Even when we can't cure a patient, we can relieve suffering. On average, we kind of stink at pain control in the ED. One physician, Dr. Ed Gentile, has created a simple path to optimal acute pain control in the ED. I heard this lecture on the EM:RAP podcast and got permission from Drs. Gentile and Herbert to repost it here. This is not a critical care topic per se, but it is applicable to the critically ill, the non-critically ill–basically any patient who is in pain in the ED.

Patient Controlled Analgesia without the Pump

by Ed Gentile, MD

Need for an effective and efficient process is self evident .

Acute pain protocol for moderate/severe pain

• Administer morphine 0.1 mg/kg IVP (If pt is > 55 y/o, substitute morphine 0.05 mg/kg IVP for this 1st dose)
  + diphenhydramine 0.5 mg/kg IVP
• 7 minutes later the patient is asked, “Would you like more pain medicine?”
• If the answer is yes, give a 2nd dose of morphine 0.05 mg/kg IVP
• 7 minutes later, the patient is asked again, “Would you like more pain medicine?”
• If the answer is yes, give a 3rd dose of morphine 0.05 mg/kg IVP
• This continues every 7 minutes until the patient answers “no” to the question or the patient is asleep.

According to Dr. Gentile, “We don't want to use the minimum, but the optimum pain dose for all patients.”

The protocol uses morphine because it has the longest half-life .

Diphenhydramine prevents antihistamine effects: nausea, vomiting, hypotension.

The protocol is unbiased and controlled by the patient!

Photo by Azarius

Update:

There finally is a study validating this process:

Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication?      (doi:10.1016/j.annemergmed.2015.04.035)

Podcast: Play in new window | Download (Duration: 29:19 — 26.9MB) | Embed

Subscribe: Apple Podcasts | Google Podcasts | Spotify | RSS | More

• Author
• Recent Posts

Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).

Latest posts by Scott Weingart, MD FCCM (see all)

• EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan - January 23, 2021
• EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
• EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020