Current 4th year med student on an audition rotation in EM. Seems like it should be simple but for some reason I'm having issues when it comes to deciding which pain medications to order for my patients. Tylenol/NSAIDs seem like a safe bet and simple choice most of the time, but choosing when to jump to Norco/Morphine/Fentanyl/etc. and which one to choose at the time seems to be tripping me up. For some reason I feel hesitant to as I'm nervous about overmedicating the patient. Does anyone have some general advice that they live by when deciding what their patients receive for pain management to simplify things?
Pain Management Advice?
- Thread starter Pokedoc
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Undifferentiated young person with a “my ___ hurts, doc.” = tylenol +\- Motrin. If you get the vibe they need something “strong that the doctor gave me” reach for IV toradol.
Young people with broken bones or potentially surgical abdomens = narcotics right off the bat. Even if you think they may be pain seeking. You’ll feel like a jerk when you deny someone opiates and they end up having an appendicitis.
Old people = always be judicious. Pain can cause delirium just as opiates can in the elderly so it’s a balancing act. You can also snow them pretty easily. Also tend to avoid NSAIDs in this group and reach for tylenol early.
As far as picking an opiate.
Trauma or need something very short acting = fentanyl
Confirmed badness that needs longer acting = dilaudid
Sending someone home with narcotics = oxycodone
Dont Forget about topical anesthetics! Patients LOVE lidocaine patches.
Young people with broken bones or potentially surgical abdomens = narcotics right off the bat. Even if you think they may be pain seeking. You’ll feel like a jerk when you deny someone opiates and they end up having an appendicitis.
Old people = always be judicious. Pain can cause delirium just as opiates can in the elderly so it’s a balancing act. You can also snow them pretty easily. Also tend to avoid NSAIDs in this group and reach for tylenol early.
As far as picking an opiate.
Trauma or need something very short acting = fentanyl
Confirmed badness that needs longer acting = dilaudid
Sending someone home with narcotics = oxycodone
Dont Forget about topical anesthetics! Patients LOVE lidocaine patches.
Tylenol and ibuprofen first.
Trauma patients (in trauma bay) - fentanyl
Blood pressure low or very low normal - fentanyl instead of morphine
Broken bone or other serious pathology (abnormal labs/abnormal imaging/abnormal vital signs and physical exam with concerning story) - morphine IV/IM
Pregnant - Tylenol
Pregnant and serious problem - morphine
Chance of pregnancy - Tylenol then ibuprofen once pregnancy test is negative
I rarely give PO narcotics because my patients that get narcotics usually have an IV.
Nurse bothering me about patient calling out in pain - go see the patient because either something has changed or patient is a pain seeker
Known pain seeker - Tylenol
Known pain seeker while labs are complete and waiting on imaging (if ordered) - ibuprofen
Allergic to Tylenol/ibuprofen (pain seeker majority of time) - depends: abdomen bentyl, rest of body tramadol
Allergic to dilaudid (rare)- always been someone with a serious problem
I usually give “4 and 4” (4 mg morphine and 4 mg zofran).
Trauma patients (in trauma bay) - fentanyl
Blood pressure low or very low normal - fentanyl instead of morphine
Broken bone or other serious pathology (abnormal labs/abnormal imaging/abnormal vital signs and physical exam with concerning story) - morphine IV/IM
Pregnant - Tylenol
Pregnant and serious problem - morphine
Chance of pregnancy - Tylenol then ibuprofen once pregnancy test is negative
I rarely give PO narcotics because my patients that get narcotics usually have an IV.
Nurse bothering me about patient calling out in pain - go see the patient because either something has changed or patient is a pain seeker
Known pain seeker - Tylenol
Known pain seeker while labs are complete and waiting on imaging (if ordered) - ibuprofen
Allergic to Tylenol/ibuprofen (pain seeker majority of time) - depends: abdomen bentyl, rest of body tramadol
Allergic to dilaudid (rare)- always been someone with a serious problem
I usually give “4 and 4” (4 mg morphine and 4 mg zofran).
This may serve as a helpful framework to start with.
However, I don't use the numeric score to determine mild/moderate/severe. I use other indicators (nature of complaint/how painful it looks to you/vital sign indicators) to decide if I think it's mild/moderate/severe pain.
I honestly don't worry too much about what to give people in the ER...I tend to write morphine 6mg q6hr PRN severe and toradol 15mg q6hr PRN and mild/moderate and let the nurses give it as they please. Nothing bad is (usually) going to happen to them in the ED, and I'm much more careful about what I send them home with.
Although one time I wrote dilaudid 4mg q1 PRN 4 doses instead of dilaudid 1mg q4 PRN 4 doses...and the pt got 8 mg of dilaudid in 2 hours. needless to say the pt almost died and management came a-talkin' to me.
Pt came back a few days later asking for more dilaudid. Go figure
Although one time I wrote dilaudid 4mg q1 PRN 4 doses instead of dilaudid 1mg q4 PRN 4 doses...and the pt got 8 mg of dilaudid in 2 hours. needless to say the pt almost died and management came a-talkin' to me.
Pt came back a few days later asking for more dilaudid. Go figure
- Feb 23, 2010
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If this actually happened, yes, you screwed up. Also, your nurses are ****ing terrible. I can't think of a single RN I've ever worked with who would give a pt 4mg of dilaudid before asking me if I really meant to order that.
100% agree...I wondered too about the RN and I even think I asked her. But it was my fault. Thankfully there was no harm to the pt
You’ll save yourself a lot of time and headaches if you just talk to the patient about this. I heard this on an EMRAP a while back and it’s a game changer. These are some of the questions I routinely ask.
Would you like a medication for pain?
Do you have a ride present or did you drive yourself here? (If thinking opiates, this is very important and a lot of Docs overlook this).
What medications have you had in the past that have helped your pain?
Would you like an oral medication or an injection (if no iv)?
You’d be shocked how many of these you get wrong on your initial assumptions. Sometimes patients won’t know medications and you can educate them on the differences. Regardless, spending one minute up front can definitely help you from having a patient upset at nurses and upset with you on a survey. Discussions are better than just throwing dilaudid at everyone too.
Would you like a medication for pain?
Do you have a ride present or did you drive yourself here? (If thinking opiates, this is very important and a lot of Docs overlook this).
What medications have you had in the past that have helped your pain?
Would you like an oral medication or an injection (if no iv)?
You’d be shocked how many of these you get wrong on your initial assumptions. Sometimes patients won’t know medications and you can educate them on the differences. Regardless, spending one minute up front can definitely help you from having a patient upset at nurses and upset with you on a survey. Discussions are better than just throwing dilaudid at everyone too.
I start off strong: for those patients who express severe pain, have a normal BP, and will require an extensive lab/CT work-up, I order 1 mg of Dilaudid IV right off the bat. I cut this in half for the petite or elderly.
For those that do not require a line, I throw Zofran ODT and Norco 10 mg at them.
For annoying patients, I order Ativan.
For retching and psychosomatic patients, I order Haldol.
Ibuprofen and Tylenol? Ha. Good one.
You're probably too worried about overmedication. I remember a nurse complained to me that I had ordered Norco for a patient that clearly had alcohol on board. You think a dose of Norco is going to do anything to a professional alcoholic??
Keep in mind that the above is what I do if I have to do an extensive work-up in the ER. If I know them to be malingering, drug-seeking, or complete BS, then I discharge them.
If the patient is legit, then I just toss them the proverbial ball and say, "I would love to treat your pain with something strong, but unfortunately our hands are tied due to the fact that you drove here. You have the option of having someone pick you up, in which case we can give you a dose here. Otherwise, you have the option of filling a prescription." Then, I leave the room and tell the nurse that the patient cannot get the dose of pain medication until and unless we lay eyes on the person driving the patient home.
If the patient has any red flags and is a drug-seeker, then I just tell them that I wish I could help them but the man won't let me. But, I encourage you to follow up with your PCP and I can also give you the number of a pain specialist.
If the patient is writhing around in pain and requires an extensive workup, then I think hitting them with the Dilaudid (especially if they have that coupon) makes sense... especially since then I don't care if they want or don't want pain medication. An initial slug of aggressive pain medication just makes the rest of the ER visit so much smoother. Ninety percent of the time I don't even need to redose them.
I don't get the oral vs IV medication question. They get IV medication if they need labs and CT scan with IV contrast. In this case, knowing whether they have a ride or not is irrelevant, since it will be out of their system (practically speaking) by the time of discharge.
If they do not require labs or CT scan, then I almost never give them the option of IV meds. I give them oral medication -- or, very rarely, I'll give them a slug of Toradol or Morphine through an IM route. But yes, in this treat-and-street patient, it is very important to find out if they have a ride or not.
I try talking to patients as little as possible. What a waste of valuable time.
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My revised 2020 WHO plan is:
1 mg slug of Dilaudid IV
On a serious note, I am liberal with the initial dose (especially while work-up is pending) and then more conservative with discharge prescriptions, especially if my work-up has failed to find anything.
Which advice did you follow? Who won out?
The WHO algorithm or my first-Dilaudid-is-on-the-house option?
I didn’t say don’t give dilaudid. I said you’ll be better off having a discussion about pain rather than just blindly ordering it.
I think you misinterpreted the second part. It’s oral vs IM if no IV. Some people would really prefer oral to IM meds they just won’t tell you unless asked.
I also try to spend as little time in the room but having up front discussions about pain has been such an amazing time saver it’s well worth the extra 30 seconds.
endocarditis/spinal abscess IVDA patients that leave AMA every 3 days are tough to treat because you can't just throw dilaudid at them. Or, well, you can but then they AMA when that train stops on the floor.
I've had phenomenal success recently loading them with toradol and gapapentin then landing the pain train with 0.1 mg/kg/hr ketamine infusion. Hospitalists seem to like it--they always continue it on the floor when I start. Doesn't make them feel great but makes them STFU, which is how I titrate pain in anyone
I've had phenomenal success recently loading them with toradol and gapapentin then landing the pain train with 0.1 mg/kg/hr ketamine infusion. Hospitalists seem to like it--they always continue it on the floor when I start. Doesn't make them feel great but makes them STFU, which is how I titrate pain in anyone
Of course, I try not to give drug-seekers any narcotics at all.
The 1 mg dose of Dilaudid just tends to work for 90% of patients, so it's an easy order. Meanwhile, Morphine is often underdosed... If you start ordering the weight-appropriate dose, nurses balk.
I don't often give Dilaudid because I think I can get adequate analgesia with appropriate doses of morphine; this means routine use of 8mg, not 4mg. For the nurse that you think will balk, just give 4mg and then 25 minutes later put another 4mg. It's crazy how they won't bat an eye at that but seeing the EIGHT number sets them off.
- Feb 23, 2010
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Agree with Clive and Cumbre lines. I don't give dilaudid outside of significant ortho injuries / cancer pain / you are the one patient per month who looks like they're actually in agony and I suspect badness. Too high a euphoria:analgesia ratio. Almost all the docs at my shop have adopted a similar thought process and over the past few years I've noticed that our drug seeking population has decreased to near zero.
Many of us (myself included) also don't Rx oxycodone. If you're going home with an opioid rx from me (rare in of itself, and essentially never for acute on chronic pain) it's for IR morphine which is less euphorogenic.
Many of us (myself included) also don't Rx oxycodone. If you're going home with an opioid rx from me (rare in of itself, and essentially never for acute on chronic pain) it's for IR morphine which is less euphorogenic.
As a now hospice doc who does a lot of complicated pain management (granted I work inpatient), even my nurses balk at an equivalent dilaudid: morphine ratio. They don't blink at 8 of morphine, but 16 makes them pause. So I switch drugs, add adjuncts or start an infusion. But badness is my specialty, and if you need me to manage your pain, you've got other problems.
I just don't see a high risk with one dose at the front end, especially if they are writhing in pain.
I am on the stricter side when it comes to discharging with a narcotic prescription. I also avoid giving a script for Oxycodone.
This goes exactly against my practice pattern, which is to have as few conversations as possible. I try to streamline everything, which means minimizing conversations and confrontations.
Plus, I did try to put up this fight early on in my attending career (explaining to nurses about the Morphine dosage), but now I realized it's just so much easier to switch to Dilaudid at a 1 mg.
Along the same lines, my philosophy is to delegate tasks so that I can focus on management, disposition, and moving the meat. The last thing I want to do is pushing meds. I especially don't want to be the doc who walks around with Dilaudid in his pocket.
I don't disagree with you here. But, that's why I go to the 1 mg Dilaudid dose (and 0.5 mg for petite or elderly)... It works like a charm.
Anyway, I guess I'm being quite dogmatic here with my practice. It's just that I find one solid dose in the beginning of the care breaks the patient's pain and makes the whole ER visit much smoother, so I prefer to do that rather than working my way up with other meds. Hit 'em hard right from the get-go. That's been my evolved practice... and I honestly think it results in a lot less redosing and readministration of pain meds.
I don't think I am the cause of this, since I am a minimalist and do not order huge work-ups on BS.
But, when I *do* order a big work-up, then I make them comfortable by giving them a good first (and usually last) dose.
Like you say later in your post, there is no one right way here. Just different practice patterns. I personally do not get the use of giving piddly doses of Morphine and having to redose, instead of just hitting them once with a good dose. Like I said, 1 mg is the sweet spot for 90% of patients, in my experience.
I disagree.
I move the meat. The docs that spend hours talking to the patient about each and every thing are the ones who sign out a wildfire to their colleagues.
Not saying you do that, but just my view of things.
Yeah, this is exactly where I think we differ. You think this "takes seconds," but I think it "takes minutes" because you have to coordinate with the nursing staff. And I try to shave as many minutes as possible so that I can. move. the. meat. I have rollerblades on the entire shift, and try to think about every minute how to maximize throughput (without harming patient care).
Giving the patient a bunch of options to choose from -- 'would you like this med or that' -- is a surefire way to get stuck in a room for a long time as the patient hems and haws.
Agreed. To each their own!
what do you mean by that?
I like the concept...but it's really a small dose of ketamine. I usually give 0.2-0.3 mg / kg as a one time bolus for pain. or around 15 mg for most normal sized adults.
Love it.
I love low-dose ketamine, especially in opioid tolerant patients. I go 0.15mg/kg in 100mL over 15 minutes. They're usually less dysphoric with an infusion than with a bolus, and it's pretty easy to stop if they get any adverse effects.
10 mg ketorolac IV is equianalgesic to 30mg, and I'm pretty happy to go with a lower dose routinely.
Droperidol 0.625mg IV can be magically effective when all else fails.
I almost always give 15 mg. I realize the study showing 10 mg is equivalent to 30 mg, but our vials contain 30 mg/2 mL. It's easier to draw up 1 mL than it is to draw up 0.66 mL.
I used droperidol during my EMS days. Was a great antipsychotic and antiemetic. Cures just about everything like migraines and cannibanoid hyperemesis syndrome, gastroparesis, etc. Maybe I'm cavalier, but I almost always start with 1.25 mg.
I used droperidol during my EMS days. Was a great antipsychotic and antiemetic. Cures just about everything like migraines and cannibanoid hyperemesis syndrome, gastroparesis, etc. Maybe I'm cavalier, but I almost always start with 1.25 mg.
Some people have obliquely addressed this, but since you mention you're an MS4, this is a good thing to explicitly discuss for learners -- hydromorphone (Dilaudid) is a very different drug than morphine. This is why you're seeing some back/forth between attendings about using it. At a pharmacologic level, it is acetylated in a similar fashion to diacetylmorphine, AKA heroin, and for this reason it crosses the blood brain barrier and provides a euphoria / high that is unmatched by morphine or most other analgesics we use in the ED. Even at equianalgesic doses, the feeling that people get (I imagine, I have never personally experienced this) is qualitatively different than what they feel from morphine or most of the rest of our armamentarium.
This is why I choose to reserve hydromorphone for either confirmed badness or end-of-life care, and avoid it for the treatment of acute on chronic pain or vague abdominal pain or most anything else. I think there is a qualitative difference that promotes drug seeking behavior specifically for this drug that is rooted in its pharmacology, and that its use can truly harm patients. It seems to lead to the creation of patients who say that "morphine does not work" for their pain, and who will come to the ER again and again to receive this specific experience and who will complain if they don't get it. I will use it as well for certain pre-existing conditions, e.g. chronic kidney disease or chronic liver disease, where this may affect the metabolism of the drug or the build-up of certain metabolites, but think there are seriously compelling reasons to avoid it as your first-line analgesic.
The treatment of pain in emergency medicine is a huge part of the job. It's worth taking time to really understand the options you have available, and how to tailor your treatment to the patient and the condition in front of you. You'll do better by your patients, and will be appreciated by your nurses and your colleagues, if you do so -- unfortunately this will mean that there's not necessarily a great one size fits all solution, but if you recognize that and act accordingly, I think you'll be a better doctor for it.
This is why I choose to reserve hydromorphone for either confirmed badness or end-of-life care, and avoid it for the treatment of acute on chronic pain or vague abdominal pain or most anything else. I think there is a qualitative difference that promotes drug seeking behavior specifically for this drug that is rooted in its pharmacology, and that its use can truly harm patients. It seems to lead to the creation of patients who say that "morphine does not work" for their pain, and who will come to the ER again and again to receive this specific experience and who will complain if they don't get it. I will use it as well for certain pre-existing conditions, e.g. chronic kidney disease or chronic liver disease, where this may affect the metabolism of the drug or the build-up of certain metabolites, but think there are seriously compelling reasons to avoid it as your first-line analgesic.
The treatment of pain in emergency medicine is a huge part of the job. It's worth taking time to really understand the options you have available, and how to tailor your treatment to the patient and the condition in front of you. You'll do better by your patients, and will be appreciated by your nurses and your colleagues, if you do so -- unfortunately this will mean that there's not necessarily a great one size fits all solution, but if you recognize that and act accordingly, I think you'll be a better doctor for it.
I've actually found that spending an extra 5min talking on the front end often saves me 20min on the back end and overall increases my efficiency. YMMV
TheGenius, why are you writing for "prn Q4h" meds? What are you doing wrong that these patients are being managed longer than 2-3 hours by yourself in the department? Is it an institutional problem, or do studies just come back super slow for you? Nurses would murder me if I had patients in the department longer than that for routine complaints.
Back to Dilaudid, I've almost completely phased it out. I use it now only for severe pain like a femur fracture, or for breakthrough acute pain that has not responded to morphine. I almost never give it for run-of-the-mill abdominal pain, back pain or any other painful, but non-emergent condition. I find morphine works well with repeated doses and/or combined with toradol.
I'm also not worried about toradol in the elderly. One dose of NSAIDS does not cause kidney issues. Most studies looking at toradol had the patients on routine doses for days and weeks at a time.
I do PO narcotics on most of the drug seekers. They can't complain I didn't address their pain, but they also don't get the high/euphoria from an IV push dose. Agree with asking if people have a ride. I find I can turf most of the drug seekers this way. 90% of them came in by EMS, or drove themselves. Most for obvious reasons don't have a normal person who will come pick them up at the hospial.
Back to Dilaudid, I've almost completely phased it out. I use it now only for severe pain like a femur fracture, or for breakthrough acute pain that has not responded to morphine. I almost never give it for run-of-the-mill abdominal pain, back pain or any other painful, but non-emergent condition. I find morphine works well with repeated doses and/or combined with toradol.
I'm also not worried about toradol in the elderly. One dose of NSAIDS does not cause kidney issues. Most studies looking at toradol had the patients on routine doses for days and weeks at a time.
I do PO narcotics on most of the drug seekers. They can't complain I didn't address their pain, but they also don't get the high/euphoria from an IV push dose. Agree with asking if people have a ride. I find I can turf most of the drug seekers this way. 90% of them came in by EMS, or drove themselves. Most for obvious reasons don't have a normal person who will come pick them up at the hospial.
I agree. There are precious few good reasons to give hydromorphone over morphine and "allergy" is never one of them.
Our health system has completely removed Dilaudid from all ER's except one (which is our burn center). Since our ER is across the street from the main hospital, I can literally tell patients we don't have it in the building and it must come from the pharmacy across the street.
May I remind you of the nurse who gave vec instead of versed while in radiology.
- Feb 23, 2010
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Yeah, this kinda proves my point. We all remember this lady because she was horrible and a departure from the norm. I'm not saying all nurses are great. I'm saying that both the one from Vandy and the one that @thegenius referenced are bloody terrible.
I've noticed this too about under dosing morphine. Order sets are probably responsible for this. If the order sets is 4 mg, the patient will get 4 mg. The person could be on 50 morphine equivalents of opiates a day at home, but people always order that standard dose of 4 mg or 5 mg. It takes too much time for the doc to change the order to the appropriate weight based dose. It's also true that nurses balk when the appropriate dose is ordered. My nurses never push back when I explain the weight based approach or explain the patient needs a higher dose to get any benefit due to opiate tolerance.
I'm fine with the shift away from dilaudid but I'm far from the majority who now considers it a dirty word, akin to IV heroin solely responsible for turning innocent pt's all into homeless drug seekers. It's incredible to me how quickly physicians are swayed and influenced (for right or wrong) into changing mass opinions on drugs, therapies, treatments, etc.. through concerted and coordinated efforts at reforming our practice habits at the state, hospital, CMG, employer level. We wouldn't even be having a discussion about dilaudid 10 years ago. In fact, we'd probably all feel highly pressured to GIVE IT d/t press ganey scores, pt satisfaction, etc.. Personally, I'd much rather have latitude NOT to give it than silently forced to give it more often so I'm happy with the change even if I don't exactly march to the drum. I feel that for once we've been given an element of our autonomy back in how we choose to treat pain in the ED. However, it can be equally as frustrating for me on occasion when I need to treat someone for legit pain and have additional hoops to jump through in order to given an IV narcotic/opioid. Be that as it may, I still consider our current environment preferable to how it was 10 years ago when nurses were harassing us non stop about pain scores.
I would also add from personal experience, that I had dilaudid exactly once in my life after a cervical ACDF and I just remember waking up from surgery feeling like there was a molten hot bar of metal in my neck. I've got a very high pain tolerance but this was easily a 9. I remember the nurse asking me if I needed anything for pain and I croaked "yes please". She gave an unknown amount of dilaudid..I dunno maybe 0.5 or 1mg and it felt like a crashing sea of cool water flowing over my face and neck and dulling the pain to a very tolerable 4 or 5. I was able to drift off to sleep for awhile and I don't remember ever feeling any sort of euphoria. The stuff works when used appropriately. I can't speak about morphine because I've never had it.
I would also add from personal experience, that I had dilaudid exactly once in my life after a cervical ACDF and I just remember waking up from surgery feeling like there was a molten hot bar of metal in my neck. I've got a very high pain tolerance but this was easily a 9. I remember the nurse asking me if I needed anything for pain and I croaked "yes please". She gave an unknown amount of dilaudid..I dunno maybe 0.5 or 1mg and it felt like a crashing sea of cool water flowing over my face and neck and dulling the pain to a very tolerable 4 or 5. I was able to drift off to sleep for awhile and I don't remember ever feeling any sort of euphoria. The stuff works when used appropriately. I can't speak about morphine because I've never had it.
I'd like to clarify my position.
The opioid mantra I was taught in fellowship is "why not morphine?" This means, whenever prescribing an opioid, I should ask, "why not morphine?" because it's often the best studied, the cheapest, and available in the most formulations. That said, in the ED there are often valid answers to that question, and in those cases I'll use hydromorphone/oxycodone/fentanyl. Worked last night and gave one patient Oxy, because we don't have PO morphine in our Pyxis and I didn't want to wait. Gave another patient IV hydromorphone for her poorly controlled post op pain, because that's the agent she had at home and I was hoping to get her dc'd back to her PO regimen.
So, while I think it's good to ask yourself "why not morphine?" when Rx'ing opioids, I do not think a dogmatically anti-dilaudid approach is wise.
I don't disagree with you at all man and wasn't directing my post at you Wilco. All the mentions of dilaudid reminded me of ordering it several shifts ago at my new job for a legitimate case/pt and the charge nurse and pharmacist came up and stood over me with judging eyes and sternly educated me about how dilaudid was not allowed in the ED under any circumstances and I should basically be ashamed of even thinking of ordering it for someone. Keep in mind I rarely order opioids as it is... I didn't mind changing it to morphine but I just remember feeling incredulous and looking around for a camera filming me on some covert episode of the twilight zone. I just shook my head, smiling under my mask and was reminded of how times change. That was fresh on my mind when reading all these posts. Hell, I don't disagree with the dilaudid free policy but it's funny to me how we single out dilaudid as such a dirty drug...immoral and completely unfit to wear the mantle of analgesic. It's the new Hester Prynne of the drug world. All in the span of a few years. Crazy times we live in, lol.
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That ish is crazy, groove. Is it really too much to ask that we be allowed to use clinical judgement in the use of opiods? We go from one extreme to the other.
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