Today an update on pain management in the ED. Sergey is a great friend and a previous guest on the show when he discussed the Opioid-Free ED.
Sergey Motov, MD
Sergey is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is a Research Director who is passionate about safe and effective pain management in the ED. He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.
The Pain-Free ED
Sergey has an amazing site, with resources and lectures: The Pain-Free ED
A Brief Discussion of the Advantages of Morphine over Hydromorphone and Fentanyl from a Euphoria Perspective in Patients with Intact Organs
This is far more an issue for what you send these patients home on.
Sergey recommends MSIR tablets 7.5-10 mg Q 6 hrs for 3 days for most acute pain indications in patients without organ failure. There is also liquid 10 mg/5 ml, so 1/2 tsp gets you 5 mg.
Consider diclofenac gel in the appropriate patient. Now available over the counter. Apply twice/day.
Giving Fentanyl For Longer Duration Pain Means the Patient will be in Pain Again Soon
- Consider a regimen that matches the duration of pain
Kidney Failure
- Do Not Use Morphine
- Hydromorphone–avoid in ESRD, If you feel the need to use it in more mild renal failure, Drop Dose by 75% (e.g. from 1mg to 0.25 mg per dose)and extend dosing regimen (from q4-6 hrs extended to q8-12hrs)
- In the ED, you should probably use Fentanyl. Still reduce dose by 75% of standard and extend dosing intervals
- When you need to send the patient home, do not use tramadol. Mild to moderate, use oxycodone with sig. dose reduction. In the future, buprenorphine may be the agent of choice.
Liver Failure
- Very low dose morphine, but probably the better idea is:
- Fentanyl with a dose reduction and interval extension
- For sending a patient home, Oxycodone consider half dose with extension of intervals
Ketamine
- Recent trial compared 0.15 mg/kg to 0.3 mg/kg with no difference
- Breath-Actuated Nebulized Ketamine
Sergey does not Like IM Pain Meds
- Causing pain to relieve pain doesn't make a ton of sense
More from Sergey
- More on Kidney and Liver Failure Pain Management
- Pain Pearls on Opioids
- Handout on Analgesics for Hepatic and Renal Failure
Do a Virtual Resus Fellowship
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Hello, I really enjoyed listening to this podcast and have been listening to your podcast, Scott Weingart, for many, many years! I am an RN with many years of PICU experience who has transitioned to pediatric hospice over the past 3 years. I’m curious to understand why the rectal route for administration of opioids and other medications such as Ketamine, is considered a last resort , ” extreme ” or not at all, in the acute care setting ? I certainly remember many instances working in the PICU unable to get IV access, and scrambling to manage pain and anxiety,… Read more »
After so long I have read such an amazing article.
Am really looking forward to read more such article like this in the
Near future.
After so long I have read such an amazing article.
Am really looking forward to read more such article like this in the
Near future.
Source: https://www.smartbusinessbox.com/what-is-sales-report/
Hi Thanks for this, excellent stuff!! Gotta say I was becoming a fentanyl fan but after hearing this I’ll be thinking some situations differently. Regarding this issue I’d like to pose a question based on a clinical case I faced. 19 years-old boy who crashed on a bike, hit the steer and came to the ER after having an abdominal ecography (first triage not very urgent) that showed signs of ruptured spleen. Although hemodinamically stable when he went to the CT he couldn´t lie back because of intense pain. In this situation, we opted to go for fentanyl because we… Read more »
we’ll see what Sergey says, but in these cases that are compensated shock, I like fentanyl!!!!
I am a prehospital provider, both critical care and 911. Our pain control protocols vary so much based on medical director, area and level of comfort. We recently obtained Ketamine and fentanyl in addition to morphine and last resort versed for use in pain control. Most start with fentanyl then move to ketamine…only to stop and stair at their now completely unresponsive patient. In the setting of prehospital pain control where we need the best bang for the buck in short time, would you still recommend morphine and how does what we give prehospital change the approach of ER treatment… Read more »
i love fentanyl for ems!!