EMCrit 302 – Pain Management Update with Sergey Motov

Today an update on pain management in the ED. Sergey is a great friend and a previous guest on the show when he discussed the Opioid-Free ED.

Sergey Motov, MD

Sergey is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is a Research Director who is passionate about safe and effective pain management in the ED. He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.

The Pain-Free ED

Sergey has an amazing site, with resources and lectures: The Pain-Free ED

A Brief Discussion of the Advantages of Morphine over Hydromorphone and Fentanyl from a Euphoria Perspective in Patients with Intact Organs

This is far more an issue for what you send these patients home on.

Sergey recommends MSIR tablets 7.5-10 mg Q 6 hrs for 3 days for most acute pain indications in patients without organ failure. There is also liquid 10 mg/5 ml, so 1/2 tsp gets you 5 mg.

Consider diclofenac gel in the appropriate patient. Now available over the counter. Apply twice/day.

Giving Fentanyl For Longer Duration Pain Means the Patient will be in Pain Again Soon

* Consider a regimen that matches the duration of pain

Kidney Failure

* Do Not Use Morphine

* Hydromorphone--avoid in ESRD, If you feel the need to use it in more mild renal failure, Drop Dose by 75%  (e.g. from 1mg to 0.25 mg per dose)and extend dosing regimen (from q4-6 hrs extended to q8-12hrs)

* In the ED, you should probably use Fentanyl. Still reduce dose by 75% of standard and extend dosing intervals

* When you need to send the patient home, do not use tramadol. Mild to moderate, use oxycodone with sig. dose reduction. In the future, buprenorphine may be the agent of choice.

Liver Failure

* Very low dose morphine, but probably the better idea is:

* Fentanyl with a dose reduction and interval extension

* For sending a patient home, Oxycodone consider half dose with extension of intervals

Ketamine

* Recent trial compared 0.15 mg/kg to 0.3 mg/kg with no difference

* Breath-Actuated Nebulized Ketamine

Sergey does not Like IM Pain Meds

* Causing pain to relieve pain doesn't make a ton of sense

More from Sergey

* More on Kidney and Liver Failure Pain Management

* Pain Pearls on Opioids

* Handout on Analgesics for Hepatic and Renal Failure

Do a Virtual Resus Fellowship

Resus Leadership Academy

Now on to the Podcast...