Pain Management

[cmailliard]

During part of my Casualty Care class we talk about Pain Management and its importance in overall patient care. When the body is in pain several things happen but one of the important items is an increase in heart rate. This is a result of activation of the Sympathetic Nervous System (SNS) which is the same system that activates in Fight, Flight or Freeze. This heart rate increase will occur independent of the pathophysiologic response to the injury that has caused the pain (shock will result in an increased heart rate as a way to compensate for a falling blood pressure).

So why is this important? Controlling pain will help control blood loss in the trauma patient. Control the pain, lower the pulse (SNS activation only), less bleeding will occur. From an overall patient management standpoint, pain management is important for patient comfort as well.

This lesson was reinforced last night when I had severe left side flank pain. I have had kidney stones before, but never with this level of pain. After trying to fight through it for close two hours I finally went to the ED at midnight. I was sweating, nauseated and barely able to walk. My heart rate upon arrival was 140. This rate was pure SNS activation in response to pain as the injury (kidney stones) should not produce an increased heart rate. After some Toradol, Dilaudid and Norco my pain deceased and my heart rate dropped back down into the 70's.

In the absence of a Doc or Medic who can give you some good controlled substances, here are the pain management choices that work well in the trauma patient:
Tylenol
Mobic (Prescription only but you can find and order from Online Canadian sources)

AVOID - ASA, Motrin or other NSAID, they jack up you body's natural ability to clot, something you need in trauma.

Mobic is a NSAID but does not have the same effect on your body's ability to clot. Mobic is one of the simple meds for pain management used by the military.

Pop Quiz
What life threatening injury can present with flank pain? This is a differential diagnosis. Given the signs and symptoms what could the injury or illness be? In my case last night, peeing blood is a good thing because you can pretty much rule out this life threatening condition.

[Great-Kazoo]

Pop Quiz
What life threatening injury can present with flank pain? This is a differential diagnosis. Given the signs and symptoms what could the injury or illness be? In my case last night, peeing blood is a good thing because you can pretty much rule out this life threatening condition.

Gall Stones. If stuck in the duct after removal can cause serious pain and other issues. Like an infection. Or your pancreas is acting up.


A SIDE NOTE REGARDING NSAID'S :
Not everyone can take them. Those with ulcers need to be aware of the issues associated with nsaids.
one link of many on the issue http://patients.gi.org/topics/aspirin-and-nsaids/

[cmailliard]

A SIDE NOTE REGARDING NSAID'S :
Not everyone can take them. Those with ulcers need to be aware of the issues associated with nsaids.
one link of many on the issue http://patients.gi.org/topics/aspirin-and-nsaids/

Good point. Be sure to know your medical history and what you should and shouldn't be taking.

[TheGrey]

I think NSAIDS can also be problematic for people that have had a kidney removed. My Dad is one of those people, and he also has arthritis. His doctr told him he could take NSAIDs on occasion, but not often because it would stress his remaining kidney.

[BlasterBob]

I think NSAIDS can also be problematic for people that have had a kidney removed. My Dad is one of those people, and he also has arthritis. His doctr told him he could take NSAIDs on occasion, but not often because it would stress his remaining kidney.

I just had my left kidney removed last April. The VA Doc took that along with the ureter and bladder cuff. The Doc did NOT make any mention that I should refrain from anything, only said to drink a LOT of water for the rest of my life. Hmm??

[Great-Kazoo]

I just had my left kidney removed last April. The VA Doc took that along with the ureter and bladder cuff. The Doc did NOT make any mention that I should refrain from anything, only said to drink a LOT of water for the rest of my life. Hmm??

Unfortunately doctors are not known for being informative. Unless you ask they "assume" you already know that.

I asked about a script I was given. Mentioned interaction with something else I was on. Fukin idiot said Oh yes maybe I should give you something else[facepalm]

[SamuraiCO]

You are left with acetaminophen 3000-4000mg per day for pain control. I would use NSAIDS after trauma was controlled and no further risk of bleeding. Then is OK. Up to 3600mg ibuprofen and 1500mg naproxen (both OTC). Lots of fluids in your case. Hot pads. For discharge then I see you for your scrips of norco or percocet for pain, tamsulosin to open the urinary tubes and zofran for nausea. Our regular Saturday and Sunday nght ER concoction.

[cmailliard]

You are left with acetaminophen 3000-4000mg per day for pain control. I would use NSAIDS after trauma was controlled and no further risk of bleeding. Then is OK. Up to 3600mg ibuprofen and 1500mg naproxen (both OTC). Lots of fluids in your case. Hot pads. For discharge then I see you for your scrips of norco or percocet for pain, tamsulosin to open the urinary tubes and zofran for nausea. Our regular Saturday and Sunday nght ER concoction.

Pretty much what I was sent home with - Percocet for pain, Zofran for nausea, Flomax for flow and Cipro for the infection.

For the pop quiz the big life threat for someone with flank pain is a AAA or Abdominal Aortic Aneurysm. I told my wife, thank God I am peeing blood. The Doc (who actually was an old friend I had not seen in 5 years since he moved away and since came back) said the same thing "Blood in there?" Yep. "Good that's what we like to see."

GZ all good things you brought up. The point is when talking medicine it is more often ruling things out to come to a diagnosis. For most of this stuff (belly issues) high tech tools are very helpful (CT, MRI, etc.) but there are some old school things that can help.

[BlasterBob]

Zofran is certainly MY friend when coming out of a anesthetic when nausea is going to be an issue.

[Wulf202]

Zofran makes me so dizzy it's worse than the symptom it's treating

[ray1970]

I gave up managing pain years ago. I don't like any of the meds. They either don't work or if they do then I don't like the side effects.

I passed kidney stones on two separate ocassions with no meds, refused them after breaking my shoulder blade, and deal with a herniated disc in my lower back daily.

People handle pain differently. Trauma might be a different situation. Maybe drugs would be good for me then. I really don't know.

[cmailliard]

I gave up managing pain years ago. I don't like any of the meds. They either don't work or if they do then I don't like the side effects.

I passed kidney stones on two separate ocassions with no meds, refused them after breaking my shoulder blade, and deal with a herniated disc in my lower back daily.

People handle pain differently. Trauma might be a different situation. Maybe drugs would be good for me then. I really don't know.

Just take more, eventually your pain will go away, of course so will your respiratory drive [hahhah-no]

People are different. Not every patient reads the textbook, which why it is usually practicing medicine. I had a guy with no pulse, anywhere, taken by 4 different responders, who got up and walked to the stretcher. I put down "Rule Out Demonic Possession" for my impression on my paperwork. Got into a little bit of trouble for it. But, it is the example I give of why we must treat the patient, everything is not black and white in medicine.

[Jeffrey Lebowski]

I just had my left kidney removed last April. The VA Doc took that along with the ureter and bladder cuff. The Doc did NOT make any mention that I should refrain from anything, only said to drink a LOT of water for the rest of my life. Hmm??

I wouldn't sweat it, Bob. Are they checking your blood work regularly, I'm assuming?
I wouldn't take it by the handful, but I also wouldn't do that with two kidneys either.

[BlasterBob]

I wouldn't sweat it, Bob. Are they checking your blood work regularly, I'm assuming?
I wouldn't take it by the handful, but I also wouldn't do that with two kidneys either.

Yep, blood work every three months. Next week VA is going to get me in for Ultra Sound, CT scan and another cystoscopy which I will have at three month intervals for the rest of my life above the sod. I never look forward to the cystoscopy although they are pretty painless with the stuff they inject in the ole peter. All three of these tests within a three hour window. Worst part is waiting for the results of these tests. Hey, stay healthy Jeff.

[XJ]

So just for my edumacation: acetaminophen is preferred for extra-ordinary pain not related to hangovers, but for bumps & bruises encountered during ordinary landscaping or garage work where many beers are involved it is better to choose ibuprofen?

[Jeffrey Lebowski]

Yep, blood work every three months. Next week VA is going to get me in for Ultra Sound, CT scan and another cystoscopy which I will have at three month intervals for the rest of my life above the sod. I never look forward to the cystoscopy although they are pretty painless with the stuff they inject in the ole peter. All three of these tests within a three hour window. Worst part is waiting for the results of these tests. Hey, stay healthy Jeff.

Good to know, keep at it. You stay healthy too, my friend. [Beer]


So just for my edumacation: acetaminophen is preferred for extra-ordinary pain not related to hangovers, but for bumps & bruises encountered during ordinary landscaping or garage work where many beers are involved it is better to choose ibuprofen?

Ibuprofen and other NSAIDs are antipyretic (fever), analgesic (pain), and anti-inflammatory. These are mostly kidney drugs.
Acetaminophen isn't anti-inflammatory, but is the other two. Also has less side effects, IMO. This is a liver drug.
Hopefully let that be your guide.