Cases Scenarios in Pain Management: Don’t Let First Impressions Fool You!

Alexis LaPietra, DOPhyllis Hendry, MD, FACEP, FAAP

DisclosuresAlexis LaPietra, DO

–Nothing to disclose

Phyllis Hendry, MD–Principal investigator, Pain Assessment and Management Initiative (PAMI), a free access online

educational site funded by Florida Medical Malpractice Joint Underwriting Association

Learning ObjectivesReview clinical cases that illustrate how to manage difficult pain management scenarios

in the emergency department including high risk populations such as elderly and impaired patientsDescribe the importance of vital signs in complex pain emergency cases. List ways to address patient safety aspects of ED pain management cases from triage to

discharge and tricks for avoiding bad outcomes

Case ContextPain is a component of the presenting complaint in up to 78% of ED visits Medical schools provide minimal training in pain management Most EDs are overcrowded and patients have a variety of acuity levels, diseases,

resources and ages–Toddler in a MVC with fractures to an elderly patient with arthritis and back pain

Emergency physicians are under tremendous pressure to see patients rapidly (triage to discharge time) while balancing care for patients in pain and other emergent priorities

Triage Trickery

Triage Trickery18 YO BM transported by rescue for sickle cell pain. Paramedic to triage nurse

–“Took one dose of pain meds about 4 hours ago. Didn’t even try anything else. You know the usual. Just looking for some IV drugs... Hasn’t even called his doctor……”

Triage nurse to resident doctor and nursing staff–“18 yo SS patient in room 4 on Norco, looking for drugs”

Resident to attending physician–“ Frequent flyer-SS drug seeker in room 4, doesn’t look like he’s in pain”

Attending physician: goes into room with preconceived attitude

Triage Trickery: The Rest of the Story!Never hospitalized before for painDoesn’t have SS disease, has a different hemoglobinapathyHas old Rx for Norco but left in city where he attends college and has a hematologistVisiting grandparents for summer vacationHonor student

Triage Trickery Summary ED triage done very rapidly and under pressure to decrease waiting times EMS personnel often have limited time to get history Emergency care providers have potential for bias depending on patient population,

years of experience, and previous casesBurn outAlways take your own historyAsk open ended questions

The Devil is in the Discharge PlanningMedico-legally, what happens to the patient after ED discharge is as important as what

happens in the EDPatient must be deemed safe for discharge after receiving analgesic or sedative

medications or procedural sedation and analgesia (PSA)A discharge pain plan is crucial

–Unfunded patients–Long delays for appointment–Limited time to formulate and discuss discharge planning and education

The Devil is in the Discharge Planning: Case 174 YO BM arrives via EMS with left hip pain after falling from his front porch steps. EMS report: “patient discharged an hour ago from your facility with ankle

sprain…took a cab home and stumbled while trying to walk up porch steps with crutches. Now complaining of left hip pain.” ED History: patient initially thought to have a fracture on arrival and given morphinePMH: has fallen 3 times over the past 2 months2nd ED visit- hip fracture, abrasions and contusions

The Devil is in the Discharge Planning: Case 2 ED 7 am shift changeRecently discharged 18 yo carried in by boyfriend after “passing out” in hospital

parking lot and hitting her headNow pale, sleepy, oriented X 3, face bleeding, ……..Seen in ED overnight for miscarriage, bleeding and abdominal pain Received morphine at 5 am, discharged at 6:30 am

The Devil is in the Discharge Planning: Case 2 Cont’dOn further history and chart review

–Vital signs not repeated at discharge–Patient had nothing to eat or drink for 12 hours–Patient had no transportation home- was walking from ED to bus stop to wait for first bus

The Devil is in the Discharge PlanningTake Home Points “Road test” patientKey discharge patient safety determinants:

discharge vital signs, ability to tolerate fluids, pain level, transportation, ability to care for self or reliable care giverDischarge medication review and follow-up

plan PAMI Pain Management and Dosing Guide: http://pami.emergency.med.jax.ufl.edu

Between Triage and DischargeED Case Scenarios

Case 318 M h/o schizophrenia who is transferred from group home to the ED for abdominal

pain. He will not let you examine him and he is rolling around on the floor–Security has to place him in a bed. He is agitated and will not answer any of your questions. –Unable to get vitals but you notice he is diaphoretic and breathing fast

Case 3 Cont’dGroup home counselor arrives, states he is very histrionic he just needs to be sedated, he

is always complaining of abdominal painPatient receives Ativan 2 mg IM

–VS- HR:120 BP:105/80 RR:29 T:99.9F O2: 100% RA

Past ED visits are mostly for abdominal pain, last CT was a year ago

Case 3 Cont’dOrder some labs Imaging…?

–XR vs CT abd/pelvis

Case 3 Cont’dSome of the other staff say he is a “regular” he always just gets sedatedYou still cannot examine him after the Ativan. He is screaming he does not want to be

hereNext step?

–More sedation?–Let him relax, his vitals signs were not terribly abnormal

Case 3 Cont’dAtivan 2 mg IMHaldol 5 mg IM In 15 minutes you are able to examine him and get lab work. Abdomen is rigid and he grimaces with superficial palpation in all quadrantsHR 135 BP 95/60

Case 3 Cont’dWBC 14,000

–Bands 25%

Lactate 9.4CO2 11Now what?

Diagnosis

CT: Volvulus

Disposition–OR

Case 437 M with history of developmental delay, nonverbal, is brought in by caretaker for

chest pain. Patient is pacing and rubbing his chest and refusing to eat. Very anxious. Caretaker says he was fine, they were watching TV and eating tortilla chips

VS- HR 140 BP: 167/89 RR: 25 T: 98 O2: 100% RA

Physical exam including posterior pharynx is unremarkable

Case 4 Cont’dPatient receives viscous lidocaine,

bismuth subsalicylate, and famotidine

Chest XR- appears normal

Case 4 Cont’dPatient is given midazolam 4 mg IM

Patient is getting more and more agitated and now is becoming a bit violent

Discussion to do labs

Case 4 Cont’dWBC 12,000

All other labs including troponin are normal

Repeat VS- HR: 135– EKG: sinus tachycardia, otherwise normal

CT scan?– Patient is not cooperative, additional sedation? Pain medication?

Case 4 Cont’dCT chestPneumomediastinum

Disposition–Endoscopy suite for EGD–Found to have large esophageal

tear with a small edge of dorritoembedded in wall

Case 580 F presents with mild right lateral rib pain s/p mechanical trip and fall up the stairs,

no LOC. Reports after fall she is getting “dizzy” when she stands up–PMHx: HTN Meds: norvasc

–VS HR:97 RR:16 T:98.9 O2: 100%RA

–BP supine: 115/90 BP standing: 90/50

–PE: no obvious injury, mild right chest tenderness, abdomen benign

Case 5 Cont’d Labs sent, EKG done (normal), CXR normal

–Observation for syncope evaluation?

Labs are normal, you call over to OBS and tell them the case

Resident wants to do a FAST for “completeness”

Diagnosis

FAST Exam–Grade IV liver laceration

Disposition–OR

Don’t get Fooled by….Special Populations Psychiatric and Special Needs patients

– Difficult to obtain history • Broad differential

– May be uncooperative with exam• Remember to control pain!• Sedate if necessary• Fully evaluate and perform thorough work up

– Must rule out medical emergencies• Do not presume there is no underlying medical disease• Trust vital signs• Do not be afraid to do a higher resource work up

Don’t be Fooled by…. Special PopulationsGeriatric patients

–Unreliable vital signs–Unreliable physical exam–Unreliable pain perception

Err on the side of caution–Get imaging–Frequent re-evaluation–Ensure follow up or place in OBS

Daoust JEmMEd 2016

Case 650 M presents after solo car MVC with head laceration. States he walked 2 miles to local

community hospital. He has no complaints but admits to EtOH.VSS and no PMHx, smells of alcoholHead lac is repaired with 2 staples and ER team is letting him “sleep it off”No trauma activation because there are only minor injuries and no focal neuro deficits

Case 6 Cont’dAn hour later the nurse grabs you and says the drunk guy is waking up and he is

complaining he cannot get up to pee

PE: 1/5 strength in bilateral lower extremities, he has labored breathing and c/o SOB

90 minutes into ED course Trauma ALERT is placed

Case 6 Cont’dPatient is unable to move extremities

Patient is intubated for severe respiratory distress

Patient is sent off for pan scans

Case 6, cont’d Fracture dislocation of C5 on C6, with cord

impingement

Neurosurgery on for spine came in for decompression

Case 729 M jumped off of a 2 story roof while evading police. Was eventually apprehended

and brought to ER by police to be medical cleared

Patient ambulating without complaint just a minor limp, said he twisted his ankle

He admits to using PCP

Case 7Patient relatively uncooperative, does not want to get undressed

–Gross physical exam reveals no apparent injuries–He asks for pain medication and he gets ibuprofen 600 mg

After an hour he urinates and has gross hematuria

You disrobe him, see blood at the meatus and when you palpate his pelvic he c/o severe pain on the LEFT, he cannot move his LLE secondary to pain

Ouch!

Pelvic XR–LEFT superior and inferior rami

fractures–Uretheral injury

Disposition–Trauma service

Don’t be fooled by…..Alcohol and drugs

–Patient history can be unreliable–Patient exam can be unreliable assume the worst and DISROBE

• Must re-eval when sober

–When mechanism of injury is severe (eg: high speed MVC or fall from height) treat patient as a trauma until proven otherwise

–EtOH and drugs can significantly compromise pain tolerance and appreciation for life/limb threatening injury

Case 8 33 F presents with c/o abdominal pain. She states she is maintained on opiates at home, for

chronic abdominal pain and lupus. She admits she has been taking more than normal, because the pain has been a bit different, and she ran out

She states it feels just a little worse than her “normal pain” and asks for hydromorphone IV and a script upon discharge

VS- HR: 125 BP: 156/80 RR: 22 T: 99.7 F O2: 100% RA

PE- moderate abdominal tenderness diffusely

Case 8 Cont’dShe gets 1 L NS, hydromorphone 2 mg IV, and ondanestron 4 mg IVRepeat VS- HR: 129 BP: 100/70Patient states pain is severe now and getting worsePhysical exam is unchangedAdditional pain meds?

You send off labs

Case 8 Cont’d Lactate 7

WBC 25,000

Again physical exam reveals moderate tenderness in abdomen but she is complaining the pain is continuing to worsen despite hydromorphone and crying for more pain medication

Case 8You get the CT Ischemic bowel due to thrombus in SMA

–She had 7 cm of ischemic bowel resected

Case 962 F presents with acute on chronic left hip pain. She states she has had persistent pain

ever since her THA 2 years ago. Something with a “D” works for her when she comes to ED and she’d like a doseVS- HR:110 BP: 167/89 RR:20 T: 101.9 O2: 100% RAShe cannot range left hip but states that’s normal for her. She states she is hot because

she was sitting outside in the sun. She again states she needs the “D” medication

Case 9 Cont’dXR- hardware in place, no dislocationHydromorphone 1 mg IVWBC 18,000CRP 7You want to do a CT of the hip, she refuses states she just wants a script for home

Case 9, cont’dYou argue with her, you give her a second dose of hydromorphoneShe agrees with CTCT- exudative fluid collection around hardware consistent with ABSCESS

Don’t be fooled by…..Chronic pain patients

–Look for red flags• Vital Signs• Lab work• Change in character of pain• Increased frequency of pain meds at home

–Perform thorough physical exam–Pain medication is therapeutic not diagnostic

Case 1067 M presents with RUQ abdominal pain. VSS no PMHx Labs unremarkable, mild tenderness RUQUS normal Patient discharged home with acetaminophen

Case 10 Cont’dHe returns 2 days later, pain is worse and unrelentingVSS, moderately tender in RUQMorphine 5 mg IV

CT abd/pelvis- unremarkable for acute pathology, he feels better

Discharge home with tramadol

Case 10 Cont’dHe returns again 2 days later (Day 6) pain is excruciatingVSS, states Tramadol is not helpingOn ROS- he does state he has a new rash that was there 4 days ago but no one

asked or looked

Case 10 Cont’dPhysical Exam

–Shingles

Disposition–Home with Acyclovir

Don’t be Fooled by….Fully Clothed Patients Expose every patient

–Full inspection is important• Genitourinary, Axillary, and Skin

–Avoid extensive work-up–Uncover emergency conditions otherwise thought to be benign

Eye Orbital CellulitisRuptured Globe

Ear Malignant Otitis Externa

Throat Ludwig’s AnginaRetropharyngeal Abscess

Chest/Back Aortic Dissection

Abdomen Mesenteric IschemiaAbdominal Aortic Aneurysm

Skin Necrotizing Fasciitis

Extremity Compartment SyndromeArterial Occlusion

Take Home MessagesBeware of EMS and triage histories- take your own Do not be afraid to order a higher resource work up in geriatric, EtOH/drug abuse,

psychiatric, or special need patientsVital signs are an important predictor of “badness”ALWAYS fully expose the patient

Take Home MessagesGive the benefit of the doubt to chronic pain patients and remember pain medication is

not diagnostic ED discharge planning is critical yet there are limited resources and timeAdverse events often occur soon after discharge or transition of care to another facility

or part of the hospitalA large proportion of ED patients have no insurance and no PCP plus comorbidities

making them high risk for “bounce backs”

Questions? Thank You! phyllis.hendry@jax.ufl.edu

lapietra@sjhmc.org

Emergency care providers, residents and students often learn best by case scenarios We welcome your interesting, de-identified

cases to use in our mission of improving ED and EMS pain education and pain management in the patients we serve 365/24/7