REBEL Cast Episode 40: Research From the Past Year – Pain Control

Welcome back to Episode 40 of REBEL Cast. We have taken some time off but don’t worry, we are back. In this episode, we will be discussing some studies from the past year that caught our attention, dealing with pain control. With the hundreds of journals in EM/CC and the thousands of publications it is hard to stay up to date with current research. This 3 part series will be dedicated to discussing current literature and how it can be applied to your clinical practice.

Episode 40 – Research From the Past Year – Pain Control

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Evidence Based Medicine (EBM)

Study #1:

Motov, S et al. A Prospective Randomized, Double-dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. Am J Emerg Med 2017 PMID: 28283340

Blog Post HERE: Low Dose Ketamine for Acute Pain in the ED – IV Push or Short Infusion

RCT with 48 pts with acute abdominal, flank, or musculoskeletal pain with initial pain score of ≥5 to ketamine 0.3mg/kg by IV Push (over 5 min) vs Short Infusion (0.3mg/kg mixed in 100mL NS over 15 min)

Patients with Bothersome Adverse Effects 5min IV Push: 92% 15min IV Infusion: 54% NNH = 3

No difference in pain score decrease from baseline = approx decrease of 5 from baseline

Bottom Line: Low dose ketamine of 0.3mg/kg, mixed into 100mL of Normal Saline given over slow infusion (15 minutes) has a decreased side effect profile (i.e hallucinations or dizziness) and equal analgesic profile when compared to IV push (5 minutes) low dose ketamine.

Study #2:

Motov S et al. Comparison of Intravenous Ketorolac at Thee Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2017 PMID: 27993418

Blog Post HERE: The Ketorolac Analgesic Ceiling

Single Center RCT of 240 pts randomized to 10, 15, 30mg IV toradol 10mg Group Pain Score: 7.7 –> 5.2 (Diff: 2.5) 15mg Group Pain Score: 7.5 –> 5.1 (Diff: 2.4) 30mg Group Pain Score: 7.8 –> 4.8 (Diff: 3.0) No statistical or clinical difference between doses Need for rescue analgesia no different between groups

Bottom line: Based on the best available literature at this time, providers should switch to giving 10 mg of ketorolac IV for acute pain in the ED.

Study #3:

Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. Am J Emerg Med 2017. PMID: 28320545

Blog Post HERE: Diabetic Gastroparesis Needs HUGS

Retrospective Study of 52 patients with diabetic gastroparesis, n/v, or abdominal pain with 5mg IM haloperidol Hospital Admission: 10% vs 27% Less Opioid Narcotics Median ED LOS: 9.2 vs 25.4hrs Median Hospital LOS: 43.68hr vs 38.42hr No Dystonic Reactions, akathisia, excessive sedation or cardiovascular complications observed

Bottom Line: In this small, retrospective study, 5mg IM Haldol decreased rates of admission and amounts of opioids administered in patients with diabetic gastroparesis.

Well that’s it for part 1 of this 3 part series. Stay tuned as Swami and I are going to tackle some more papers published in the past year that we think you should know about. Two more things before we let the listeners go…

First, REBEL EM is proud to announce our first ever clinical conference, Rebellion in EM, happening May 11th – 13th, 2018 in San Antonio, TX. Just go to rebellioninem.com to register.

Finally, as always, be sure to follow us on Facebook and Google+ REBEL EM, two words, no periods. Until next time REBEL EMers.

References:

Motov, S et al. A Prospective Randomized, Double-dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. Am J Emerg Med 2017 PMID: 28283340 Motov S et al. Comparison of Intravenous Ketorolac at Thee Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2017 PMID: 27993418 Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. Am J Emerg Med 2017. PMID: 28320545