By Meaghan Mercer, DO
Emergency Medicine Resident
“The relief of pain should be among the highest priorities for an ED physician. The relief of human suffering does not require that a diagnosis be made first, but rather it simply requires a compassionate heart and motivation to anticipate and meet the patient’s needs using a wide variety of available techniques.” Richard Bukata
This idea came from a great lecture on the EMA site from 2014 called the “Ouchless ED” and a lecture on pain control without opiates that one of the Vegas residents @waltvegasemr gave us. Patients who get adequate analgesia have a high association with patient satisfaction[1]. Here are some methods to improve pain control in patients and a discussion on ways to do this without narcotics.
Intranasal (IN) Fentanyl in Peds and adults
Anyone who has contact with pediatric patients knows that IVs can cause considerable fear and distress in a patient and can prolong the time to pain medication administration. In all pediatric patients who require opiate pain control, intranasal fentanyl should be considered.
Emergency Medicine Resident
“The relief of pain should be among the highest priorities for an ED physician. The relief of human suffering does not require that a diagnosis be made first, but rather it simply requires a compassionate heart and motivation to anticipate and meet the patient’s needs using a wide variety of available techniques.” Richard Bukata
This idea came from a great lecture on the EMA site from 2014 called the “Ouchless ED” and a lecture on pain control without opiates that one of the Vegas residents @waltvegasemr gave us. Patients who get adequate analgesia have a high association with patient satisfaction[1]. Here are some methods to improve pain control in patients and a discussion on ways to do this without narcotics.
Intranasal (IN) Fentanyl in Peds and adults
Anyone who has contact with pediatric patients knows that IVs can cause considerable fear and distress in a patient and can prolong the time to pain medication administration. In all pediatric patients who require opiate pain control, intranasal fentanyl should be considered.
Numerous studies have been done which show that IN fentanyl provides rapid and safe control of severe pain. These studies have looked at kids with severe pain from burns[2], acute upper limb fractures [3], specifically in younger patients ages 1-3[4] and as an acceptable alternative to IV morphine for the management of pain in the prehospital setting[5]. IN Fentanyl works well for adults as well with msk pain/injuries and is a great adjunct (16)!
Dosing and administration:
Foley Placement
In any awake patient the idea of having a foley placed is not a pleasant one. The general grimace that comes with the procedure could be avoided. Options to alleviate pain is injecting a small volume of 2% lidocaine jelly into the urethra then placing the tube with adequate lubrication. This also can decrease sphincter contraction that creates resistance to the catheter placement. In both males[6] and females[7] there is statistically significant pain reduction.
Lidocaine & IV Placement
There is pain associated with lidocaine infiltration. A few studies have looked at ways to decrease the sensation. A small subset of studies show that warm lidocaine may improve pain scores and buffered lidocaine significantly decreased the discomfort associated with its administration as a local anesthetic[8][9].
Do we need to decrease pain with IV insertion? Lidocaine injection does increase cost and a little extra time but patients will appreciate efforts to relieve pain and stress associated with IV placement. I think this should absolutely be considered in patients who have difficult IV access and may require multiple sticks, deeper lines with US guidance, and A-Line placement. The infiltration of lido has not been shown to distort the anatomy and make placement more difficult.
Opioid alternatives
Prescription drug addiction and abuse is growing at an alarming rate and we have to be a voice in the discussion. We also want to make sure to address our patient’s pain appropriately. Here is some good literature that may help you in your Rx decisions.
Other options that can be explored:
References
[1] Shill, J., et al. Factors associated with high levels of patient satisfaction with pain management. Acad Emerg Med. 2012 Oct;19(10):1212-5
[2] Finn, M., et al. Intranasal fentanyl for analgesia in the paediatric emergency department. Emerg Med J 27(4):300, April 2010
[3] Crellin, D., et al. Does the standard intravenous solution of fentanyl (50 microg/mL) administered intranasally have analgesic efficacy? Emerg Med Australasia 22:62, February 2010
[4] Cole, J., et al. Intranasal fentanyl in 1-3-year-olds: a prospective study of the effectiveness of intranasal fentanyl as acute analgesia. Emerg Med Australasia 21(5):395, October 2009
[5] Rickard, C., et al. A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 25(8):911, October 2007
[6] Siderias, J., et al. Comparison of topical anesthetics and lubricants prior to urethral catheterization in males: a randomized controlled trial. Acad Emerg Med, 11(6):703, June 2004
[7] Chung, C., et al. Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial. Emerg Med Australasia 19(4):315, August 2007
[8] Matsumoto AH, et al. Reducing the discomfort of lidocaine administration through pH buffering. J Vasc Interv Radiol. 1994 Jan-Feb;5(1):171-5.
[9] McNaughton, C., et al. A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med 54(2):214, August 2009
[10] Hoppe, J., et al. Association of Emergency Department Opioid Initiation With Recurrent Opioid Use. Ann Emerg Med. 2014 Dec 18.
[11] Clark, E., et al. A Randomized, Controlled Trial of Acetaminophen, Ibuprofen, and Codeine for Acute Pain Relief in Children With Musculoskeletal Trauma. Pediatrics Vol. 119 No. 3 March 1, 2007 pp. 460 -467
[12] Holdgate, A. Pollock, T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004
[13] Wilbur, L., et al. Should Topical Nonsteroidal Anti-inflammatory Drugs Be Used to Treat Acute Musculoskeletal Conditions? Ann Emerg Med 59(4):283, April 2012
[14] Zempsky, W.T., et al. Use of low-dose ketamine infusion for pediatric patients with sickle cell disease-related pain: a case series. Clin J Pain 26(2):163, February 2010
[15] Lester, L., et al. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J Emerg Med 28(7):820, September 2010
[16] Farahmand, S et al. Nebulized fentanyl vs intravenous mor- phine for ED patients with acute limb pain: a randomized clinical trial. Am J Emerg Med. 2014 Sep;32(9):1011-5.
Dosing and administration:
- Recommended dose 1.5-2 ug/kg
- Give ½ the dose per nostril with 1ml per nostril ideal
- Strongly consider giving oral pain medication at the same time (ibuprofen/tylenol always good choices) so that as the IN medication wears off the oral medication has kicked in
- There is often a dead space in the delivery device and some of the drug is not delivered
Foley Placement
In any awake patient the idea of having a foley placed is not a pleasant one. The general grimace that comes with the procedure could be avoided. Options to alleviate pain is injecting a small volume of 2% lidocaine jelly into the urethra then placing the tube with adequate lubrication. This also can decrease sphincter contraction that creates resistance to the catheter placement. In both males[6] and females[7] there is statistically significant pain reduction.
Lidocaine & IV Placement
There is pain associated with lidocaine infiltration. A few studies have looked at ways to decrease the sensation. A small subset of studies show that warm lidocaine may improve pain scores and buffered lidocaine significantly decreased the discomfort associated with its administration as a local anesthetic[8][9].
Do we need to decrease pain with IV insertion? Lidocaine injection does increase cost and a little extra time but patients will appreciate efforts to relieve pain and stress associated with IV placement. I think this should absolutely be considered in patients who have difficult IV access and may require multiple sticks, deeper lines with US guidance, and A-Line placement. The infiltration of lido has not been shown to distort the anatomy and make placement more difficult.
Opioid alternatives
Prescription drug addiction and abuse is growing at an alarming rate and we have to be a voice in the discussion. We also want to make sure to address our patient’s pain appropriately. Here is some good literature that may help you in your Rx decisions.
- Short courses of opioids are presumed to be safe for acute pain but opioid-naive ED patients prescribed opioids for acute pain are at increased risk for additional opioid use at 1 year[10].
- In kids with acute msk trauma ibuprofen trumps acetaminophen and codeine[11].
- Both NSAIDs and opioids can provide effective analgesia in acute renal colic[12].
Other options that can be explored:
- Lower cervical IM lido injections for headaches. https://www.youtube.com/watch?v=0jIqzJs5c2g
- Topical NSAIDs in musculoskeletal injuries[13]
- Low Dose Ketamine for Pain Control[14][15]
References
[1] Shill, J., et al. Factors associated with high levels of patient satisfaction with pain management. Acad Emerg Med. 2012 Oct;19(10):1212-5
[2] Finn, M., et al. Intranasal fentanyl for analgesia in the paediatric emergency department. Emerg Med J 27(4):300, April 2010
[3] Crellin, D., et al. Does the standard intravenous solution of fentanyl (50 microg/mL) administered intranasally have analgesic efficacy? Emerg Med Australasia 22:62, February 2010
[4] Cole, J., et al. Intranasal fentanyl in 1-3-year-olds: a prospective study of the effectiveness of intranasal fentanyl as acute analgesia. Emerg Med Australasia 21(5):395, October 2009
[5] Rickard, C., et al. A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 25(8):911, October 2007
[6] Siderias, J., et al. Comparison of topical anesthetics and lubricants prior to urethral catheterization in males: a randomized controlled trial. Acad Emerg Med, 11(6):703, June 2004
[7] Chung, C., et al. Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial. Emerg Med Australasia 19(4):315, August 2007
[8] Matsumoto AH, et al. Reducing the discomfort of lidocaine administration through pH buffering. J Vasc Interv Radiol. 1994 Jan-Feb;5(1):171-5.
[9] McNaughton, C., et al. A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med 54(2):214, August 2009
[10] Hoppe, J., et al. Association of Emergency Department Opioid Initiation With Recurrent Opioid Use. Ann Emerg Med. 2014 Dec 18.
[11] Clark, E., et al. A Randomized, Controlled Trial of Acetaminophen, Ibuprofen, and Codeine for Acute Pain Relief in Children With Musculoskeletal Trauma. Pediatrics Vol. 119 No. 3 March 1, 2007 pp. 460 -467
[12] Holdgate, A. Pollock, T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004
[13] Wilbur, L., et al. Should Topical Nonsteroidal Anti-inflammatory Drugs Be Used to Treat Acute Musculoskeletal Conditions? Ann Emerg Med 59(4):283, April 2012
[14] Zempsky, W.T., et al. Use of low-dose ketamine infusion for pediatric patients with sickle cell disease-related pain: a case series. Clin J Pain 26(2):163, February 2010
[15] Lester, L., et al. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J Emerg Med 28(7):820, September 2010
[16] Farahmand, S et al. Nebulized fentanyl vs intravenous mor- phine for ED patients with acute limb pain: a randomized clinical trial. Am J Emerg Med. 2014 Sep;32(9):1011-5.
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