Clinical tricks, quick-fixes, combos, cocktails

[beyond all hope]

I want people to post their ER tricks that get them through the day. Little things that don't appear in textbooks. I thought I had heard most of them but I realize how little I know every day.

Here I go.

GI cocktail: viscous lidocaine, Maalox and Bentyl/Donnatol (antispasmodic) all PO +/- antiemetic

Headache: Tylenol, Phenergan, +/- O2

Drug seekers: "I will not give you Morphine or Demerol because it causes constipation/nausea/other BS quasi-medical reason."

Severe Agitation: Haldol + Ativan + Benadryl, all IM

Todo Me Duele (everything hurts): Toradol IM + IVF +/- sedative

Local anesthetic for kids: use an insulin syringe (30 G needle) and distract them before injecting

Tell us your dirty little tx and secrets. Unleash the dogs of medicine so that Dispo can be conquered worldwide!

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[whasupmd2]

Berman DA, Porter RS, Graber M. The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial. Emerg Med. 2003 Oct;25(3):239-44.

 

[Hayduke]

Liquid prednisone tastes like posterior vent + airplane glue. Check w/ your pharmacy, but consider injectable dexamethasone via oral route. It is tasteless and more concentrated therefore smaller volume= less yacking.

Before cutting the wedding band off that LOL, try wrapping the proximal figer w/ the strap off an O2 mask. Wrap flat (like tape) over knuckle and under ring so that the ends are opposed distally. Pull the ends apart as you edge the ring over the knuckle. It takes a couple of tries, but it has never failed for me.

Keep a scut-monkey at the bedside when flushing w/ a morgan lens. It's a drag when the fluid runs dry and a panicked pt. performs a self-cornectomy.

 

[NinerNiner999]

Constipation? try 1/2 Fleet's phospha-sodium enema and 1/2 ginger ale rectally. Stand back, duck, and cover...

 

[ERMudPhud]

Renal Colic-- Antiemetic of choice, and IV Dilaudid, wait 10-15 minutes and then give 800 mg PO motrin. In double blinded studies motrin has been as effective as toradol, way cheaper, and less incidence of renal failure.

My wife's esophageal foreign body cocktail- 5mg IV valium, IV Glucagon, and PO soda (ginger ale, coke, whatever) I don't know what the valium is doing but her success rate is way better than mine.

 

[DrQuinn]

My headache cocktail (see ER intubations thread):

Magnesium 1 gm, Benadryl 12.5 mg, Reglan 10 mg. All IV. Repeat in 1-2 hours if no better. Works like a charm, and it may help hte patietn get sleep.

Obviously, if a patietn comes in with a more "serious" headache, this is not what I use, but this is for the non urgent patients with chronic type headaches. D/C with reglan.

Q, DO

 

[DocWagner]

Quinn that is a truly bizarre HA cocktail...mine is Phenergan 12.5mg IV or Compozine 5mg IV and Toradol 30mg IV. If Toradol doesn't work then Nubain 5mg IV (all can be used IM I just double the dose).
Or just Fiorinol.

Renal Colic, Phenergan 12.5 mg IV, Toradol 30mg IV, MSO4 2mg IV

Don't use GI cocktail.

Back pain cocktail Toradol 60mg IM, stretches, offer a rack and a crack...home with diazepam 5mg #5, Naprosyn 500 #15 maybe the "V" word #5 and an ice pack.

Constipation Mag Citrate to go home 1 bottle


"OH ITS MY LUMBAGO and only demerol works" pain...explain that I don't give demerol and give Lodine (its an NSAID, but I pronounce it like Codeine and then they like it).

 

[deleted6669]

"give Lodine (its an NSAID, but I pronounce it like Codeine and then they like it)."

or pronounce dolobid as dilobid and it sounds kinda like dilaudid......

 

[DrQuinn]

Quinn that is a truly bizarre HA cocktail...mine is Phenergan 12.5mg IV or Compozine 5mg IV and Toradol 30mg IV. If Toradol doesn't work then Nubain 5mg IV (all can be used IM I just double the dose).
Or just Fiorinol.

QUOTE]

Our hospital doesn't have Compazine... apparently there's a shortage (interesting how the company can't make Compazine but since Zofran has come out, they're suggesting we use that instead... *same company*).

Q, DO

 

[Hayduke]

Constipation? try 1/2 Fleet's phospha-sodium enema and 1/2 ginger ale rectally. Stand back, duck, and cover...

I like the idea of sipping the other 1/2 ginger ale, but you could also try a SMOG and free yourself from the temptation.
SMOG=sorbitol, mineral oil and glycerin. 1:2:2.

I learned this while working as a nurse in Knoxville while attending UT. The sorbitol layers out to a festive orange and white sundae. GO VOLS!

 

[Robz]

I like the idea of sipping the other 1/2 ginger ale, but you could also try a SMOG and free yourself from the temptation.
SMOG=sorbitol, mineral oil and glycerin. 1:2:2.

I learned this while working as a nurse in Knoxville while attending UT. The sorbitol layers out to a festive orange and white sundae. GO VOLS!

This has nothing to do with adding to this thread but this cocktail is ultra cool....I'll have to start singing rocky top if I ever do that.

 

[Apollyon]

I like the idea of sipping the other 1/2 ginger ale, but you could also try a SMOG and free yourself from the temptation.
SMOG=sorbitol, mineral oil and glycerin. 1:2:2.

I learned this while working as a nurse in Knoxville while attending UT. The sorbitol layers out to a festive orange and white sundae. GO VOLS!

They lied to me! I was told SMOG was Duke-specific. I wish I could remember what was in the "Rocket Fuel" that this one Ob was telling me about.

 

[docB]

Our hospital doesn't have Compazine... apparently there's a shortage (interesting how the company can't make Compazine but since Zofran has come out, they're suggesting we use that instead... *same company*).

Q, DO

We can't get IV compazine either. Damn the FDA for their "black box" on droperidol. That stuff is the nectar of the gods. Agitation, headache, nausea, engine knocks and pings, everything.

One thing I've started doing at my suburban hospitals is telling the solid citizen drug seekers that they're junkies. There's this whole cadre of whiney, regular folk types that don't even know that they're seekers. They just know that when they don't feel good they can take a hit of a "D" and they feel great. They know that all the other stuff doesn't give them the same high so they say it doesn't work. What I've been doing is when they say that they only get relief with Demerol I tell them, "Oh, so you've develped an addiction. You see, Demerol isn't really a pain medicine, it just gets you high so you don't care. Your reliance on Demerol to feel better is the same as a street junky's reliance on heroin. I'll give you the Demerol just this once but I'm going to call your doc and let them know that you are going to ERs and seeking. You need to think about taking steps to get off this stuff."
Often they just get angry and AMA or they take their hit and wander off but the words "junkie" and "heroin" stick with them. And what are they gonna do? I treated their pain (damn JACHO and thier "5th vital sign" crap) and I can't be dinged by the board for suggesting that a patient seek help for a substance abuse problem.

 

[Febrifuge]

Ballsy! I like it.

Do you then call the patient's PC doc? How do those conversations usually go?

 

[docB]

Yeah, I call the doc and say "Your patient is here for their Demerol. Do you know that they've gotten to this point?" Most say that they'll discuss it with them. Some say to just give it to them and others say to give them Motrin and boot them.
As for the patients some get offended and leave but at least they know there's a problem. Remember, I'm talking about regular folks who aren't consciously seeking, they just know that to feel good they need the D and nothing else will do. Others get offended and still take the shot, those are the ones turning the corner to being real abusers.
The conversations are tough. The patients will keep coming back to what ever their medical complaint is, "But my back pain, migraines, neuropathy, fibromyalgia is diferent!" I tell them that I know that they have pain but that thier craving for euphoric drugs is a new and seperate problem.

Boy, I just reread my other post and it sounds harsh. I bet I get flamed. The good points of this strategy are that even though the patient winds up hating me they do get their pain treated and they to get made aware that there's a problem.

 

[Chris_Topher]

Non-clinical: Drug rep pens are nurse candy. Pass out a little candy now and again for good help or for no particular reason, and you are much more likely to get a quick chaparone for that vag exam.

 

[NinerNiner999]

I like the idea of sipping the other 1/2 ginger ale, but you could also try a SMOG and free yourself from the temptation.
SMOG=sorbitol, mineral oil and glycerin. 1:2:2.

I learned this while working as a nurse in Knoxville while attending UT. The sorbitol layers out to a festive orange and white sundae. GO VOLS!

Who said anything about sipping the other 1/2 of ginger ale?

 

[Hayduke]

Who said anything about sipping the other 1/2 of ginger ale?

Ok...I made that up. Waste not etc.
It's being creative w/ the leftover part of the sorbitol that demonstrates true thrift.

 

[mikecwru]

Non-clinical: Drug rep pens are nurse candy. Pass out a little candy now and again for good help or for no particular reason, and you are much more likely to get a quick chaparone for that vag exam.

Totally! The shinier, the better.

mike

 

[Sessamoid]

Renal Colic-- Antiemetic of choice, and IV Dilaudid, wait 10-15 minutes and then give 800 mg PO motrin. In double blinded studies motrin has been as effective as toradol, way cheaper, and less incidence of renal failure.

I don't know what the valium is doing but her success rate is way better than mine.

Valium's effect is probably as muscle relaxant.

Do you have the citation for the study b/w motrin and toradol? I'd love to read that. I've generally been of the opinion that opioids are next to useless in renal colic. I've hit small adults with 40+ mg of morphine to practically no effect for kidney stone pain. It did however make him more nauseous.

 

[Scrubbs]

I think the differences in how we all treat headache are really interesting...

I generally start with 10mg Reglan IV and 1L NSS bolus... if that doesn't work after 30min or so, they get 25mg of Benadryl with 30mg Toradol - both IV. Have not had this regimen fail and I send 'em out with PO Reglan and Neuro f/u (especially for repeat offenders).

Of course, more serious sounding headaches get the full w/u, but for your migraines... works like a charm!

 

[amr122]

Here's the abstract from the study comparing im toradol with po ibuprofen:

INTRAMUSCULAR KETOROLAC VS. ORAL IBUPROFEN IN EMERGENCY DEPARTMENT PATIENTS WITH ACUTE PAIN

Neighbor, M.L., et al, Acad Emerg Med 5(2):118, February 1998

BACKGROUND: Although intramuscular (IM) ketorolac has become popular for the management of patients with acutely painful conditions, as a nonsteroidal anti-inflammatory drug (NSAID), its mechanism of action is similar to that of other NSAIDs.

METHODS: This randomized, double-blind study, from San Francisco General Hospital, compared the effects of a single dose of IM ketorolac (60mg) or oral ibuprofen (800mg) in 101 adults with moderately to severely painful (a score of 5-8 on a 0-10 point scale) conditions. Provision of supplemental analgesics was permitted at the discretion of the managing physicians.

RESULTS: There were no differences between the two groups in underlying diagnoses or mean pretreatment pain scores. Pain decreased significantly over the two-hour monitoring period in both groups, and there were no significant differences between the groups at any time. The mean pain score decreased from 6.8 at baseline to 3.7 at two hours in the ketorolac group, and from 7.0 to 3.8 in the ibuprofen group. By two-hours, 40% of the patients in both groups continued to report moderate to severe pain. Five patients in the ketorolac group (9%) and four in the ibuprofen group (8%) were given supplemental analgesics.

CONCLUSIONS: At the authors' institution, the cost of a single dose of ketorolac ($6.80) is substantially higher than that of either ibuprofen ($0.03) or an 8mg dose of IV morphine ($0.48). In this study, IM ketorolac was not superior to oral ibuprofen in patients with moderate to severe pain. The authors suggest that their findings do not support routine use of IM ketorolac in these circumstances.

adam

 

[Sessamoid]

Here's the abstract from the study comparing im toradol with po ibuprofen:

INTRAMUSCULAR KETOROLAC VS. ORAL IBUPROFEN IN EMERGENCY DEPARTMENT PATIENTS WITH ACUTE PAIN

adam

That doesn't really answer my question, since I use only IV toradol for renal colic. Also, I'm only really interested in renal colic here, as toradol has been shown in lab studies to decrease renal blood flow in dogs to an obstructed kidney, which is hypothesized to be the main source of the pain relief.

Toradol, an NSAID used for renal colic, decreases renal perfusion and ureteral pressure in a canine model of unilateral ureteral obstruction. Perlmutter A - J Urol - 01-APR-1993; 149(4): 926-30

My question is whether or not all NSAIDs have this property, and I was unable to find any studies that address this question. Though apparently, Europeans have been using IV indomethacin (not available in the US) for a long time with similar results.

 

[ERMudPhud]

While its true that this study looks at multiple types of pain and IM injection it should be kept in mind that pharmacokinetics of IV vs IM toradol are very similar with the IM half-life of absorption being less than 5 minutes. Indeed PO absorption of NSAID on an empty stomach can be in a similar range (<10 minutes). So, the IM study is probably applicable to IV usage.

As for the effects of NSAIDS on renal perfusion based on the following date the answer would have to be maybe.

Oliver JJ, Eppel GA, Rajapakse NW, Evans RG.
Related Articles, Links

Lipoxygenase and cyclo-oxygenase products in the control of regional kidney blood flow in rabbits.
Clin Exp Pharmacol Physiol. 2003 Nov;30(11):812-9.
PMID: 14678242 [PubMed - in process]

2:
Kristova V, Djibril NM, Fackovcova D, Kriska M, Kurtansky A.
Related Articles, Links

Comparison of vasoconstrictor responses to selected NSAIDs in rabbit renal and femoral arteries.
Bratisl Lek Listy. 2002;103(2):50-3.
PMID: 12061021 [PubMed - indexed for MEDLINE]

3:
Bergamo RR, Cominelli F, Kopple JD, Zipser RD.
Related Articles, Links

Comparative acute effects of aspirin, diflunisal, ibuprofen and indomethacin on renal function in healthy man.
Am J Nephrol. 1989;9(6):460-3.
PMID: 2596536 [PubMed - indexed for MEDLINE]

I don't think that we know for sure why NSAIDs help with renal colic, decreased perfusion may be part of it and in that case some NSAIDs may be more potent than others depending on which article you believe.

Given the head to head study of pain relief with toradol vs motrin, the increased cost of toradol, and the reported increased risk of renal failure with toradol, I've never felt it was worth giving. The increased renal failure may be due to the exact same decrease in perfusion that is hypothesized to contribute to the pain relief or may be for other more idiopathic reasons.