nerve blocks in a dilaudid free ED

[MSmentor018]

I've seen the back and forth controversy regarding nerve blocks for humerus, radial/ulnar fx. mike stone does it without any problems. ortho of course gets upset and brings up the whole compartment syndrome issue. if the pt is getting lido only which will wear off by 4 hrs, isn't it pretty safe?

we're converting to a dilaudid and perco-snack free ED so I am trying to give some alternatives

---

Members don't see this ad.

 

[gutonc]

I'm not EM, but recently had the pleasure of being a trauma activation after a bike wreck (LOC despite wearing a helmet) and had a displaced radial and non-displaced ulnar fracture. Got a little Vitamin F in the ED (Trauma surgeon on that day was a friend of mine, which was kind of hilarious). Got a scrip for 20 oxy's that I never filled.

Personal anecdotes out of the way now...isn't acute fracture one of the few true indications for opioids in the ED? I get not giving it for other stuff, but this just seems a bit cruel.

 

[Vandalia]

I have to agree with gutonc.

The whole "opioid free ED" or "I never give opioids" seems to me too far of a step in the direction of a rigid, protocol driven, "mid-level" medicine.

Physicians evaluate the situation, apply a knowledge base, and make a decision after balancing all the alternatives. Sometimes that means opioids, more often it doesn't. But that is what we are (I assume) board certified EM physicians for.

There are a few things that are illegal and/or clearly beyond the ethical pale. But otherwise if you have been doing EM for even a little while you know that for everything you say never could/would happen.... it quickly does.

EDIT: One of my colleagues suggested starting a "cardiology free ED." Would definitely help with the patients-per-hour.

 

[TooMuchResearch]

I have to agree with gutonc.

The whole "opioid free ED" or "I never give opioids" seems to me too far of a step in the direction of a rigid, protocol driven, "mid-level" medicine.

Physicians evaluate the situation, apply a knowledge base, and make a decision after balancing all the alternatives. Sometimes that means opioids, more often it doesn't. But that is what we are (I assume) board certified EM physicians for.

There are a few things that are illegal and/or clearly beyond the ethical pale. But otherwise if you have been doing EM for even a little while you know that for everything you say never could/would happen.... it quickly does.

EDIT: One of my colleagues suggested starting a "cardiology free ED." Would definitely help with the patients-per-hour.

Agree. Or "like" button.

 

[gutonc]

Also, have you ever had a nerve block like that? I had one when I had the surgery to repair said fracture. It was cool for awhile, but 12 hours of a completely non-functional right arm, followed by another 12 hours of that pins and needles sensation that made me wonder if my arm was just waking up or if I was getting compartment syndrome under the cast.

 

[MSmentor018]

Also, have you ever had a nerve block like that? I had one when I had the surgery to repair said fracture. It was cool for awhile, but 12 hours of a completely non-functional right arm, followed by another 12 hours of that pins and needles sensation that made me wonder if my arm was just waking up or if I was getting compartment syndrome under the cast.

i had the same for my injury. the mix of lido/steroid/bup and I was numb for almost 36 hrs. you're right, pain was completely gone but I really couldn't fell under the splint. that's why i am thinking of plain lido. on the anesthesia board one said compartment syn pain should appear even when blocked

we have fentanyl/morphine/norco. just no dilaudid and percocet.

 

[21isFun]

i had the same for my injury. the mix of lido/steroid/bup and I was numb for almost 36 hrs. you're right, pain was completely gone but I really couldn't fell under the splint. that's why i am thinking of plain lido. on the anesthesia board one said compartment syn pain should appear even when blocked

we have fentanyl/morphine/norco. just no dilaudid and percocet.

Honest question...what do you when the patients list allergies to "morphine, toradol, Tylenol, Vicodin , etc" aka:anything not dilaudid or Percocet

Do they get an exception? I feel like all the patients will pull that crap to get around the policy.

 

[TooMuchResearch]

i had the same for my injury. the mix of lido/steroid/bup and I was numb for almost 36 hrs. you're right, pain was completely gone but I really couldn't fell under the splint. that's why i am thinking of plain lido. on the anesthesia board one said compartment syn pain should appear even when blocked

we have fentanyl/morphine/norco. just no dilaudid and percocet.

Your ED has decided to continue to use short acting high potency synthetic opioid but get rid of the longer lasting one?

Is this sort of policy common? I haven't heard of anything like this anywhere around here.

 

[Jlaw]

I don't see the harm in narcs for trauma. If someone is willing to break a bone to get some vitamin D I'm happy to supply it. Ortho at our shop basically lets us do whatever we want. Actual pain management is very attending driven, some love doing nerve/hematoma blocks, some give IV lido for certain complaints, others just give opiates. If the patient isn't complaining much they might get nothing, or 800mg of motrin. My experience is that blocks work very well. I've only had 1 patient who didn't respond despite US visualization of the block and I've never had any compartment syndrome bouncebacks.

We have a huge narc problem so trauma is one of the few things we give them for, we are probably one of the more hard line ED's, patients don't even argue and I haven't seen any overt seekers yet, the word has gotten out that we aren't the easy fix. I'm 6 months into residency and have only given narcs a couple dozen times...some trauma and the rest for confirmed appy's, SBO's and kidney stones. We pretty much refuse to give them for chronic pain and if a pt is discharged with a script we write for 1-2 days and tell them they have to go to their follow up appt to get more.

 

[MSmentor018]

Honest question...what do you when the patients list allergies to "morphine, toradol, Tylenol, Vicodin , etc" aka:anything not dilaudid or Percocet

Do they get an exception? I feel like all the patients will pull that crap to get around the policy.

haldol, gabapentin, lidocaine, ketamine, tylenol IV, norflex, zanaflex...etc. no benadryl IV unless for allergic reaction or preventive
the only exception is pallative care, active cancer, terminal illness. in that case you should get whatever you want.
you can treat pain at the site by stopping the pain track from being developed (nerve blocks) or at the neck (systemic).

scott weingart has an emcrit podcast on "the opoid free ed". you don't have to listen, read the list/cocktails he uses
http://emcrit.org/podcasts/opioid-free-ed/
this is sergey's website
http://www.painfree-ed.com/lectures

we're an outlying small community ED, no trauma. the level I and II center in town have posted policies already so the seekers are coming to the outskirts !
even zdoggmd has an opinion on it

 

[Angry Birds]

Gotta be honest, nerve blocks are far more time-intensive compared to simply writing "Dilaudid 1 mg IV."

 

[the argus]

we have fentanyl/morphine/norco. just no dilaudid and percocet.

Could you please explain the reasoning for this. As far as I'm aware, no opioid has ever been shown to be more beneficial or dangerous than another.

Is it just because those are the ones people know and ask for, so you can just say "we don't have that" instead of arguing with drug seekers?

 

[MSmentor018]

Is it just because those are the ones people know and ask for, so you can just say "we don't have that" instead of arguing with drug seekers?

Gotta be honest, nerve blocks are far more time-intensive compared to simply writing "Dilaudid 1 mg IV."

yep, that's exactly the reason

it's the standard big brother kinda thing. we all know that seekers or not, the opoid thing is getting out of control. you're right, anything you do outside of writing for dilaudid burns a ton of time (pt's angry, have to explain, may take more than 1 med for relief, nerve block, nursing time....etc) . if we all don't individually stand up and say no, a goverening body will intervene and say no for us

 

[TooMuchResearch]

yep, that's exactly the reason

it's the standard big brother kinda thing. we all know that seekers or not, the opoid thing is getting out of control. you're right, anything you do outside of writing for dilaudid burns a ton of time (pt's angry, have to explain, may take more than 1 med for relief, nerve block, nursing time....etc) . if we all don't individually stand up and say no, a goverening body will intervene and say no for us

The government is going to tell us we can't use a common legal opioid for acute pain management in undifferentiated ED patients?

That's fine, but until then, I'm using it.

 

[Hamhock]

Gotta be honest, nerve blocks are far more time-intensive compared to simply writing "Dilaudid 1 mg IV."

.
birdstruck

 

[MSmentor018]

The government is going to tell us we can't use a common legal opioid for acute pain management in undifferentiated ED patients?

That's fine, but until then, I'm using it.

not the govt, just my hospital system

 

[canigetawhatwhat]

I dont give dilaudid. Ever.


Horrible drug.

 

[TooMuchResearch]

I dont give dilaudid. Ever.


Horrible drug.

What is horrible about appropriate analgesia?

 

[RustedFox]

What is horrible about appropriate analgesia?

QFT.

I had an attending in residency who never gave Dilaudid, because it was a... "bad drug".

I asked her one day what made it a "bad" drug. She could not articulate any further explanation.

You know the definition of "delusion"? It's a fixed, false belief.

 

[sum dude]

I have to agree with gutonc.

The whole "opioid free ED" or "I never give opioids" seems to me too far of a step in the direction of a rigid, protocol driven, "mid-level" medicine.

Physicians evaluate the situation, apply a knowledge base, and make a decision after balancing all the alternatives. Sometimes that means opioids, more often it doesn't. But that is what we are (I assume) board certified EM physicians for.

There are a few things that are illegal and/or clearly beyond the ethical pale. But otherwise if you have been doing EM for even a little while you know that for everything you say never could/would happen.... it quickly does.

EDIT: One of my colleagues suggested starting a "cardiology free ED." Would definitely help with the patients-per-hour.

Problem is we give opiates to wrong things. Who (traditionally) gets opiates? Vague abdominal pain, vague chest pain, vague back/neck pain. Who needs opiates? Fractures, abscesses, large lacerations, road rash, burns.

 

[goodoldalky]

Honest question...what do you when the patients list allergies to "morphine, toradol, Tylenol, Vicodin , etc" aka:anything not dilaudid or Percocet

Do they get an exception?

Do they have a broken leg?

 

[Janders]

Dilaudid isn't bad; how you use it might be bad.

Anyone have an IV lidocaine analgesia policy lying around (from a real live hospital using it...)?

 

[Apollyon]

Dilaudid isn't bad; how you use it might be bad.

Anyone have an IV lidocaine analgesia policy lying around (from a real live hospital using it...)?

I was thinking about that driving in to work this morning - what is the lidocaine dose for, for example, renal colic?

 

[Apollyon]

Well, I contacted my friend, Dr. Google, and found a lot online. However, the sources I saw all talked about infusions, and taking 8 hours to get to steady state. 1-2mg/kg is a load, but I don't know how this would work in the ED.

 

[Rendar5]

I dont give dilaudid. Ever.


Horrible drug.

:rolls eyes: yeah, the horror of pain reduction. omagawd...
seriously, people [in general, not necessarily here] are going from the xtreme of opiates for all pain (stubbed toe, don't want a bad press gainey) to the extreme of no opiates ever and supporting either one is just ridiculousness in and of itself. Extremist views are bad for both the doc and the patient.

 

[deleted109597]

:rolls eyes: yeah, the horror of pain reduction. omagawd...

Agree with you on the extremes.
However, not one person has ever died as a direct result of pain. Plenty have died from pain meds, either iatrogenic hypotensive shock, or simply killing them off with narcotic overdoses as an outpatient.
We can treat pain without killing people, and we need to figure out a way to do it. Jumping to narcotics first isn't the answer, but withholding them from any condition isn't the answer either.

 

[canigetawhatwhat]

Dilaudid is a bad drug. Simple.

Look around you. Huge narcotic epidemic.

Why give a drug that is euphoric?

 

[alpinism]

I like to tell my patients what my drill instructor told me in basic training.

Pain is weakness leaving the body.

 

[Janders]

Well, I contacted my friend, Dr. Google, and found a lot online. However, the sources I saw all talked about infusions, and taking 8 hours to get to steady state. 1-2mg/kg is a load, but I don't know how this would work in the ED.

Yes precisely I also consulted my colleague Dr. Google; a few lovely anesthesia-based protocols for load + infusion in the PACU / post-op setting intended for massive abdominal surgery (where it is shown to decrease opiate use and thus speed recovery, etc).

I was hoping for a few real world ED examples. Helpful for showing at P&T, ya know?

From my review, it looks like 1.5mg/kg IV lidocaine slow pushed over 3-4 minutes is reasonable for renal colic. I've seen that dose used and it is very efficacious. It looks like most people would suggest having the patient on tele for the bolus and the time period immediately following (say 30 minutes). Should they have an EKG prior; perhaps just selected patients (age based?) should have EKG prior?

 

[gman33]

Dilaudid really isn't a good drug. There is a large euphoric component which is not present in morphine or fentanyl.
This leads to more addiction and abuse.

I can control pain well without this agent, that's why I no longer use it.

 

[RustedFox]

Dilaudid is a bad drug. Simple.

Look around you. Huge narcotic epidemic.

Why give a drug that is euphoric?

By your logic, Dilaudid, Morphine, Percocet, Vicodin, Ultram, Fentanyl, Codeine, Nubain, and all opioids are all "bad drugs".

The sun is yellow. The sky is blue. Those two facts are not related.

 

[Janders]

I use dilaudid much more than morphine due to the fact is easy for me to give 1mg + 1mg IVP when needed, but hard for me to give 8mg + 8mg Morphine when needed. I also see less pruritis and nausea with it.

That said, in general, we are VERY interested in lowering the use of opiates. We prescribe very few for home in our ED. We added ketamine for acute pain, are working on adding lidocaine, sadly won't get IV APAP. But I still find myself giving IVP opiates (dilaudid largely) to patients who have real, painful, acute conditions most shifts...

 

[Vandalia]

We prescribe very few for home in our ED.

This is the critical issue. "Drug seeking" in the ED is about what they can take home, not so much the 0.2mg of Dilaudid they can get when they are here.

One of the advantages of the rise of the mid-levels is that it is now pretty much routine for a patient to be seen "next business day" after an ED visit. As such even when "take home" narcotics are indicated, there is very rarely a need for more than a couple. That is the important issue for an ED to address.

 

[TooMuchResearch]

Dilaudid is a bad drug. Simple.

Look around you. Huge narcotic epidemic.

Why give a drug that is euphoric?

You've misinterpreted the problem as being our fault for treating acute pain.

Dilaudid is a good drug. I'll continue to appropriately use it for analgesia.

 

[WilcoWorld]

You know the definition of "delusion"? It's a fixed, false belief.

...that isn't held by the rest of your community.

That last part of the definition always makes me chuckle.

 

[WilcoWorld]

I was thinking about that driving in to work this morning - what is the lidocaine dose for, for example, renal colic?

The lidocaine dose for renal colic is 30 mg of IV ketorolac.

 

[WilcoWorld]

Well, I contacted my friend, Dr. Google, and found a lot online. However, the sources I saw all talked about infusions, and taking 8 hours to get to steady state. 1-2mg/kg is a load, but I don't know how this would work in the ED.

I used to work with a guy who gave lido infusions for pain. He was an FP and did a lot of other non-EM things. He was a really good person, and definitely had his patients' best interest in mind, but it uniformly sucked to get sign out from him.

 

[goodoldalky]

I doubt seriously that there is any different "euphoria" between efficacy adjusted / equivalent doses of morphine (10mg or 0.1mg/kg) or dilaudid 1 mg (0.01 mg/kg). Those that see less "euphoria" with morphine are using the quasi homeopathic 4mg dose. (Depending on where you work, your department probably doses morphine based on what dose your supplier provides at the lowest cost 4, 5, and 6 mg all being common).

Dilaudid stimulates much less histamine release and unlike morphine does not have a renally excreted active metabolite. The data suggests that dilaudid is probably the better drug, if those factors come into play.

 

[Apollyon]

the quasi homeopathic 4mg dose.

Could you be overstating that just a bit, fella? I mean, you say 1 of Dilaudid equals 10 of morphine, but I've always read/heard 5-7 mg equivalence. And, just anecdotally, I've seen many an opiate naive pt get relief from 2 of MS. To say that 4mg is "quasi homeopathic" sounds a little exaggerated. Well, to me, at least!

 

[Psai]

Could you be overstating that just a bit, fella? I mean, you say 1 of Dilaudid equals 10 of morphine, but I've always read/heard 5-7 mg equivalence. And, just anecdotally, I've seen many an opiate naive pt get relief from 2 of MS. To say that 4mg is "quasi homeopathic" sounds a little exaggerated. Well, to me, at least!

Agree I've had 2mg morphine work just fine in many instances

 

[TooMuchResearch]

Could you be overstating that just a bit, fella? I mean, you say 1 of Dilaudid equals 10 of morphine, but I've always read/heard 5-7 mg equivalence. And, just anecdotally, I've seen many an opiate naive pt get relief from 2 of MS. To say that 4mg is "quasi homeopathic" sounds a little exaggerated. Well, to me, at least!

I think it's more 8-10

 

[Vandalia]

Could you be overstating that just a bit, fella? I mean, you say 1 of Dilaudid equals 10 of morphine, but I've always read/heard 5-7 mg equivalence. And, just anecdotally, I've seen many an opiate naive pt get relief from 2 of MS. To say that 4mg is "quasi homeopathic" sounds a little exaggerated. Well, to me, at least!

Keep in mind that there is a high placebo response rate in pain. I have had more than one patient tell me how great the pain medication they had received was working. The "pain med" was the saline flush. So while 2 mg of morphine might not do much from a pharmacological perspective, it may turn out to be very effective. EM as a whole has little patience for the "psychological mumbo-jumbo" when it comes to treatment, but in this case it might well be relevant.

 

[Apollyon]

Keep in mind that there is a high placebo response rate in pain. I have had more than one patient tell me how great the pain medication they had received was working. The "pain med" was the saline flush. So while 2 mg of morphine might not do much from a pharmacological perspective, it may turn out to be very effective. EM as a whole has little patience for the "psychological mumbo-jumbo" when it comes to treatment, but in this case it might well be relevant.

I hear what you are saying, but, still, I think that saying "2mg of morphine might not do much from a pharmacological perspective" is still a bit of a stretch. I mean, it was 10 years ago, in May or so of 2006, when one of the Duke cardiologists told me about a study in press at that time that said to go heavy on the nitro, and light on the morphine, because people would just get euphoria and analgesia from the morphine, while still having ischemia going on. I suggested 2mg morphine q5-10 min x 3 total doses, and that cards guy said that it was quite reasonable.

I just think of one time when I thought I was a touch cavalier, and I ordered 1mg Dilaudid for an old lady with a displaced hip fracture, and she became hypoxic!

 

[theboo]

Honest question...what do you when the patients list allergies to "morphine, toradol, Tylenol, Vicodin , etc" aka:anything not dilaudid or Percocet

Do they get an exception? I feel like all the patients will pull that crap to get around the policy.

My allergy list is dilaudid. I hate that hot feeling so if I ever have to get morphine I ask them to please just put it in nice and slow. I have had dilaudid pushed fast and it was awful

 

[theboo]

Yes precisely I also consulted my colleague Dr. Google; a few lovely anesthesia-based protocols for load + infusion in the PACU / post-op setting intended for massive abdominal surgery (where it is shown to decrease opiate use and thus speed recovery, etc).

I was hoping for a few real world ED examples. Helpful for showing at P&T, ya know?

From my review, it looks like 1.5mg/kg IV lidocaine slow pushed over 3-4 minutes is reasonable for renal colic. I've seen that dose used and it is very efficacious. It looks like most people would suggest having the patient on tele for the bolus and the time period immediately following (say 30 minutes). Should they have an EKG prior; perhaps just selected patients (age based?) should have EKG prior?

I am not a MD now. So I am wondering what lidocaine does as a pain drug (IV FORM)

 

[Apollyon]

I am not a MD now. So I am wondering what lidocaine does as a pain drug (IV FORM)

Lidocaine works on the sodium channel, and that is why it numbs skin. However, for that same reason, that is why it can work IV - pain receptors that have a sodium channel are affected when the lidocaine contacts them. Unfortunately, I am almost 20 years away from the biochemistry, so I can't be more specific. However, we also use lidocaine IV for certain irregular heart rhythms (although not preferentially, because we have newer, "cleaner" medications available), due, again, to the effect on the sodium channel, in this case, in the heart.

 

[BoardingDoc]

I think it's more 8-10

1 of dilaudid ~ 6.666 of morphine