Pain Cases Activities
How would you manage each of these cases? Enter doses of medications you would use.
- Mr. Scacic
78 year old man with prostate cancer and known bone mets; normally on Hydromorphone sustained-release, 12 mg BID; now in ED because of sudden increase in low back pain and intense paresthesias in both legs.
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- Mrs. Mah
82 year old woman with early dementia living at home with known malignant ascites and steady increase in abdominal pain, in ED for pain management.
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- Mrs. Plenasola
80 year old, advanced dementia, well-established advance directives of “full comfort measures only” in a nursing home. She has fallen out of bed. She has a fractured hip and pelvis and massive subdural hemorrhage and is unresponsive to any stimulus.
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Discussion: Pain Cases Activities
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Case #1 answer – start gabapentin 300 mg (I’m assuming that 25 mg BID dosing with titration based on tolerance/ response would be undertaken) seems too high for elderly.
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goal is for quality life sustaining or end of life care
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the last scenario is confusing.
adietrich
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good cases
real
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great learning
Good information
good info
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Good info
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very interesting. addressing pain is not the first thing to do.always ensures investigations and other sources of pain is rules out
good
usually let them go in the ER, but it does tie up the room
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good to know
yes
Yep
Interesting
As a palliative care consultant in addition to emergency medicine doc, the cases above are a bit interesting. I would have a bit different answer/approach to contribute.
IV medications tend to reach side effects much much faster and subcut administration lasts much longer/much more stable. Other than initial crisis dose if a patient already has an IV, we prefer subcut administration.
For case 1 – 10% of the MDD is what they state but should still be divided by 2 for conversion from PO to IV/subcut. Also gabapentin is a very slow to reach affect medicine, whereas dexamethasone would be what I would suggest while awaiting pall radiation consult.
In the last case, orders for at least PRN analgesia should be given. Patients at imminent risk of passing should likely not be transferred.
interesting
hmm
don’t get the hydromorphone conversion-we are giving 10% of daily dose which is much less than the IV equivalent of a single po dose of his hydromorphone
The 10% of MEDD that is 2,4 mg of hydromorphone for breakthrought should not be divised by 2 because given IV ??? ( 2 mg per-os is 1 mg IV )
good review to opioid meds
good cases
thanks
interesting
interesting
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Establishing a plan of care while involving the families at presentation to the ER is very helpful.
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Hard cases
so far no signs of pain or distress, as long as goals of care hasn’t changed support family
I don’t understand:
You give 10% of p.o. dose IV, without conversion?
If M. Scacic receive 24 mg/day of hydromorphone p.o, It is the equivalent of 8-12 mg hydromorphone IV.
So I would have give 0.8-1.2 mg hydromorphone IV or approximately 4 mg morphine IV, not 2,4 mg of hydromorphone IV ?!?
2,4 mg of hydromorphone is PO, they forgot to convert in IV : 120 mg Po morphine x 10% = 12 mg PO morphine = 2,4 PO hydromorphone = 1,2 IV hydromorphone.
So true !!!
it is important to check for pain control and ajust ,discussion with patient /family of the goal to be confortable
interesting
La educación es primordial para que todo el equipo de salud hable el mismo idioma
we need to be clear in the patients course of their desease
buenos consejos
NO PAIN
🙂
pain hurts
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I’ve been in the situation where it is hard to accept the face,nothing else can be done
Agree with above that in LTC staff is quite skilled at EOL care.
i would have contacted the family informed them of the prognosis and confirmed their wishes/the pt’s wishes and avoided the ER transfer in the first place. offered support as they needed. It was stated full comfort measures only.
although I always teach learners that q15min opioid is the best pharmocologic/physiologic way to dose…I also teach them it is not the best logistical/practical way of writing orders. The reality is it takes 2-5min for an RN to prepare an opiod dose (get syringes/supplies,go get locked meds, sign out meds, lock up, administer to patient), for an RN managing 3-4 (or more) patients, it is not practical for him/her to spend 30% of their time getting analgesia for a single patient. My personal opinion is that, unless they are 1:1 it isn’t practical to expect dosing any more frequently than q30min. You can write the order for q15, but you might want to follow it up with a brief congenial check with the RN about realistic expectations.
sometimes is difficult to send back to a nursing home someone who is imminently dying
Of course if you think the patient is going to die imminently or in the ambulance, it’s best to keep the person in ED. However that too is complicated since few EDs are well set up to manage the dying person (ED RNs are busy providing urgent care to others, little familiarity with comfort measure dosing, no one is really familiar with the patient, etc.)
In fact most nursing homes have quite well developed protocols for end of life care and staff feel comfortable providing that care (after all MANY people die in NHs). I have had NH RNs say to me “I think you should send her back here –she wanted to die at home after all.” A quick conversation with someone at the NH to ensure that plan will work might ensure a much more hmane and compassionate death for the patient and a better experience for the family.