosing? I use 0.3mg/kg and a solid 25-50% of my patients go ****oo for coco puffs. They either get into this agitated dissociative state or they flip out and grip the bed rails going "Ohhhhhh my gawwwwwwd! oh my gaaaaawwwwwwwd!" Maybe it's my pt population.
 
We just got a letter from from one of our (geeky) medical directors outlining all the research on how terrible Toradol is for old people with the increased risk of bleeding. Suggestion was to give......Tylenol or Aspirin!

I pointed out that most of the studies he quoted looked at bleeding after days or weeks and multiple doses of Toradol.

I plan to continue giving Toradol as Tylenol isn't going to cut it for most ED pain, and I don't want to give old unsteady people morphine or opiates which will make them fall and end up with a REAL emergency.
 
Groove said:
What are you dosing? I use 0.3mg/kg and a solid 25-50% of my patients go ****oo for coco puffs. They either get into this agitated dissociative state or they flip out and grip the bed rails going "Ohhhhhh my gawwwwwwd! oh my gaaaaawwwwwwwd!" Maybe it's my pt population.
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I've used on the lower end of the 0.1-0.3 range (I don't think I've done 0.3). Again, I also don't use it much (probably <10x in past 2 years) so my experience could be because I haven't given it enough to see the effect you have seen. Ive had people say some goofy things, but haven't had an particularly alarming reactions. I have used small doses of ketamine to facilitate a semi-conscious intubation (usually by giving 10-20mg at a time and titrating to affect). Haven't had any particularly concerning reactions there either.
 
For low dose ketamine, how long do you guys typically infuse it for? I've seen it anywhere from 2 minutes to 30 minutes @_@

I've tried the lower end of things, only had one reaction but it was bad enough that we were banned from using LDK forever lolololololo (mostly due to crap nursing but this is another story)
 
Why wouldn't you use haldol for headache? It works just like droperidol. As in, the most effective medication studied. Better than reglan or compazine. All you have to do is have the nurses give it (IV is perfectly fine, no matter what they say). After a few, you'll get converts. Just like with hyperemesis, chronic pancreatitis, vague fibro flares, or anything else. It does just enough supratentorially that the dopaminergic pathway works really, really well. I promise.
 
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Odd they skipped sumitriptan for HA. Its the highest level of recommendation in HA guidelines. I use it all the time. It can save you a ton of time. When you write for IVF, reglan and toradol, it takes like an hour for the patient to get all their meds. SC imitrex +/- IM toradol, and usually 15 min they are better and can go home. If not, you can then write for the IV reglan as a rescue and you've only wasted like 15 minutes. But my experience is that a large percentage of migraines can be discharged without an IV.

I never did this until I started working in provider in triage and had to treat things without an IV. Then I realized how often these patients could be rapidly dispositioned and it really changed my practice.
 
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Dr.McNinja said:
Why wouldn't you use haldol for headache? It works just like droperidol. As in, the most effective medication studied. Better than reglan or compazine. All you have to do is have the nurses give it (IV is perfectly fine, no matter what they say). After a few, you'll get converts. Just like with hyperemesis, chronic pancreatitis, vague fibro flares, or anything else. It does just enough supratentorially that the dopaminergic pathway works really, really well. I promise.
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I don't doubt you at all and maybe some day I'll try it, but I probably have 95% success with toradol, reglan, benadryl and I have 100% success when I've added 4 of morphine and I typically don't even have to do that. Migraines are not where I'd probably ever feel the need to try out haldol. It just feels odd reaching for a first gen antipsychotic as my first line tool for a migraine headache of all things but I get it. Diff strokes, diff folks.
 
Groove said:
A femoral nerve block is not rocket science. Taking the 10 mins to set up, get the equipment, get semi-sterile, have someone hold them still while you're spear fishing on the US...all to avoid an IV dose of medication that would have given this guy instant relief is insanity.

Also, you've got nitrous in your ED? Man, I've never even SEEN nitrous in an ED. My dentists office...sure. ED? Never. I can't think routine nitrous would be very common.

Oh man...Ketamine intranasal for an extremity fracture, LOL. I'm just envisioning my writhing patient going from cursing to dissociative yelling and talking to dead presidents...but hey...morphine BAD! MORPHINE VERY BAD!

Slap slap!
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You could get a tech to gather everything, but at our big ED usually they can't find the stuff.
We do actually have nitrous in some of our EDs, haven't tried it for acute pain before, mostly pediatric procedures that don't need actual sedation.
I'll do intranasal fentanyl sometimes while IV is getting placed. Helps but definitely not enough.
 
Groove said:
I don't doubt you at all and maybe some day I'll try it, but I probably have 95% success with toradol, reglan, benadryl and I have 100% success when I've added 4 of morphine and I typically don't even have to do that. Migraines are not where I'd probably ever feel the need to try out haldol. It just feels odd reaching for a first gen antipsychotic as my first line tool for a migraine headache of all things but I get it. Diff strokes, diff folks.
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Droperidol, back when you could get it, was an amazing drug. I don't care what you gave it for, it worked. It's like an "be a normal person with a normal pain tolerance" switch. Cyclic vomiting, gastroparesis, chronic unexplained abd pain, migraines that only respond to narcotics... I'm telling you, that drug worked wonders as both an anti-emetic and for pain.
 
gamerEMdoc said:
Droperidol, back when you could get it, was an amazing drug. I don't care what you gave it for, it worked. It's like an "be a normal person with a normal pain tolerance" switch. Cyclic vomiting, gastroparesis, chronic unexplained abd pain, migraines that only respond to narcotics... I'm telling you, that drug worked wonders as both an anti-emetic and for pain.
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Man, if I had a dollar for every droperidol story. Sadly, it was FDA pimp slapped with the black box warning before my time and I've never had the opportunity to try it. Nowadays, I use droperidol stories to gauge how long someone's been in practice and how much more senior they are to me. For instance, If they say "back when we used droperidol!", I automatically know they've been practicing over 20 years because it got black boxed in 2001.

For instance, I suddenly see you with a few more wrinkles and gray hair than I had imagined. I mean, "gamerEMDoc" had me picturing this young, spry dude punching away on his PS4 but now that you've slipped up by bragging about your droperidol days....I'm seeing you decidedly more middle aged with some serious gray going on...still punching away at the PS4 I suppose. :D
 
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Groove said:
Man, if I had a dollar for every droperidol story. Sadly, it was FDA pimp slapped with the black box warning before my time and I've never had the opportunity to try it. Nowadays, I use droperidol stories to gauge how long someone's been in practice and how much more senior they are to me. For instance, If they say "back when we used droperidol!", I automatically know they've been practicing over 20 years because it got black boxed in 2001.

For instance, I suddenly see you with a few more wrinkles and gray hair than I had imagined. I mean, "gamerEMDoc" had me picturing this young, spry dude punching away on his PS4 but now that you've slipped up by bragging about your droperidol days....I'm seeing you decidedly more middle aged with some serious gray going on...still punching away at the PS4 I suppose. :D
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I use droperidol and I graduated residency in 2011.
The black box doesn't mean you can't use it. Zofran is black boxed. Do you use it?
There is literally zero reason for morphine for headaches. It actually increases the rebound probability. The rest of your regimen is fine. Although the studies for reglan (which has the same side effects as haldol I might add) show the maximally effective dose is 20mg. Are you using that much?
Haldol's not just a first gen antipsychotic. It's an antiemetic. And a good one at that.
 
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I used droperidol up until about 2013 when hospital removed it form our formulary. For some reason we allow hospital pharmacists to overrule orders of physicians, like IV Haldol because of idiotic theoretical "black boxes".
 
Dr.McNinja said:
I use droperidol and I graduated residency in 2011.
The black box doesn't mean you can't use it. Zofran is black boxed. Do you use it?
There is literally zero reason for morphine for headaches. It actually increases the rebound probability. The rest of your regimen is fine. Although the studies for reglan (which has the same side effects as haldol I might add) show the maximally effective dose is 20mg. Are you using that much?
Haldol's not just a first gen antipsychotic. It's an antiemetic. And a good one at that.
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Not about the black box for me. I've used it for a long time after it was black boxed. The issue was there was a droperidol shortage since like 2012. We couldn't get it even if we wanted it, so eventually I just moved on to other drugs. I just looked it up and saw there's a new manufactorer since early 2019, so maybe it's not on shortage anymore. But its been like over 5 years since I could even get it, so I'm just used to not even thinking about it now.
 
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GeneralVeers said:
I used droperidol up until about 2013 when hospital removed it form our formulary. For some reason we allow hospital pharmacists to overrule orders of physicians, like IV Haldol because of idiotic theoretical "black boxes".
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Yeah I bet it got removed though because they couldn't get it. It was a national shortage, there was no manufacturer for a long time and it was on back order.
 
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There's a big thread on the twittersphere about people getting droperidol back.
I simply substituted haldol at twice the dose I was using droperidol at. It works just fine, just the same.
 
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Dr.McNinja said:
I use droperidol and I graduated residency in 2011.
The black box doesn't mean you can't use it. Zofran is black boxed. Do you use it?
There is literally zero reason for morphine for headaches. It actually increases the rebound probability. The rest of your regimen is fine. Although the studies for reglan (which has the same side effects as haldol I might add) show the maximally effective dose is 20mg. Are you using that much?
Haldol's not just a first gen antipsychotic. It's an antiemetic. And a good one at that.
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This sounds like it's heading for getting lost in the weeds. No opiates for headaches. Only exception? Brain tumor or skull fracture. Reglan? 20mg, all the time (well, virtually), with premedication of Benadryl 50mg.

Recall that most of the nausea drugs we use (until the 5-HT3 inhibitors came along) were psych meds. Recall that you have as many nerves in the GI tract as in the brain. Nausea in the brain is headache in the gut. Reglan, Phenergan, Inapsine, Haldol, Tigan (remember THAT one?) - all psych meds. But, as a side effect, the antinausea properties were found. Hell, the first antipsychotic, chlorpromazine, is still used for hiccups. What about Zyban, for smoking? It's Welbutrin. The psychiatrists noticed that the schizos were smoking less. Boom - bupropion gets a new name, and a new life.

I just don't think of Haldol. I have to readjust my muscle memory.
 
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gamerEMdoc said:
Odd they skipped sumitriptan for HA. Its the highest level of recommendation in HA guidelines. I use it all the time. It can save you a ton of time. When you write for IVF, reglan and toradol, it takes like an hour for the patient to get all their meds. SC imitrex +/- IM toradol, and usually 15 min they are better and can go home. If not, you can then write for the IV reglan as a rescue and you've only wasted like 15 minutes. But my experience is that a large percentage of migraines can be discharged without an IV.

I never did this until I started working in provider in triage and had to treat things without an IV. Then I realized how often these patients could be rapidly dispositioned and it really changed my practice.
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I probably should use it more (Imitrex). Reason I don't is most people who say they have "migraines" actually don't have a migraine, they have some other form of headache. And I don't think Imitrex works nearly as well as for tension HA's, stupidity HA's, eat-popeyes-24-7 HA's, and other such stuff.
 
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Dr.McNinja said:
I use droperidol and I graduated residency in 2011.
The black box doesn't mean you can't use it. Zofran is black boxed. Do you use it?
There is literally zero reason for morphine for headaches. It actually increases the rebound probability. The rest of your regimen is fine. Although the studies for reglan (which has the same side effects as haldol I might add) show the maximally effective dose is 20mg. Are you using that much?
Haldol's not just a first gen antipsychotic. It's an antiemetic. And a good one at that.
Click to expand...

Really? I haven't worked in a single ER down here in the South that has it available. In fact, I haven't met a single ER doc that uses it in the last 10 years. I thought they stopped making it or it was in such short supply with a bad rap (admittedly undeserved) that most places stopped stocking it. It wasn't even available when I started residency in 2009 and had been gone from the institution for several years. All my attendings talked about it though. I'd love to try it.

I've found that morphine seems to have a synergistic effect with the other meds. It's purely anectodal, but def not my imagination. I only really use it for the ones where I have a higher pre-test probability that they won't improve after one round of meds and I want to throw everything at them before I start pulling out spinal needles.

I use Toradol 30mg IV (30mg for migraines, 15mg for everything else...again, anectodal.), Reglan 10mg IV, Benadryl 25mg IV and 95% of my migraines are completely abated. For a select few I'll bump in 2 or 4mg morphine IV.
 
I had a pt in SC that was a bounce back migraine. This was an especially tragic case, because this girl was on piano performance scholarship, at a GOOD school. The headaches were getting so bad, it was affecting her performance, and she was truly gifted.

My colleague (at one of the other hospitals we covered) did everything right (Reglan, Benadryl, Decadron, Toradol), but threw on 1mg of Dilaudid, too.

She comes to me, and described the HA in a way that I use now - "it's like someone snapped a rubber band on my head, and, now, it's even worse".

So, no opiates for HA.
 
Sooooo much to talk about in this thread--

(1) We, a small community ED, were early and strong proponents of all that ALTO stuff you posted. I'm still a believer in the great majority. This BIGGEST plus? Getting the press-gainey literate, "i'm only happy if you give me 4mg IVP dilaudid x 3 q 10 minutes" albatross to fly away. Plus it ABSOLUTELY let me get a bunch of stuff on the formulary (IV lido, ketamine for pain, lidoderm in the ED) which I never would have gotten otherwise. But um... we sure still let docs do what they want! 0% of us give IV dilaudid for migraines now, and I think if one person started they'd hear about it from the group. But you want to use opiates on fractures or renal colic? Go for it. Big brother isn't interested. Entertainingly, now the RNs might be suggesting you try ALTO med first line (often a good idea!), but you can still do as you please...

(2) I haven't given an opioid to a migraine in 9+ years, and I haven't had an unhappy migraineur in 8+ years. At our shop, most of us go with Reglan + toradol + benadryl + 1L NS IVF in a dark room as first option. Sometimes people add APAP or Zofran depending on the precise symptoms. 2nd line I find most of us using some combination of Mg, Decadron, Re-dosed Reglan or.... DROPERIDOL / HALDOL. The rare 3rd line would be anti-epileptic or perhaps low dose ketamine (personally I don't use it for migraine, but YMMV).

(3) Droperidol / Haldol. So much to say. First, they are wonderful anti-emetics. Secondly, the are perhaps the ONLY thing that slows down cannabinoid hyperemesis. Third, they... can be pretty solid for migraines! Especially the kind that is super nauseated and "can't sleep". I typically grab an EKG before I use either agent, since I've typically tried something else first line. I have at least 2 chronic migraineurs from the past 6mo who now ASK for droperidol (the type that visits about every 2-3mo).

So yes Droperidol has a black box. So do many meds. It was one of the earlier / scarier black boxes, and a lot of hospitals dropped it from the formulary at that time. Even if it stayed on formulary, it was often unavailable. In fact, during the past few years, NO generic US manufacturer was making it. However, this changed in the past year, and generic droperidol is back on the market! So... if I have it in MY ED, you COULD have it in yours! The price isn't bad... Haldol was quoted about $1 a vial to me, droperidol close to $5, with zyprexa being about $20.
 
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Choosing Wisely: An Initiative of the ABIM Foundation

Choosing Wisely was an 11-year campaign launched by the ABIM Foundation, aimed at promoting conversations between clinicians and patients about unnecessary medical tests, treatments, and procedures. In addition to detailing the initiative's history, the site offers various resources and research...
www.choosingwisely.org
www.ncbi.nlm.nih.gov

Opioids should not be used in migraine - PubMed

Opioids should not be used for the treatment of migraine. This brief review explores why not. Alternative acute and preventive agents should always be explored. Opioids do not work well clinically in migraine. No randomized controlled study shows pain-free results with opioids in the treatment...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Migraine and the Opioid Crisis | American Migraine Foundation

The national opioid crisis effects migraine patients in a multitude of ways, from medication overuse to limited access and reluctance to prescribe.
americanmigrainefoundation.org americanmigrainefoundation.org
 
Anybody ever tried propofol for status migraines? I’ve used it once or twice and it worked surprisingly well though it was a pain to go through all the moderate sedation paperwork.
 
Groove said:
Really? I haven't worked in a single ER down here in the South that has it available.
Click to expand...
I trained in NC. We had it until the day I graduated. I used up the entire hospital's stock in the first 2 years out of residency here in Texas. Yes, it was hard to come by, which is why I switched to haldol. It's no longer hard to come by.
 
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Groove said:
Anybody ever tried propofol for status migraines? I’ve used it once or twice and it worked surprisingly well though it was a pain to go through all the moderate sedation paperwork.
Click to expand...
The data looks good, but like you, it's not worth the paperwork. If I had someone that failed literally everything else, and the choice was admission or milk of amnesia, I might try that.
 
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Dr.McNinja said:

Choosing Wisely: An Initiative of the ABIM Foundation

Choosing Wisely was an 11-year campaign launched by the ABIM Foundation, aimed at promoting conversations between clinicians and patients about unnecessary medical tests, treatments, and procedures. In addition to detailing the initiative's history, the site offers various resources and research...
www.choosingwisely.org
www.ncbi.nlm.nih.gov

Opioids should not be used in migraine - PubMed

Opioids should not be used for the treatment of migraine. This brief review explores why not. Alternative acute and preventive agents should always be explored. Opioids do not work well clinically in migraine. No randomized controlled study shows pain-free results with opioids in the treatment...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Migraine and the Opioid Crisis | American Migraine Foundation

The national opioid crisis effects migraine patients in a multitude of ways, from medication overuse to limited access and reluctance to prescribe.
americanmigrainefoundation.org americanmigrainefoundation.org
Click to expand...
I hate fioricet with a fiery passion.
 
We had it around here until 2014ish, right when I started residency, then poof, all gone for 5 years
Groove said:
Really? I haven't worked in a single ER down here in the South that has it available. In fact, I haven't met a single ER doc that uses it in the last 10 years. I thought they stopped making it or it was in such short supply with a bad rap (admittedly undeserved) that most places stopped stocking it. It wasn't even available when I started residency in 2009 and had been gone from the institution for several years. All my attendings talked about it though. I'd love to try it.

I've found that morphine seems to have a synergistic effect with the other meds. It's purely anectodal, but def not my imagination. I only really use it for the ones where I have a higher pre-test probability that they won't improve after one round of meds and I want to throw everything at them before I start pulling out spinal needles.

I use Toradol 30mg IV (30mg for migraines, 15mg for everything else...again, anectodal.), Reglan 10mg IV, Benadryl 25mg IV and 95% of my migraines are completely abated. For a select few I'll bump in 2 or 4mg morphine IV.
Click to expand...
 
Haldol is amazing and I use it as my second to last resort (last resort would be a narcotic) for headaches and it works like a dream. Same thing for fibromyalgia or any other patients with a weird constellation of symptoms who are crazy and you know you have to get them out of the ER before they make another symptom up and you’re MRIing their whole body. 5 mg IM does the trick and usually patients are really happy and chill afterwards, and do the “thank you so much, I feel great” thing.

IV lidocaine for kidney stones? I heard about this a few years ago but when I asked a few of the attending about it they looked at me like I had three heads. Is anyone actually doing this...?!

Sumatriptan SC does work so much quicker for migraines than the IV meds - patients seem to get better in 20 minutes. I used this last night in a patient who was already prescribed the pills for migraines and was stoked to see how fast it worked .For some reason I am a little more leery of it; I have had a few patients get the “triptan tightness” in the chest and it kinda turned me off.

For headaches...Can’t get an IV? A thousand allergies? Can’t get a ride home? Scared of an IV? Oral meds not working? Sphenopalatine block. I have done it a few times and it at least provides some if not significant relief. Long sterile swab soaked in 4 percent lidocaine inserted in the nostril that’s the same side of the headache, slide up till you hit resistance. Let it sit for 5-10 minutes.
 
Yes I use IV lidocaine for renal colic. I find it about as effective as toradol-- 1/3 with nothing, 1/3 feel better, 1/3 start tap dancing and want to hug you.

For me toradol + anti-emetic is first line. Second line is Lidocaine or Opioid, depending on a lot of case-by-case factors...
 
Groove said:
Anybody ever tried propofol for status migraines? I’ve used it once or twice and it worked surprisingly well though it was a pain to go through all the moderate sedation paperwork.
Click to expand...

I really want to...it's so infrequent that I get someone with status migraines though.
I heard it's 10 mg IVP q3-5 minutes, until the HA breaks? Or is there a max dose? There better be a max dose or else the pt is gonna get a tube LOL
 
Dr.McNinja said:

Choosing Wisely: An Initiative of the ABIM Foundation

Choosing Wisely was an 11-year campaign launched by the ABIM Foundation, aimed at promoting conversations between clinicians and patients about unnecessary medical tests, treatments, and procedures. In addition to detailing the initiative's history, the site offers various resources and research...
www.choosingwisely.org
www.ncbi.nlm.nih.gov

Opioids should not be used in migraine - PubMed

Opioids should not be used for the treatment of migraine. This brief review explores why not. Alternative acute and preventive agents should always be explored. Opioids do not work well clinically in migraine. No randomized controlled study shows pain-free results with opioids in the treatment...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Migraine and the Opioid Crisis | American Migraine Foundation

The national opioid crisis effects migraine patients in a multitude of ways, from medication overuse to limited access and reluctance to prescribe.
americanmigrainefoundation.org americanmigrainefoundation.org
Click to expand...

Not that I use narcotics for headaches...

...I believe there is a difference between treating a HA with a one time dose of IV narcotic vs an Rx of narcotics. The rebound effect for any medicine generally occurs with medicines that you are taking repeatedly.
 
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thegenius said:
Not that I use narcotics for headaches...

...I believe there is a difference between treating a HA with a one time dose of IV narcotic vs an Rx of narcotics. The rebound effect for any medicine generally occurs with medicines that you are taking repeatedly.
Click to expand...
That belief is why so many people are on heroin now. A single dose of narcotics can cause addiction. There's plenty of data for that.
Moreover, even though you and I both say we don't, statistically half of ED visits for headaches get narcotics. That's appalling.
Parenteral opioids, the most common class of medications used for acute migraine treatment in the ED setting, are used in approximately 50% of all migraine visits.11,24 Opioids have been linked to repeat ED visits, reduced effectiveness of first-line acute migraine treatment options, increased recurrence rates of migraines, and poor treatment outcomes.25
Click to expand...
www.uspharmacist.com

Pharmacotherapy for Primary Headache Disorders in the Emergency Department

www.uspharmacist.com www.uspharmacist.com
 
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No, the reason why people get addicted to heroin is it’s the most addictive substance commonly used by man. No ER docs use heroin for migraines.
 
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