Extreme pain protocol?

[Makati2008]

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I have a question and I hope that some of you can give me some guidance. At our facility we use midlevel providers to provide the most coverage in the ER at this time. Due to having to use Schedule II narcotics for pain control time to time and to remain in compliance with the DEA and TX DPS it was stated that we must form protocols to use these medicines, (For example we can use Morphine due to it being in the Chest Pain protocol admission orders) and it appears the staff here wants a protocol written for "severe pain" to catch the usages in a easier manner.

Does anyone have any guidance on the situation?

Thanks!

 

[deleted109597]

No standards in the literature. Littrell, K. Kern, K. Acute ischemic syndromes: Adjunctive therapy Cardiology Clinics - Volume 20, Issue 1 (February 2002)

ACC/AHA(2002) guidelines recommend 1-5mg IV every 5-30min for pain not relieved by 3 sublingual NTG

Journal of the American College of Cardiology
Volume 36, Issue 3, September 2000, Pages 970-1062

Morphine does increase risk of death in NSTEMIs based on CRUSADE trial though.

American Heart Journal
Volume 149, Issue 6, June 2005, Pages 1043-1049

 

[Makati2008]

Thanks Sir,
For chest pain we have a protocol set up but do you think that the literature has something for problems such as fractures, abdominal problems (diverticulitis, appendicitis, etc...) and other things that cause "extreme pain".

When I was told to do research and I heard work on and find an extreme pain protocol to implement here at the hospital I thought it was an impossible/difficult task due to pain being a subjective finding in nature. Do you think that basing the protocol off of the WHO step ladder is a feasible ideal in your opinion?

 

[tkim]

http://www.medscape.com/viewarticle/714500?src=mp&spon=45&uac=79648BN

 

[deleted109597]

The 1+1 gets a lot of use here. Some places are still sketchy on the dilaudid though. Here it is comical, because if you write 10 of morphine the nurses won't give it ("you're sedating" "it's my license" etc), but 2mg dilaudid they won't bat an eye.
The problem with the WHO ladder is that it starts with non-opioids. However, you might get better luck with it. There is so much difference in opioid sensitivity that any protocol won't catch all of them.
Truthfully, the chest pain protocol can probably be used directly, as it can give pretty high doses of morphine, but most nurses don't want to be pushing pain meds q5min.

 

[BADMD]

Here it is comical, because if you write 10 of morphine the nurses won't give it ("you're sedating" "it's my license" etc), but 2mg dilaudid they won't bat an eye.

I love that "Its my license" thing. Do nurses really think they are going to lose their license for giving an appropriate weight based dose of an opiate as ordered and verified by the physician. I've actually started to push back with something to the effect of "We both know that isn't true."