Dr. Victoria Landry
Link to article
https://pubmed.ncbi.nlm.nih.gov/32989888/
Dr. Victoria Landry
Link to article
https://pubmed.ncbi.nlm.nih.gov/32989888/
Only 75% of cases receiving TXA are receiving it within 3 hours of injury. And only ½ of theses cases are having the drip started.
CRASH study found patients receiving TXA after 3 hours do not benefit.
If emergent reversal of anti-coagulation from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.
Consultants accepting transfers from other regions through NB trauma line may request that patient stop in ED first for evaluation/imaging prior to transfer to floor or ICE.
The consultant should make every effort to evaluate their patient on arrival to ED
Expectation is that TCP and/or consultant clearly delineate their plan with ED charge MD.
I might not have gotten that one quite right, but the MTP policy follows a 4:1:1 rule – after 4th unit of PRBCs, give a unit of platelets and FFP.
Patients occasionally “self-present” to triage with significant injuries or a history of a high energy MOI. The most efficient way to mobilize resources is to have the triage RN call a “Trauma CODE”.
Pain management in pediatric population is often challenging. If IV access is delayed consider alternative routes – intranasal fentanyl 1.5 ug/kg using MAD (mucosal atomizing device).
Chest tube sizes 36 F and 345F are now no longer being stocked on chest tube cart.
Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.
Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.
Dr. Talbot /Dr. Chandra/ March
Question: Does increasing the dose of intravenous Ketorolac improve analgesia in emergency department patients with a variety of pain syndromes?
Population: 240 patients, 80 allocated to each group
Adult patients (18-65) who presented to the emergency department with acute (less than 30 d) moderate to severe (intensity of 5 or greater on a standard 0-10 pain scale) flank, abdominal, musculoskeletal, or headache pain, who would routinely be treated with ketorolac by the attending emergency physician.
(Exclusion criteria: Older than 65 yrs, pregnancy or breastfeeding, active PUD, acute GI hemorrhage, history of renal or hepatic disease, allergy to NSAIDs, unstable vitals systolic BP <90 or > 180 mmHg or HR < 50 or > 150, and patients that had already received analgesic.
Intervention (1): Ketorolac 10 mg IV (given over 1-2 minutes)
Intervention (2): Ketorolac 15 mg IV (given over 1-2 minutes)
Intervention (3): Ketorolac 30 mg IV (given over 1-2 minutes)
Patients who still desired pain medications after 30 minutes were offered Morphine 0.1 mg/kg IV as a rescue analgesic.
Outcome: Primary: Reduction in the numeric pain scale score at 30 minutes from medication administration
Secondary: Rates and percentage of subjects experiencing adverse events or requiring rescue analgesia.
Design: Randomized control trial
Ketorolac dose | Pain Score
Initial |
Pain Score
30 min |
Difference |
10 mg | 7.73 | 5.13 | 2.6 |
15 mg | 7.54 | 5.05 | 2.5 |
30 mg | 7.8 | 4.84 | 3.0 |
Patients in all dosing regimens had clinically significant improvement in their pain scores after 30 min. The reduction in pain persisted through to 120 minutes.
There was no difference in the rate of rescue morphine use by group over time.
There was no difference in the common adverse effects (dizziness 18% vs 20% vs 15%, nausea 11% vs 14% vs 10%, headache 10% vs 2.5% vs 3.8%, itching 0% vs 1.3% vs 1.3%, or flushing 0% vs 1.3% vs 0%).
Other more serious side effects were not documented (gastrointestinal bleeding, renal impairment, changes in bleeding times). There are other studies that suggest that some of these adverse effects are dose related and therefore lower doses would be expected to reduce these complications.
Ketorolac had similar analgesic efficacy profiles at doses of 10 mg, 15 mg and 30 mg IV for short term treatment of acute moderate to severe pain in the Emergency Department. The results of the study provide a basis for changes in practice patterns and guidelines in the Emergency Department supporting the use of the 10 mg IV ketorolac dose.
Patients presenting to the emergency department with moderate to severe pain receiving a single dose of intravenous Ketorolac had a significant reduction in pain with no difference between the dosing regimens of 10mg, 15 mg and 30 mg IV.
We recommend a change to our renal colic protocol and our ED Assessment order set to administer Ketorolac 10 mg IV instead of 30 mg IV of the treatment of a variety of conditions with moderate to severe pain. Unfortunately, the Ketorolac used in the emergency department comes in a 30 mg/ml vial. It is more efficient to draw up the full dose for each individual patient than be taking 1/3 of a ml out and possibly throwing the remainder out. Recommend asking Emergency Department pharmacist to determine if other solution strengths are available. Ketorolac could be a narcotic sparing analgesic, where in the opinion of the attending physician, appropriate patients can be given ketorolac and then reassessed at 30 minutes and rescue mediation given as required.
Pain management is one of the most important components of patient care in the Emergency Department. Evidence suggests that patients in pain are commonly under-treated, under-recognised and treatment is often delayed. The process for recognition and management of pain should be a priority for Emergency Departments. Pain control should start in the pre-hospital phase for those brought in by ambulance or at Triage for those who self-present. Response to analgesia should be monitored during the patient’s stay in the Emergency Department and consideration given to analgesia requirements post discharge.
Paint control is one of the top clinical priorities for SJRHEM