The Ketamine vs All battle continues

ketamine. Ketamine. Ketamine! KETAMINE!!!!

Is there anything the SoMe wonderdrug can not do? I mean, isn’t the answer *always* ketamine?

This is a single center, randomized, prospective parallel study for patients aged 18-70 with moderate to severe acute, traumatic, orthopaedic pain with pain scale >80 on VAS. With about 25 patients per treatment arm, they compared intranasal Ketamine (1 mg/kg), IV morphine (0.1mg/kg), and IM morphine (0.15 mg/kg).

 

The details:

Rule ins: Must have GCS 15, weight 50-110kg, systolic bp 90-160 mmHg, HR <100 bpm.

Rule outs: head trauma, history of regular opiates or psychiatric disorder, analgesia within 3 hours, “a large meal ingested within the previous hour,” any LOC, dizziness, vomiting, or nausea were excluded as well.

 

The group measured pain scales every 5 minutes for 1 hour, as well as ADRs at end of 1 hour. They deemed a 15 mm score reduction in pain deemed significant.

 

Time to onset was fastest in the IV morphine route at 8.9 minutes, Ketamine came in second at 14.3 minutes, and IM morphine, unsurprisingly, brought up the rear with 26 minutes. The time of onset between Ketamine and the two morphine routes was insignificant, though the time to onset between IM and IV morphine was statistically significant.  Also not surprisingly, Ketamine had significantly higher ADRs (difficulty concentrating 58% vs ~21%, confusion 50% vs ~15%).  While pain reduction at one hour was similar across all treatments, there was a trend for decreased patient satisfaction with Ketamine (58% satisfaction vs ~70% with morphine – this was not statistically significant).

 

While I would love to say this trial adds to the data for usage of Ketamine… not quite. It really does not look at the patients for which we would **want** to use ketamine – namely, say those with poor access that an IN analgesic may work wonders; those with an opiate habit; and seriously, what trauma patient doesn’t come in a bit tachycardic?  And while yes, the results are about in line with what we’ve seen in the past and sort of come to expect (reasonable analgesia, somewhat decreased patient satisfaction, higher ADRs) this just is not a real world study that we can point to and say, “this is why we need IN Ketamine in our protocols.”

Versed, Pavlov, & the NGT

I admire & strive for efficiency, empathy, and efficacy.  Thus, if a certain painful procedure extends lengths of stay without significant benefit to the patient, I’m hesitant to order it. However, sometimes it is frowned upon to not play nice in the sandbox with our Pavlov consultants who request NG tubes for small bowel obstructions.

 

Thus, if you must place an NG tube for an obstruction, keep today’s study in mind.

Up at The U (of Vermont), patients that were ordered an NG tube and were between 18 and 60 years of age were given 1 ml of intranasal atomized co-phenylcaine (lidocaine 5% with 0.5% phenylephrine to each nostril, followed by either placebo or 2 mg of IV midazolam with NG tube placement within 5 minutes of placebo or midazolam. Using a 100 mm VAS for pain and discomfort, as the primary endpoint, the patients were interviewed 15 or 45 minutes after the procedure.

After 51 total cases (23 of which qualified for the study), the trial was stopped early as several ED clinicians felt that midazolam prior to insertion was superior to topical anesthetics alone and did not want their patients randomized in the study.

Hence, the numbers are a good bit low. Only 13 patients in the control arm, and 10 in the treatment arm. The mean difference in pain scores was 31mm and 36mm for discomfort. None of the midazolam placements were rated difficult by nursing who placed the NG tube, whereas 3/13 in the control group were rated as difficult or very difficult to place.

So yes. The numbers are small, and the authors shed some light on questions we would have. They spoke about anecdotally about 1mg of midazolam for those over 60 years old or with known pulmonary disease – which they felt did not alleviate pain or discomfort. Here, I think a 1mg bolus followed by 0.5mg boluses as needed is reasonable.

They cite a paper stating that 91% of providers would change their practice if new literature showed a convenient way to reduce patient discomfort. Well, here it is. So, if Pavlov’s dog barks and you HAVE to place an NG tube, hopefully your institutional policy allows IV midazolam without considering it procedural sedation (or, potentially using intranasal midazolam for anxiolysis).

“The Treatment of Pain is Very Important.”

Back to pain being the 5^th vital sign, or so this study may have us believe. This study included an independent investigator essentially sneaking into the patient room to tell half the patients that “the treatment of pain is very important and be sure to tell the staff when you have pain.”

77.6% of the control vs 88.8% of the intervention group reported being provided with the above “pain advice” and the intervention group had an absolute and relative increase in satisfaction of 6.3% vs 14.2%, respectively. 91.3% of patients who were “very satisfied” had received this advice vs 76.3% of patients who were not “very satisfied” having received “pain advice.”

I think that ultimately, the aforementioned increase in patient satisfaction goes with giving clear instructions, and being clear with your projected management and expectations. I imagine that having a third party (such as Dr McDreamy) come over and say, “the treatment of pain is very important and be sure to tell the staff when you have pain,” will undoubtedly boost patient satisfaction. Likewise, I also question if it buys a bit (too much?) into “pain is the 5^th vital sign” that got us into our current opiate frenzy in the first place. Regardless, there is potential for this to be a useful word choice in the quest for improved Press Ganey scores.

Less paperwork, equal efficacy with shoulder blocks.

Raise your hand if setting up conscious sedation is a small act of God in your ED.

Glad to see you’re all still here. Now, lets talk about how we can reduce that paperwork, and make the best use of nursing & clinician time in a busy ED.

The June AJEM issue compares suprascapular blocks (21 patients) to Ketamine procedural sedation (20 patients) for shoulder dislocations. There was no difference in success or patient/physician satisfaction. Time spent in the ED was significantly longer in the sedation group, and side effects were not observed in either group.

Previous studies looking at intra-articular lidocaine vs conscious sedation (here, here, and here)  also showed a decreased LOS without a difference in satisfaction, pain control, or efficacy.  Shoulder blocks and intra-articular have great efficacy in all the studies I was able to find, all showing excellent pain control and improved LOS. The caveat is this study  which shows that if a patient has had conscious sedation for a shoulder reduction in the past, they would prefer conscious sedation over a block.

You can review how to do an intra-articular block on YouTube  thanks to Mike Stone and Academic Life in EM.

Day Four of Christmas – Why are we not checking the database?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the fourth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Despite the national attention narcotic misuse has received recently, there is scant evidence on the effect of a statewide prescription monitoring program within the ED. Sadly, evidence shows class II, III, IV, V analgesic prescription rates from ED providers increased from 2001-2010, while nonopioid analgesia prescriptions remained stable.  I would be curious to see if prescriber habits have changed since the recent onslaught of naroctic overdoses in the media, especially since 49 of the 50 states have a state-wide prescription monitoring program.  Have we written for fewer tablets per prescription? Say, from 20 to 12 tabs? Are we writing for less oxycodone and more NSAIDs (or for more hydrocodone or Tramadol rather than percocet) after implementation of a statewide database?  Are we even using the tools at our disposal?  If not, then why not?  Are we too busy?  Too burned out?  Just want to “get the patient out of the ED?”  Just don’t care?  Don’t want conflict?  Is there an difference between MDs, PAs, and NPs?  What about level of experience?  Does type of workplace (urgent care, office, ED) matter?  Do we think we can actually spot the addict – because multiple studies show we suck at it.

In New York state, all urgent care centers, ambulatory surgery centers, private practices, dental offices, and clinics are required to check the database  if writing for 5 days of narcotics.  Sadly, ED’s are not required to do this. NY actually makes it easy – while providers must register, they can designate another person to check the database.  I’ve heard of urgent care centers having the triage nurse checking the database before they see the provider.  Sadly, I’ve seen colleagues write for “a few days” to get the patient through “until their pain doctor sees them in 2 days” – despite this being a known red flag for substance abuse.

All providers are in a unique position – the patient that has an extensive database history also needs your help.  Rather than be confrontational, we can sit down, explain you are concerned about their recent prescription pattern, and would like to offer them help if they feel as though they need it.  If they decline, I still refer them to detox on their discharge papers.

So, I would like to see if providers are changing practice since implementation of a statewide prescription monitoring database, and if not, then why.  There is hope, interventions show we can change  (though durability is a separate issue). As a provider, if you are not interested in checking the database for every prescription you write, consider moving to Missouri, the only state without a database, also known as America’s drug store.

ACEP opioid policy: www.acep.org/content.aspx?id=88197

Why Are You Not Doing Femoral Blocks?

     I’ve been on a bit of a rant lately about how the ED sets the course for the remainder of the inpatient stay. The most recent eye-catching paper to come across my QxMD feed reinforces this.

     326 patients with an acute hip fracture who received a fascia iliaca compartment block in the ED were compared to 100 patients who had received “standard of care” – IV, IM, or oral meds at the teams discretion. Not surprisingly, there was a reduction in pain score and opiate requirement with the iliaca block. Most surprisingly was the 9.9 to 15 day difference in length of stay, as well as inpatient mortality of 5.5% vs 15% in the iliaca nerve block vs standard treatment, respectively. The authors admit there may be confounding factors at play, however, these are striking numbers and the largest study of a nerve block I have seen in the acute setting, and these are hard to argue with. For those of you wondering, this study then retrospectively looked at 1586 patients that were given an iliac block at their participating institutes, and noted only 2 (TWO) incidences of systemic anesthetic toxicity.

     Now, given the above, lets compare iliaca to femoral nerve blocks. A previous study of 110 patients showed a statistically significant pain improvement with the femoral nerve block vs the iliaca block, and that the femoral block arm required less parenteral narcotics.

     If you have not yet done a sono guided femoral nerve block – try it out! (https://www.youtube.com/watch?v=5ht_N8j2KL8) Its pretty easy, and takes about five minutes to do the procedure, plus a few more for set up.  If admin gives you grief, its hard to argue with improved pain control, LOS & mortality.

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PMID: 23789738

PMID: 24949565

Bier me, STAT!

For distal radius fractures, hematoma blocks are cruel. Think about it: you are injecting several CC’s into a fresh, painful, fracture site. I have yet to see a patient * not * cringe, no matter who does the block. To top this all off, I have yet to see it provide adequate analgesia during reduction. So, not only are we making them miserable by providing an injection into their fracture, we are then manipulating them-sometimes more than once- after not providing significant analgesia. It’s not really a nice thing to do. I’ve seen mid-levels, ED attendings, and orthopods all do this with pretty much the same results.  The definition of insanity if doing the same thing repeatedly and expecting a different result. So let’s try and stop the insanity by having a Bier (block).

Doing a literature dive, let’s start by saying there is an overblown concern over lidocaine toxicity. In a study of 1816 Bier blocks by anesthesia for hand surgery, there were 9 adverse reactions (1 medical error, 3 with improper cuff inflation, 5 with inadequate analgesia). None of the adverse reactions resulted in failure to complete the procedure or in serious morbidity / mortality. A second study of 416 patients showed no morbidity or mortality, but 39 episodes of transient hypotension or bradycardia of which none required an intervention. A third study was done on 484 patients. The block was ineffective for 1 patient, tourniquet related problems were reported in 5 patients, but no anesthetic toxicity. The block was given by the operating surgeon and not by anesthesia – thus it is likely safe for ED providers to perform.

Now let’s compare it to hematoma blocks. Over four studies looking at over 400 patients total, there is significantly more pain during manipulation with hematoma block than with a Bier’s block, and the Bier’s block had fewer re-manipulations, better pain control, and better radiological outcome.

Lastly, there is a modified Bier’s Block involving a single tourniquet. In comparison to the two tourniquet technique, there is no significant difference between forearm and conventional Bier’s block for pain control, and no major complications, looking at three different studies, totaling about 150 patients. Patients were also given less lidocaine in the forearm group (160mg vs 300mg).

So, there you have it. The Bier’s block is safe and more effective than a hematoma block for distal radius fractures, and you can even use a single tourniquet rather than two pneumatic cuffs. So go ahead, enjoy a Bier with your patient.

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PMID: 17123673
PMID: 17324303
PMID: 23407261
PMID: 23508563
PMID: 20122591
PMID: 18040193
PMID: 22627706
PMID: 3935242
PMID: 3893460
PMID: 2205997
PMID: 9413772