What’s Your Diagnosis? Pain Management: Beyond Opioids November 1, 2019

Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case, on nonconvulsive status epilepticus, right. Click here to check out the answer!

Case Presentation: A 73-year-old woman in the ED after “twisting” her ankle

A 73-year-old woman with a history of peptic ulcer disease and stage 3 chronic kidney disease presents to the ED after “twisting” her ankle. She tried acetaminophen at home, but it didn’t adequately alleviate her pain. Currently, she complains of 6/10 pain at rest. She has mild swelling and tenderness at the posterior edge of her lateral malleolus. You order an ankle x-ray to evaluate for fracture and consider giving her oxycodone…

You wonder whether there is a better and safer alternative…

Case Conclusion

You concluded that your first patient likely had either an ankle sprain or a malleolar fracture, and that icing the area and immobilization was likely to improve her pain. With her comorbidities, you were concerned about using systemic NSAIDs, and you were concerned about giving her an opioid because of the association with adverse outcomes in older patients. You decided to apply ice, elevate the extremity, and order topical diclofenac. The radiograph was normal, and the patient’s pain improved with icing, immobilization with an air cast, and topical diclofenac. You discharged the patient with a prescription for topical diclofenac, a walker, and orthopedic follow-up.

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Brain Teaser: When should ketorolac be avoided? August 22, 2019

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Test your knowledge and see how much you know about pediatric pain management in the emergency department.

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The correct answer: C.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on guidance on assessing pain in pediatric patients and provides evidence-based recommendations for developing strategies to successfully manage pain in pediatric patients.

“Traumatic Pain Management…” Case Conclusion August 6, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, General Emergency Medicine, Trauma , add a comment

After establishing hemodynamic stability with your motor vehicle collision patient, you considered the potential for masking serious injuries with analgesia but realized that appropriate pain control has not been shown to contribute to missing serious injuries in this context. After a dose of IV fentanyl, her heart rate normalized and her pain improved, but she still had tenderness with palpation of the left upper quadrant. A CT scan showed a grade II splenic laceration but no other emergent pathology. You consulted a trauma surgeon, who agreed with your plan for admission for observation and pain control.

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Traumatic Pain Management… July 25, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, General Emergency Medicine, Trauma , 5 comments

A 35-year-old female who was the restrained driver in a front-impact motor vehicle collision arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

What do you do?

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