Good summary! I agree that 4mg of morphine is generally not enough, but, as you note, there's a lot of resistance to “appropriate” doses. I tend to give 4mg — which everyone is comfortable giving — and just repeating as often as necessary.
Great post. I think one of the best ways to optimize pain management in the ED is to implement a nursing-driven pain management protocol. We recently developed and implemented a protocol at Maine Medical Center, where physicians can pick from either normal weight-based opioid dosing in patients at low-risk of AEs or a decreased weight-based regimen in patients at high-risk of AEs. Patients must present with moderate to severe acute pain with a VAS of 4-10 and our goal is to reduce pain by at least 50% within the first hour. One of the most crucial aspects of the protocol is proper re-evaluation of the patient, so I think the patient should ideally be reevaluated at least every 20 minutes until pain has been controlled. In addition to opioids and adjunctive medications (non-opioids, diphenhydramine, ketorolac, etc.), non-pharmacological interventions are also implemented. Exclusion criteria from the protocol includes: critical illness, intoxication/AMS, chronic pain, or opioid allergy. Obviously there are numerous barriers to protocols like this (i.e. need for department-wide buy-in), but I think it is worth a shot. So far, the protocol has been successful, but this is in a small subset of patients. It will be interesting to see how it plays out for us over the next year…
Good summary! I agree that 4mg of morphine is generally not enough, but, as you note, there's a lot of resistance to “appropriate” doses. I tend to give 4mg — which everyone is comfortable giving — and just repeating as often as necessary.
Great post. I think one of the best ways to optimize pain management in the ED is to implement a nursing-driven pain management protocol. We recently developed and implemented a protocol at Maine Medical Center, where physicians can pick from either normal weight-based opioid dosing in patients at low-risk of AEs or a decreased weight-based regimen in patients at high-risk of AEs. Patients must present with moderate to severe acute pain with a VAS of 4-10 and our goal is to reduce pain by at least 50% within the first hour. One of the most crucial aspects of the protocol is proper re-evaluation of the patient, so I think the patient should ideally be reevaluated at least every 20 minutes until pain has been controlled. In addition to opioids and adjunctive medications (non-opioids, diphenhydramine, ketorolac, etc.), non-pharmacological interventions are also implemented. Exclusion criteria from the protocol includes: critical illness, intoxication/AMS, chronic pain, or opioid allergy. Obviously there are numerous barriers to protocols like this (i.e. need for department-wide buy-in), but I think it is worth a shot. So far, the protocol has been successful, but this is in a small subset of patients. It will be interesting to see how it plays out for us over the next year…
great post!