the queen of frequent flyers... help.

[stoic]

so i'm out in the middle of nowhere on a rural med rotation. the hospital i'm at is super tiny (ie 20 beds). we've got an ER, but it's not staffed unless someone shows up. i'm staying in a call room for the rotation, so i'm 1st call whenever someone comes to the ER at night.

anyway, we've got this lady who for the past few months or so has been coming in every 2 or 3 nights with migranes. the docs have basically dumped her in my lap because they're so sick of dealing with her... as in if she shows up - and is the only er patient - they won't be coming in. basically they say, "we don't care what you do as long as you don't give her narcotics and get her out of the ER before we round in the morning."

she's been ct'ed several times and worked up by 2 different neurologist over in the big city (our nearest specialist backup is 85 miles away). no cause of the migranes can be found. no objective findings on PE.

i'm reaching the end of my rope with this patient. no matter what we throw at her, she doesn't get relief (unless it's narcotics, and that's not happening).
she reports that she can't take anything po b/c of nausea. so the last few times i've just given her im toradol and rectal reglan. of course this just pisses the patient off and she ends up storming out AMA. not that i care if she leaves, but she keeps coming back - sometimes in less than 24 hours. i don't know if she's banking on me not being there or what, but i'm gonna be the only person she see's @ night for the next month or so.

what the hell should i do here guys? the attendings are generally nice guys and good doctors, but they've been handling this lady for months and don't really have any sympathy for me... or any useful suggestions.

i've heard a little bit about some of the older anti-psychotics being used for migranes... is there enough evidence out there to support the use of thorazine or haldol in this sort of patient? it would make me and the nurses really happy if we could hit her with some haldol... she's such a malignant, nasty person. it would be great if we could just snow her and stick her in a corner until she falls asleep or leaves...

ok guys, help!

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[Seaglass]

Reglan 20mg IV q30 min up to 60 mg, Benadryl 25 mg IV Q30 min x 2 and decadron 10mg IV shoudl be #1. Toradol is a good choice too. THe first shot could be toradol, reglan 20, benadryl 25, Decadron 10.

Alternatives:
depakote 500 mg IV over 10 minutes may repeat with 1 gram x 1.

Also plain old benadryl and tylenol have been shown to be effective!

DON'T GIVE imitrex - you don't want to be the only one there dealing with her cardiac arrest.

MOST IMPORTANT POINT:
Don't give in. If you have decided not to give narcs then stick to it. It doesn't matter how many times she signs out AMA. Whenever she comes in make a point that if she is having such terrible migranes that require narcotic relief that there are many narcotics her REGULAR physician can prescribe and that she should see him post-haste.

Other important point:
There are some migranes that are only responsive to narcotics (whether that is how they really are or some doctor made them that way). If I see a patient that regularly follows with neurology and neurology has documented that narcotics are their goto drug for this patients break through headaches then I usually give it to them.

 

[Apollyon]

Seaglass makes some great points - one thing to be sure of, is if you give the Reglan up to 60mg, MAKE SURE the Benadryl's on board, too (unless you want to see your first dystonic reaction).

One thing about the patients with the letters from neurologists - in my experience, these letters are ragged and tattered and on their last legs, and, moreover, the patients haven't seen these doctors in YEARS.

Remember, they're coming to you on off-hours - your first question is, "Did you call your neurologist?" - the answer will either be a mumbled bull**** answer or "No", and the second question is "why?". There won't be a response.

Try calling an orthopedic surgeon or a pain doc for pain meds at night or on the weekend - the answer is a flat "no" and "call the office tomorrow morning". When these patients can't get that satisfaction, they hit you up in the ED. A junior mistake is trying to actually fix these problems, when the fix is with their primary doctors (or, alternately, NOT you).

And, as Seaglass said, DON'T GIVE IN.

 

[stoic]

thanks guys. i wrote seaglass's Rx down on an index card and will use it next time i see her.

one of the very frustrating things with the patient is that she is supposed to be seeing one of the physicians who works with the hospital on a bi-weekly basis but rarely makes her appointments with them. that's what pushed them over the edge with her. on more than one occasion she's missed her clinic appointment and then shown up that night in the ER.

we have a letter from one of the neurologist she saw on file stating that he can't differintiate the migrane type or trigger and that at this point any treatment that works - if one could be identified - would be ok... with the caveat that the patient has displayed a strong history of narcotic seeking and that in his opinion, they should be avoided.

even with all that, it's hard not to feel guilty when she begs for narcotics because that's all that gives her relief.

another question:
say you have a patient you who think has a legit migrane and the reglan/benadryl/dexamethasone doesn't provide relief. after that cocktail can you give narcotics? also, since demerol is faux pas, what's the narcotic of choice in these patients?

 

[southerndoc]

What about DHEA, magnesium, and dexamethasone? Works like a charm. Have yet to see any patient fail that regimen

 

[Hawkeye Kid]

i've seen the following combo work on more than one occasion, and one of the attendings i worked with as a student said he had >90% success with it (yes, he kept track)...
2.5 haldol
30 toradol
10 reglan
1L NS

 

[stoic]

What about DHEA, magnesium, and dexamethasone? Works like a charm. Have yet to see any patient fail that regimen

pt has poorly controlled HTN, so the attendings are reluctant to start the DHE protocal. everytime i've seen her, her pressures have been 180's over 100's.

would these pressures stop you guys?

i don't think they've used IV reglan/dex with her (just po/pr reglan), so that's definately worth a shot.

if the reglan/benadryl/dex/toradol cocktail doesn't produce results, i'm going to get the ok to try some haldol in the mix.

does this all go in IV push? as in push reglan/push benadryl/push dex or are some of the meds infused more slowly?

 

[Apollyon]

thanks guys. i wrote seaglass's Rx down on an index card and will use it next time i see her.

one of the very frustrating things with the patient is that she is supposed to be seeing one of the physicians who works with the hospital on a bi-weekly basis but rarely makes her appointments with them. that's what pushed them over the edge with her. on more than one occasion she's missed her clinic appointment and then shown up that night in the ER.

we have a letter from one of the neurologist she saw on file stating that he can't differintiate the migrane type or trigger and that at this point any treatment that works - if one could be identified - would be ok... with the caveat that the patient has displayed a strong history of narcotic seeking and that in his opinion, they should be avoided.

even with all that, it's hard not to feel guilty when she begs for narcotics because that's all that gives her relief.

another question:
say you have a patient you who think has a legit migrane and the reglan/benadryl/dexamethasone doesn't provide relief. after that cocktail can you give narcotics? also, since demerol is faux pas, what's the narcotic of choice in these patients?

Get over feeling the guilt. Seriously. The "relief" is getting high.

Legit migraine does not respond to opioids. That's all there is to it. There is no narc of choice.

 

[DrMom]

let's see:
she's been fully worked up
she has a pattern of not keeping her appts with her regular physicians but then shows up in the ED
she demands narcotics and leaves AMA if she doesn't get them


I wouldn't feel sorry at all.

 

[NinerNiner999]

let's see:
she's been fully worked up
she has a pattern of not keeping her appts with her regular physicians but then shows up in the ED
she demands narcotics and leaves AMA if she doesn't get them

Are you working somewhere in Baltimore by chance?

 

[DrMom]

Are you working somewhere in Baltimore by chance?

nope. I'm still in okieland

 

[stoic]

let's see:
she's been fully worked up
she has a pattern of not keeping her appts with her regular physicians but then shows up in the ED
she demands narcotics and leaves AMA if she doesn't get them


I wouldn't feel sorry at all.

well gee, when you put it that way... ok. no more feeling guilty.

how effective is benadryl at preventing dystonic rxn? the nurses here (and me) don't have any experience watching for or dealing with this side effect.

 

[totalbodypain]

Don't discount the educational opportunity in your everyday seekers. I owe my skill with the LP needle to the thankless perseverence of fine young women such as the one you describe.
A. treat every headache she lists as a 10/10 aka worst headache of my life, as a possible SAH (after all a signifigant number of CTs are - with SAH) and pull out the old LP kit.
B. If she goes through with the procedure giver here the narcotics (you will be treating legit pain at this point).
The beauty of this technique is that in no time at all your a class a spine poker with an LP and your victim eh...em patient associates bs headache with a rather painful un-necessary procedure. Anyone who doesnt care if you LP them is either A. really sick and needs it. B. really stupid and needs it.
Ethical...probibly not. Effective....very.

 

[Apollyon]

well gee, when you put it that way... ok. no more feeling guilty.

how effective is benadryl at preventing dystonic rxn? the nurses here (and me) don't have any experience watching for or dealing with this side effect.

Dystonic reaction - tone is off - 'dystonic'. Head twisted to the side, eyes deviated (to side or upward), but mentation is maintained - they just look twisted, and can't straighten up. Believe me, you'll know it when you see it. First time I saw it, I was an intern in IM - walked into the room, and I knew it in as long as it took me to see the patient.

Benadryl is treatment - I don't know if you can prophylax against it, but 25-50mgIV would do the trick (if you're not sure, go with the 50mg) for treatment.

 

[JackBauERfan]

Don't discount the educational opportunity in your everyday seekers. I owe my skill with the LP needle to the thankless perseverence of fine young women such as the one you describe.
A. treat every headache she lists as a 10/10 aka worst headache of my life, as a possible SAH (after all a signifigant number of CTs are - with SAH) and pull out the old LP kit.
B. If she goes through with the procedure giver here the narcotics (you will be treating legit pain at this point).
The beauty of this technique is that in no time at all your a class a spine poker with an LP and your victim eh...em patient associates bs headache with a rather painful un-necessary procedure. Anyone who doesnt care if you LP them is either A. really sick and needs it. B. really stupid and needs it.
Ethical...probibly not. Effective....very.

good idea haha!

 

[USCDiver]

Don't discount the educational opportunity in your everyday seekers. I owe my skill with the LP needle to the thankless perseverence of fine young women such as the one you describe.
A. treat every headache she lists as a 10/10 aka worst headache of my life, as a possible SAH (after all a signifigant number of CTs are - with SAH) and pull out the old LP kit.
B. If she goes through with the procedure giver here the narcotics (you will be treating legit pain at this point).
The beauty of this technique is that in no time at all your a class a spine poker with an LP and your victim eh...em patient associates bs headache with a rather painful un-necessary procedure. Anyone who doesnt care if you LP them is either A. really sick and needs it. B. really stupid and needs it.
Ethical...probibly not. Effective....very.

Ahhh, you had it up until you said 'un-necessary'. If you can justify the procedure it is certainly necessary, nay mandated by standard of care, even!

 

[totalbodypain]

Ahhh, you had it up until you said 'un-necessary'. If you can justify the procedure it is certainly necessary, nay mandated by standard of care, even!

true dat, my bad....Needle welding backstabbers unite!

 

[totalbodypain]

The whole problem with the above approach is that soon they learn that the LP hurts and come up with far more colorful areas to complain of pain that either require a huge work up, an unpleasant exam or both....i.e. 500lb female seeker complaining of lower abdominal pain...spelunking anyone?

 

[southerndoc]

A. treat every headache she lists as a 10/10 aka worst headache of my life, as a possible SAH (after all a signifigant number of CTs are - with SAH) and pull out the old LP kit.

Does anyone here use photo spectrometry to assess for xanthochromia? Our lab uses visual confirmation only. A few months ago, I heard of a case where the lab reported no xanthochromia. Because the physician was so concerned, he did a CTA CoW anyhow. It demonstrated an aneurysm.

I'm wondering if soon we will be skipping the LP's and going straight for CTA's.

 

[totalbodypain]

Ours does visual confirmation only. In the south bronx they only do what they can spell...But seriously, I suspect we are missing alot of occult bleeds. CTA is the future its just uncertain whether it will be available routinely to us in the less than privledged communities on a regular basis any time soon.

 

[stoic]

Don't discount the educational opportunity in your everyday seekers. I owe my skill with the LP needle to the thankless perseverence of fine young women such as the one you describe.
A. treat every headache she lists as a 10/10 aka worst headache of my life, as a possible SAH (after all a signifigant number of CTs are - with SAH) and pull out the old LP kit.
B. If she goes through with the procedure giver here the narcotics (you will be treating legit pain at this point).
The beauty of this technique is that in no time at all your a class a spine poker with an LP and your victim eh...em patient associates bs headache with a rather painful un-necessary procedure. Anyone who doesnt care if you LP them is either A. really sick and needs it. B. really stupid and needs it.
Ethical...probibly not. Effective....very.

you know, i'm not sure she's had a recent LP. better check that opening pressure.

i was hoping i'd get to do a LP on this rotation, but had no idea the opportunity might present itself so quickly.

so now the question is, how do i get an attending into the ER at 1 in the morning to teach the med student how to do a LP on a patient they can't stand? guess i'd better look real hard for some papilledema.

 

[Seaglass]

Gawd, if the neurologist said in their note not to give narcotics then that's you're golden ticket. Just reminder her of that every time she comes.

 

[Seaglass]

There are milder dystonic reactions as well. When the patient says "I just can't sit still!" or keeps hounding you to be discharged or starts walking out of the room that's probably a dystonic reaction (if you've recently given reglan/compazine). Benadryl is still the solution. I've seen this many times with the headache cocktail.

 

[ERMudPhud]

I'm always surprised by the cocktails that appear when we have these discussions. There is a decent amount of clinical trial data out there if you choose to use it. Here's what I've found

Basically it comes down to only three drugs(outside the triptans) which have been proven to be better than placebo. Compazine, Thorazine and Reglan. There is little to no data to support that decadron, Phenergan, or depakote work for acute migraine although some like depakote have good evidence for prophylaxis. There is evidence that Mag and Toradol are no better than placebo. In head to head studies compazine always smoked the rest of the field.

1: Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C.
A randomized prospective placebo-controlled study of intravenous magnesium
sulphate vs. metoclopramide in the management of acute migraine attacks in the
Emergency Department.
Cephalalgia. 2005 Mar;25(3):199-204.
PMID: 15689195 [PubMed - indexed for MEDLINE]

IV Reglan = IV Magnesium = Placebo. Pain relief equal in all three groups but more need for “rescue” meds in placebo group

2: Bigal ME, Bordini CA, Speciali JG.
Intravenous chlorpromazine in the emergency department treatment of migraines:
a randomized controlled trial.
J Emerg Med. 2002 Aug;23(2):141-8.
PMID: 12359281 [PubMed - indexed for MEDLINE]

IM thorazine better than placebo

3: Edwards KR, Norton J, Behnke M.
Comparison of intravenous valproate versus intramuscular dihydroergotamine and
metoclopramide for acute treatment of migraine headache.
Headache. 2001 Nov-Dec;41(10):976-80.
PMID: 11903525 [PubMed - indexed for MEDLINE]

IV depakote about equal to IM DHE+Reglan

4: Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ.
Randomized clinical trial of intravenous magnesium sulfate as an adjunctive
medication for emergency department treatment of migraine headache.
Ann Emerg Med. 2001 Dec;38(6):621-7.
PMID: 11719739 [PubMed - indexed for MEDLINE]

IV Mag+Reglan WORSE than IV Reglan

5: Seim MB, March JA, Dunn KA.
Intravenous ketorolac vs intravenous prochlorperazine for the treatment of
migraine headaches.
Acad Emerg Med. 1998 Jun;5(6):573-6.
PMID: 9660282 [PubMed - indexed for MEDLINE]

Compazine better than Toradol

6: Shrestha M, Singh R, Moreden J, Hayes JE.
Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A
prospective, randomized, double-blind trial.
Arch Intern Med. 1996 Aug 12-26;156(15):1725-8.
PMID: 8694672 [PubMed - indexed for MEDLINE]

Toradol equal to Thorazine

7: Jones J, Pack S, Chun E.
Intramuscular prochlorperazine versus metoclopramide as single-agent therapy
for the treatment of acute migraine headache.
Am J Emerg Med. 1996 May;14(3):262-4.
PMID: 8639197 [PubMed - indexed for MEDLINE]

Compazine better than Reglan better than placebo

8: Coppola M, Yealy DM, Leibold RA.
Randomized, placebo-controlled evaluation of prochlorperazine versus
metoclopramide for emergency department treatment of migraine headache.
Ann Emerg Med. 1995 Nov;26(5):541-6.
PMID: 7486359 [PubMed - indexed for MEDLINE]

Compazine better than Reglan slightly better than placebo

9: Cameron JD, Lane PL, Speechley M.
Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine
headache.
Acad Emerg Med. 1995 Jul;2(7):597-602.
PMID: 8521205 [PubMed - indexed for MEDLINE]

Thorazine equal to Reglan

10: Davis CP, Torre PR, Williams C, Gray C, Barrett K, Krucke G, Peake D, Bass
B Jr.
Ketorolac versus meperidine-plus-promethazine treatment of migraine headache:
evaluations by patients.
Am J Emerg Med. 1995 Mar;13(2):146-50.
PMID: 7893296 [PubMed - indexed for MEDLINE]

Toradol equal to Demerol/phenergan! I wonder what that means?

11: Ellis GL, Delaney J, DeHart DA, Owens A.
The efficacy of metoclopramide in the treatment of migraine headache.
Ann Emerg Med. 1993 Feb;22(2):191-5.
PMID: 8427430 [PubMed - indexed for MEDLINE]

Reglan better than placebo

12: Duarte C, Dunaway F, Turner L, Aldag J, Frederick R.
Ketorolac versus meperidine and hydroxyzine in the treatment of acute migraine
headache: a randomized, prospective, double-blind trial.
Ann Emerg Med. 1992 Sep;21(9):1116-21.
PMID: 1514724 [PubMed - indexed for MEDLINE]

Toradol equal to Demerol/vistaril!

13: Larkin GL, Prescott JE.
A randomized, double-blind, comparative study of the efficacy of ketorolac
tromethamine versus meperidine in the treatment of severe migraine.
Ann Emerg Med. 1992 Aug;21(8):919-24.
PMID: 1497157 [PubMed - indexed for MEDLINE]

Toradol worse than Demerol

14: Tek DS, McClellan DS, Olshaker JS, Allen CL, Arthur DC.
A prospective, double-blind study of metoclopramide hydrochloride for the
control of migraine in the emergency department.
Ann Emerg Med. 1990 Oct;19(10):1083-7.
PMID: 2221512 [PubMed - indexed for MEDLINE]

Reglan better than placebo

15: Bell R, Montoya D, Shuaib A, Lee MA.
A comparative trial of three agents in the treatment of acute migraine
headache.
Ann Emerg Med. 1990 Oct;19(10):1079-82.
PMID: 2221511 [PubMed - indexed for MEDLINE]

Thorazine better than DHE better than IV lidocaine. Lidocaine, now that’s a new one.

16: McEwen JI, O'Connor HM, Dinsdale HB.
Treatment of migraine with intramuscular chlorpromazine.
Ann Emerg Med. 1987 Jul;16(7):758-63.
PMID: 3592329 [PubMed - indexed for MEDLINE]

Thorazine marginally better than placebo

1: Tanen DA, Miller S, French T, Riffenburgh RH.
Intravenous sodium valproate versus prochlorperazine for the emergency
department treatment of acute migraine headaches: a prospective, randomized,
double-blind trial.
Ann Emerg Med. 2003 Jun;41(6):847-53.
PMID: 12764341 [PubMed - indexed for MEDLINE]

Almost missed this one that basically showed compazine to be way better than depakote.

For the original poster. The best evidence is actually for the triptans and despite what Seaglass said their safety profile is pretty good. DHE although having a related mechanism is probably a lot less safe and I wouldn't use it. If triptans are truly contraindicated than by far the best evidence is for compazine. Give 10IV + 50 IV benadryl to stop them from crawling out of their skin. If you can't get compazine or they are "allergic" than the only others with placebo controlled support are thorazine and reglan. Anything else is unfortunately mostly witchcraft.

As for dealing with the chronic pain/noncompliance issues set some ground rules. Run it like the contracts they have at pain clinics.

1. She has to be on migraine prophylaxis even if she doesn't think it works and have proof she's taking it-script refills etc

2. She has to have made it to her most recent PCP appointment

3. She has to have something at home for breakthrough pain usually a graded plan of exedrin migraine followed by a triptan followed by two percocet with a very finite limit on the number of percocet she can have per month

4. She has to try a triptan and/or IV compazine first in the ED.

If she meets all the above criteria then and only then she can have IV dilaudid or morphine or fentanyl. (Throwing away the demerol is the best favor my hospital formulary ever gave me)

Your attendings are just being passive aggresive or avoidant if they haven't already put her on a contract like that

 

[southerndoc]

There is evidence that Mag and Toradol are no better than placebo. In head to head studies compazine always smoked the rest of the field.

1: Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C.
A randomized prospective placebo-controlled study of intravenous magnesium
sulphate vs. metoclopramide in the management of acute migraine attacks in the
Emergency Department.
Cephalalgia. 2005 Mar;25(3):199-204.
PMID: 15689195 [PubMed - indexed for MEDLINE]

Interesting that you quote this article for lack of support of IV magnesium. This study, in fact, demonstrated that intravenous magnesium was as effective as intravenous metoclopramide. The placebo arm was not the magnesium sulfate group. The placebo group received an infusion of normal saline.

This study demonstrated that placebo was just as effective as magnesium or metoclopramide in reduction of pain as assessed by a visual analog scale. Patients receiving magnesium or metoclopramide required less rescue medication than those receiving placebo.

A triple-arm study of only 113 patients is not an adequate number.

 

[ERMudPhud]

Interesting that you quote this article for lack of support of IV magnesium. This study, in fact, demonstrated that intravenous magnesium was as effective as intravenous metoclopramide. The placebo arm was not the magnesium sulfate group. The placebo group received an infusion of normal saline.

This study demonstrated that placebo was just as effective as magnesium or metoclopramide in reduction of pain as assessed by a visual analog scale. Patients receiving magnesium or metoclopramide required less rescue medication than those receiving placebo.

A triple-arm study of only 113 patients is not an adequate number.

I agree that based on one outcome, need for rescue meds and which many would consider the most important endpoint, Mag was superior to placebo. I'll have to look at the full text of the article to see whether that difference was clinically and statistically significant. However, based on their primary endpoint of decrease in pain Mag was no better than placebo. I did miss one other placebo controlled double blind study of Mag in acute migraine:

1: Bigal ME, Bordini CA, Tepper SJ, Speciali JG.
Intravenous magnesium sulphate in the acute treatment of migraine without aura
and migraine with aura. A randomized, double-blind, placebo-controlled study.
Cephalalgia. 2002 Jun;22(5):345-53.
PMID: 12110110 [PubMed - indexed for MEDLINE]

which only showed efficacy in migraine with aura. Also, don't forget the study which showed Mag made reglan less effective. This is very important if you like to use those two in a cocktail.

Finally, as for the power of a three arm study with 113 patients it should be more than adequate if you are looking for something as clear cut as pain-free at 1 hour with an efficacy twice that of placebo. Many of the studies showing compazine worked had smaller numbers and still demonstrated clear statistically significant improvements in efficacy over placebo so it isn't a power problem.

I still think the evidence is strongest for compazine, reglan, and thorazine with compazine winning all the head to head trials.

 

[stoic]

Your attendings are just being passive aggresive or avoidant if they haven't already put her on a contract like that

indeed. i would say a mix avoidant and out-dated. this is a very rural rotation - cowboy medicine in many respects. three FP's that run a clinic and hospital in a county of 1,300 people. they do c-sections as well as some operations i had no idea FP's were doing anywhere (T&A, lap tubals).

in any case, i've learned a lot and have gotten a chance to do some stuff i'd never get to do at this point in my training elsewhere. but there are some areas where these docs are really not up to speed on. especially in terms of pain management, i honestly could not believe how some of the patients are managed.

anyway, the patient reported some relief with with IM toradol and pr reglan last time i saw her. so next time i'm going to try iv reglan/benadryl + im toradol.

her home meds are supposed to be propranolol, imitrex, and vicodin. i have no idea if she's actually taking them. as mentioned previously she is not keeping office appointments on a regular basis.

 

[VA Hopeful Dr]

her home meds are supposed to be propranolol, imitrex, and vicodin. i have no idea if she's actually taking them. as mentioned previously she is not keeping office appointments on a regular basis.

If that is what she's supposed to be taking, yet doesn't keep her regular appointments and then comes to the ER asking for narcotics..... next please.

 

[roja]

Regarding Reglan, dystonia is not the only reaction. Be vary aware of akathesias. The incidince has been quoted (last time I looked) at around 1 in 100 but I think it may be more common than that.

While it definately doesn't sound like whats going on with this woman, I have seen many an unsuspecting resident go to sign out a previously calm patient AMA after reglan. If you have a patient you gave reglan to, and all of the sudden they are nervous and anxious, give them some benadryl.

As a survivor of this myself (not realizing it was the reglan) I can assure you, its a very uncomfortable situation.

And I concur with the idea that this patient needs to be on some kind of prophylaxis.

 

[Soup]

indeed. i would say a mix avoidant and out-dated. this is a very rural rotation - cowboy medicine in many respects. three FP's that run a clinic and hospital in a county of 1,300 people. they do c-sections as well as some operations i had no idea FP's were doing anywhere (T&A, lap tubals).

in any case, i've learned a lot and have gotten a chance to do some stuff i'd never get to do at this point in my training elsewhere. but there are some areas where these docs are really not up to speed on. especially in terms of pain management, i honestly could not believe how some of the patients are managed.

anyway, the patient reported some relief with with IM toradol and pr reglan last time i saw her. so next time i'm going to try iv reglan/benadryl + im toradol.

her home meds are supposed to be propranolol, imitrex, and vicodin. i have no idea if she's actually taking them. as mentioned previously she is not keeping office appointments on a regular basis.

This sounds like the place I did my rural weekend. Any chance that you're north of Salina and almost spitting distance from Nebraska? If it is, I can't imagine a better place to get some real experience as a student.

 

[docB]

Just an observation: You can tell how much of an effect the chronic pain/drug seeking/headache/back pain crowd has on EDs. We frequently have threads like this one devoted to treating/dealing with migraines, etc. in the ED. We have relatively few threads on treating the acute MI. It just goes to show how these patients just suck up ER resources.

 

[stoic]

This sounds like the place I did my rural weekend. Any chance that you're north of Salina and almost spitting distance from Nebraska? If it is, I can't imagine a better place to get some real experience as a student.

nope; i'm on about the same horizontal plane as salina, but much MUCH closer to colorado. it has been a cool experience though. i've done things out here i never could have expected to do this early. colonoscopies, EGD's, joint injections and aspirations. next week we've got a ton of epidural injections scheduled and i'm gonna get a chance to learn how to do them. and there are like 4 babies due before the end of my rotation and the docs tell me i should get to deliever at least one of them. pretty damn exciting for the summer between first and second year.

sorry it's taken so long to update, i don't have frequent access to the internet right now. i tried the reglan/benadryl/dexamethasone/toradol cocktail on her once with no result other than continued request for narcotics.

the next time i went with thorazine and toradol - it either worked or zonked her enough that she just turned the lights out and went to sleep for a couple hours and then went home.

so for her, as long as i'm there, it's thorazine and toradol. i am going to try the reglan on future patients.

 

[caroladybelle]

i don't think they've used IV reglan/dex with her (just po/pr reglan), so that's definately worth a shot.

if the reglan/benadryl/dex/toradol cocktail doesn't produce results, i'm going to get the ok to try some haldol in the mix.

does this all go in IV push? as in push reglan/push benadryl/push dex or are some of the meds infused more slowly?

Depending on the facility's policies.

As a note, reglan of 5-10 can be given as a slow push, 20mg in most facilities is bagged and run in over 15 minutes or given in a syringe pump

Benedryl is easily pushed, but of most concern, decadron 10mg SHOULD NOT BE PUSHED. Yes, some med references say you can, but it is not a good idea.

You push that and many of your patients will experience an extreme burning sensation in their lower torso/peri area and/or an antsy feeling. It is generally bagged or run in a syringe pump for doses of 4mg or more.

Many places will not permit Haldol given IVP or even IV at all, unless tele is in place, if then. And others are more relaxed. At JHUH (on a unit that handles higher acuity patients and ICU patients), it is bagged and run over 15-30minutes, depending on the dose.

 

[stoic]

Depending on the facility's policies.

As a note, reglan of 5-10 can be given as a slow push, 20mg in most facilities is bagged and run in over 15 minutes or given in a syringe pump

Benedryl is easily pushed, but of most concern, decadron 10mg SHOULD NOT BE PUSHED. Yes, some med references say you can, but it is not a good idea.

You push that and many of your patients will experience an extreme burning sensation in their lower torso/peri area and/or an antsy feeling. It is generally bagged or run in a syringe pump for doses of 4mg or more.

Many places will not permit Haldol given IVP or even IV at all, unless tele is in place, if then. And others are more relaxed. At JHUH (on a unit that handles higher acuity patients and ICU patients), it is bagged and run over 15-30minutes, depending on the dose.

good info.

when i used the reglan combo, i just bagged everything and sent it in over 20 minutes or so.

 

[EctopicFetus]

I worked at the Famous Diamond Headache Clinic as a 3rd and 4th yr.. Not much else to give besides what has been discussed. For prevention they use a lot of different things including some of the old anti-depressants. The thing is it is nothing more than trial and error.

 

[augmel]

To the OP- I'm glad you are getting some good experience, but how is it that a soon-to-be MS2 is treating patients without MD supervision? Does she get a note and an official DC from the ER (or a bill for that matter) without an attending laying eyes on her? Not criticizing you, just wondering what your attendings are thinking. Pretty sure that is fraud, especially if she is a medicare /medicaid patient.

 

[deleted87716]

Just a thought...

You know the definition of insanity, right? Doing the same thing over and over again, and expecting the outcome to change.

Assuming this patient has legitimate headaches and isn't just drug-seeking, why don't you just start her on migraine prophylaxis (Inderal, Topamax, whatever) and give her a triptan to use episodically? Be sure to tell her how to use these correctly and what potential side effects to expect. If you're going to be around anyway, schedule a follow-up appointment.

Why not? You're in learning mode, and you're already seeing her a helluva lot more than any primary care doctor would, plus you're going to be there for the next month. With any luck, you can get her headaches under control within that time. Getting her out of everyone's hair would make you a real hero in the eyes of your attendings, don't you think?

 

[stoic]

about the supervision thing... everything happens after a phone call to the oncall doc and they are the ones who order the meds. it couldn't happen this way in a larger facility, but out here, there are only two docs who run this place (hospital and clinic) and what they say goes.

supposedly she's already on propranolol and tegretol for prophylaxis with imitrex for rescue... i'd bet you $100 those scripts haven't been filled in at least a couple months. she frequently misses scheduled clinic appointments and for some reason (hmmm, what reason could that be...) is completely umotivated to be proactive in her migrane prevention...


i have this recuring fantasy of smashing her in the head with the clipboard/chart and going "HERE, DOES THIS HELP YOUR F**KING MIGRAINE?"

it would help mine.

(well, i don't really want to do that. but it would be funny to see in a movie or something.)

 

[docB]

Assuming this patient has legitimate headaches and isn't just drug-seeking, why don't you just start her on migraine prophylaxis (Inderal, Topamax, whatever) and give her a triptan to use episodically? Be sure to tell her how to use these correctly and what potential side effects to expect. If you're going to be around anyway, schedule a follow-up appointment.

We should NOT be doing primary care in the ED. We wind up getting suckered into it but we shouldn't be doing it. We really shouldn't schedule follow up appointments in the ED either. A wound check is one thing but having a chronic headache patient come back for a scheduled appointment is just wrong. What this patient needs having been throughly worked up and medicated appropriately is follow up with a pain doc and a contract for her drugs.

 

[caroladybelle]

i have this recuring fantasy of smashing her in the head with the clipboard/chart and going "HERE, DOES THIS HELP YOUR F**KING MIGRAINE?"

it would help mine.

(well, i don't really want to do that. but it would be funny to see in a movie or something.)

Ever see the movie, "Bringing Out The Dead" w/Nicholas Cage? The MD that chews out the noncompliant ER patient?

My personal favs are the patients that are on the light on schedule, for their opiates. They rate their pain consistantly as a 10 on 1/10 scale w/10 being the "worst possible pain", meanwhile going down to smoke, on the phone constantly, eating like there is no tomorrow.

You have the temptation to slam down a hammer on their little finger and say, "Now that was an 8 - tell me again what your pain level was?"

(disclaimer-yes, I know that pain is what the patient is, but I think that their mental concept of worse pain possible needs tweaking)

 

[bartleby]

The success rate in most of the primary migrane meds including triptans, compazine, reglan, haldol etc all wind up in the mid to upper 80% range depending on the study. There is proven efficacy to these meds even if the mechanism is unclear. But if you have the good fortune of treating a patient who has made the Pavlovian association between a headache being followed shortly by a dose of narcotic, neither hell, high water nor reglan are going to get that patient to say "uncle" until they get the med they associate with relief. "You know... the medication that starts with the 'd'..."

What's particularly entertaining is that if you really ask people who expect narcotics for their headaches if the medication makes their headache go away or if it just makes it better, probably 75% will admit that it does not terminate their headache.

 

[deleted6669]

"You know... the medication that starts with the 'd'..."

YUP, I KNOW JUST THE ONE.....DROPERIDOL......AND IF THE 1ST DOSE DOESN'T WORK, THE SECOND WILL.......

 

[bartleby]

Dolobid also fits the bill. Sounds just like it's narcotic "D" friend if you say it fast enough. It's a pity there's no IV formulation.

YUP, I KNOW JUST THE ONE.....DROPERIDOL......AND IF THE 1ST DOSE DOESN'T WORK, THE SECOND WILL.......