1. Pain Management in the ED
Elise O. Lovell, MD

2. Pitfalls in Pain Management
Oligoanalgesia (too little)
Withholding analgesics until definitive
diagnosis is made (too late)
Inappropriate route of administration
Inappropriate dosing schedule
Waiting for the patient to ask
Inappropriate discharge analgesic

3. Some specific analgesics
Ketorolac (Toradol)
Cox-2 Inhibitors
Tramadol (Ultram)
Propoxyphene (Darvon)
Codeine/Hydrocodone/Oxycodone
Meperidine (Demerol)
Fentanyl (Sublimaze)
Morphine
Hydromorphone (Dilaudid)

4. Case 1
28 yo male, MVC, isolated right leg
pain.
PMH: neg, no allergies
VS: 140/80, 90, 18

5. Case 1

6. Case 2
30 yo female, left flank pain,
hematuria, vomiting
PMH: neg, no allergies

7. Case 2

8. Case 3
19 yo male, RLQ pain, fever, anorexia
PMH: neg, no allergies
Surgeon calls and says: Don’t give
him any pain medication, it will mess
up my exam !!

9. Case 4
50 yo female, distal radius fracture,
no reduction needed, in splint, ready
for discharge.
PMH: negative, no allergy

10. Case 5

11. Ketorolac (Toradol)
Cyclooxygenase inhibition
Same GI side effects as all NSAIDS
Similar efficacy to Ibuprofen
Effective in renal and biliary colic
Obstructed kidney uses vasodilation
to preserve perfusion (prostaglandin
mediated effect), ketorolac -> ATN

12. COX-2 Inhibitors
Celecoxib (Celebrex), Rofecoxib
(Vioxx), Valdecoxib (Bextra)
Efficacy similar to other NSAIDS
Improved GI profile (maybe)
Increased risk of MI and CVA
All NSAIDS with Renal, BP,GI effects,
edema

13. COX-2 Inhibitors
Celecoxib (Celebrex), Rofecoxib
(Vioxx), Valdecoxib (Bextra)
Efficacy similar to other NSAIDS
Improved GI profile (maybe)
Increased risk of MI and CVA

14. Codeine/Hydrocodone/Oxycodone
Multiple strengths
Often mixed with ASA/tylenol

16. Tramadol (Ultram)
Binds to mu opioid receptors, also
inhibits norepi/serotonin reuptake
Similar analgesic potency to codeine
Seizure risk
Nausea, dizziness, sedation,
constipation
Serotonin syndrome with SSRI

17. Propoxyphene (Darvon)
Synthetic narcotic
In OD, expect seizures, also can
cause cardiac toxicity (blocks),
requires high doses of narcan to
reverse

18. Fentanyl (Sublimaze)
Stable hemodynamic profile
Minimal histamine release
High dose rapid push --> “rigid chest
syndrome”. Treat with naloxone and
muscle relaxants
Large dose -->possible apnea
Small doses frequently (1-2 mic/kg,
duration 30-60 minutes)
Also transdermal patch, lozenge,
inhaled

20. Morphine
Analgesic dose 0.1 mg/kg
Dosing ceiling from side effects, not
from arbitrary number of mg

22. Hydromorphone (Dilaudid)
High potency (1 mg equals 7 mg
morphine)

24. Meperidine (Demerol)
Not available (except for shivering)
Risk of seizures from Normeperidine
in high dose (sickle cell anemia) and
in renal failure
Serotonin syndrome with MAOI

25. Procedural Sedation
Fentanyl/Versed
Ketamine
Methohexital (Brevital)
Propofol (Diprivan)
Etomidate

27. Ketamine
Derivative of PCP
Use in kids (age 1-10 years) for short
painful procedures
Onset 5 minutes, lasts approx. 30 minutes
Dissociative state-eyes open, no one home
Midazolam helps nausea, likely does NOT
decrease emergence phenomena
Atropine no longer recommended

28. Ketamine, continued
Normal or increased muscle tone
Preserved airway reflexes
Analgesia, amnesia
Stable or increased BP and Pulse
Bronchodilator

29. Ketamine, the downside
Increases ICP and IOP
Apnea in children < 1 year
Increased secretions ->laryngospasm
(bag through it)
Emergence phenomena (older kids)
Complete recovery -> 1 hour
(concern of head positioning)
Emesis

30. Propofol (Diprivan)
Sedative hypnotic-NOT analgesic
Onset 40 seconds, off in 5-10 minutes
Side effects: Hypotension, Apnea,
Infection
Decreases ICP, anti-emetic, anti-epileptic
Decreased side effects with infusion rather
than bolus
Different dosing for induction vs.
procedural sedation vs. maintenance

31. Propofol (Diprivan) Dosing
May add low dose fentanyl (1 mic/kg IV)
as analgesic, and use lower propofol
dose
Pediatrics- use 1 mg/kg IV
“propofol syndrome” in kids seen in
PICU-longer duration sedation
(acidosis, hypotension, organ failure)

32. Let’s mix them together: “Ketofol”
1:1 mixture in same syringe
Usual dose required approximately
1.0 mg/kg
Best of both worlds (less hypotension,
less resp. sedation, less vomiting,
less emergence)

34. Methohexital (Brevital)
Not currently available
Ultra short acting barbiturate
1-1.5 mg/kg IV push
Not an analgesic
Can cause apnea, decreased BP,
also possible laryngospasm,
myoclonus, bronchospasm, N/V

35. Etomidate
Sedative hypnotic, NOT analgesic
Induction dose 0.3 mg/kg IV push, use 0.15
mg/kg for procedural sedation
Onset within one minute, off in about 10
minutes
Decreases ICP and IOP
Stable CV effects
Can cause myoclonus (not seizures),
vomiting, respiratory depression
Adrenal suppression-consider alternative in
sepsis

36. Take home points
Dose analgesics to effectiveness, not an
arbitrary number of mg
Dose early, dose often
Be proactive about offering analgesics
Remember the potency of Dilaudid
Ketorolac is expensive Ibuprofen
Etomidate and Propofol are NOT
Analgesics

39. Propofol (Diprivan) dosing
Procedural sedation: usually slow push
1-1.5 mg/kg with repeated dosing of 0.5
mg/kg, duration 8-10 minutes
Induction: 2-2.5 mg/kg, usually give 40 mg
every 10 seconds (elderly 20 mg every 10
seconds)
ICU sedation: 5 mic/kg/min (0.3 mg/kg/hr)
increase by 10 mic/kg/min (0.6 mg/kg/hr)
every 5-10 minutes