What’s pain got to do with it? Disclosures None Toxicologic Antidotes Outline 1.Case based review of the assessment and treatment of pain in the adult.

Slides:

Advertisements

Similar presentations

Palliative Sedation Pam Mansfield, MD, CCFP October 2, 2009.

Advertisements

AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

EPECEPECEPECEPEC EPECEPECEPECEPEC Withholding, Withdrawing Therapy Withholding, Withdrawing Therapy Module 11 The Project to Educate Physicians on End-of-life.

EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians.

Best Practice Tom Shiffler, MD 7/23/10

EPECEPECEPECEPEC EPECEPECEPECEPEC Module 11 Withholding, Withdrawing Life- Sustaining Treatments The Education in Palliative and End-of-life Care program.

Question and Answer Session All Faculty. Case Presentation All Faculty.

Key dosing points: Begin a bowel regimen when opioid therapy is initiated (senna + docusate). For CHRONIC pain, use a scheduled medication regimen. ( ex:

Acute Kidney Injury. 49 year old man was a single vehicle MVC in which he was ejected. His injuries include: 49 year old man was a single vehicle MVC.

Pain Management in the “Difficult Patient”

Neurological Emergencies Dr. Amal Alkhotani MBBCH, FRCPC, Epilepsy and EEG.

Multidisciplinary Approach to Sedation Goals and Treatment Algorithms to Treat Pain & Sedation Needs of PCTU Patients Connie Myres RN, MSN, CCRN & Sandra.

Injectable Opioid Treatment in England Clinical Experience Rob van der Waal.

Procedural Sedation Pharmacology Deb Updegraff R.N., P.N.P, C.N.S. Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit.

 A patient admitted to your ward is on methadone maintenance 120mg daily and had his normal dose earlier today  He was admitted after he stopped taking.

Emergency Psychiatry E. Prost. Outline 1. Emergency Room Assessment 2. Behavioural Emergencies: Assessment 3. Behavioural Emergencies: Interventions.

Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients A Randomized Trial Journal Club 09/01/11 JAMA, February 4, 2009—Vol 301, No

Palliative Care and Surgery Elizabeth Whiteman MD.

Presented By Dr/ Said Said Elshama

DOES DAILY TRACKING IMPROVE CONCORDANCE? Sedation and Analgesia Protocols in a Community-Based Intensive Care Unit Richard Nadeau, BMSc 1 Robert J Anderson,

Sedation and Analgesia in the ICU. 34 year old man was admitted to the intensive are unit 3 days ago for increasing respiratory failure from community.

Respiratory & Medical Critical Care and Paramedic Levels.

Status epilepticus. Status Epilepticus Traditionally, SE is defined as continuous or repetitive seizure activity persisting for at least 30 minutes without.

Pain Agitation & Delirium SCCM Pain assessment i. We recommend that pain be routinely monitored in all adult ICU patients (+1B). ii. The Behavioral.

THE FINAL DAY(S) Keeping the Promise of Comfort.

What’s Pain Got to Do With It? PAD Launch Day March 30 th, 2015 Donald Griesdale MD MPH FRCPC Assistant Professor Department of Anesthesiology, Pharmacology.

End of Life Care Education Case Scenario 3 End of Life Care Webinar MODULE 1.

Plasma concentration Time PO: C max ~ 60 minutes (oxymorphone ~ 30 minutes ) SQ: C max ~ 30 minutes IV: C max ~6 minutes Pharmacologic administration curves.

Toxicology for Medical Students

Drugs to Assist in Intubation Sara Park

 72 M, acute femoral fracture. History of hip, knee OA. Uses Tylenol, ibuprofen.  Used Norco in the past very infrequently. Keeps an old bottle in the.

Sedation Protocol Dr Samir Sahu. Introduction All patients should be sedated before any procedure & during ventilation to prevent discomfort and pain.

Question 27 A 16 year old boy presents to the ED with confusion, agitation and blurred vision. His mother suspects he has taken an overdose of promethazine.

C C E E N N L L E E Pediatric Palliative Care Analgesics NSAIDs  Cyclooxygenase inhibition leads to interference with production of PGs (Cox-2)  Decreased.

ADOLESCENTS IN CRISIS: WHEN TO ADMIT FOR SELF-HARM OR AGGRESSIVE BEHAVIOR Kristin Calvert.

Will This Admission Help? Leonard Hock, D.O., CMD Covenant Hospice.

Preoperative recommendations for patients with Chronic Renal Failure : Jeffrey J. Kaufhold, MD FACP March 2014.

LOGO Sedation in the ICU Prof. Bahaa Ewees Ain Shams University.

Using Opioids in the Hospitalized Patient Nicole Artz, MD Assistant Professor of Medicine University of Chicago No financial relationships to disclose.

Spontaneous Awakening and Breathing Trials Brad Winters MD, PhD March 14, 2013.

Ventilator Sedation in the ER LMH ER ROUNDS PREPARED BY SHANE BARCLAY.

Peter Coleman MD The Coleman Institute Richmond Va. USA.

Lindsay Trantum ACNP-BC VUMC Neurological ICU

The Johns Hopkins Hospital Pain, Anxiety, and Delirium (PAD) Management Protocol: An Interdisciplinary Clinical Practice Algorithm Sean Berenholtz MD,

Haemofiltration for sepsis: burial or resurrection?

Pain Assessment and Management in Children

E A B C D Reducing Delirium in the ICU Patient: The ABCDE Bundle

Sedation during mechanical ventilation : A trial of benzodiazepine and opiate in combination Crit Care Med 2006 Vol. 34, No. 5 R2 이윤정 Paul S. Richman,

Sedation and Delirium Management

A Pilot Study in Antipsychotic Reduction In Nursing Homes 9/2012-9/2013 Jabbar Fazeli, MD Jabbar Fazeli, MD

Substance Abuse Chapter 11. Substance Abuse  Self-administration of a drug in a manner that does not conform to the norms within the patient’s own culture.

PICU Analgesia & Sedation Algorithm for Endotracheally Intubated Patients Routine goal directed daily assessment. Use minimal pharmacological agents to.

Objectives Palliative pain management in the ER : Basic approach

Richmond Agitation-Sedation Scale

What’s in the Box? A Retrospective Look at CT Head in ICU

Section II: Frequent Symptoms Associated with Imminent Death

More Bang for Your Bundle:

Palliative Care in the Outpatient Setting: Pain Management

Hospice in Hospital - GIP and Beyond

Consultation Unit 1: In the Medical Clinic

}   Recommended Acute Analgesia for Adult Patients

MICU Sedation Vacation/SBT Decision Tree

Recognizing Imminent Death

Empirical Clinical Research in Continuous Deep Sedation at the End of Life Mohamed Y. Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Eng & Edin), FRCP.

Low risk of sexual dysfunction versus placebo

Copyright Notice This presentation is copyrighted by the Psychopharmacology Institute. Subscribers can download it and use it for professional use. The.

Ventilator Sedation in the ER

Low risk of sexual dysfunction versus placebo

Withholding, Withdrawing Therapy The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert.

Copyright Notice This presentation is copyrighted by the Psychopharmacology Institute. Subscribers can download it and use it for professional use. The.

Presentation transcript:

What’s pain got to do with it? Disclosures None

Toxicologic Antidotes Outline 1.Case based review of the assessment and treatment of pain in the adult ICU 2.Review the presentation and management of excited delirium What’s pain got to do with it?

Toxicologic Antidotes Outline What’s pain got to do with it?

Mr. VE 37M, multiple gun shot wounds History of Polysubstance abuse Chronic opioid use Injuries Brachial artery laceration Right rib/lung/diaphragm injuries Penetrating liver and bowel injury Toxicologic AntidotesWhat’s pain got to do with it?

Mr. VE Multiple (?8) trips to operating room Multiple complications Severe sepsis Rhabomyolysis (PRIS?) Acute kidney injury requiring dialysis High narcotic and sedative requirements Toxicologic AntidotesWhat’s pain got to do with it?

Mr. VE (3 weeks later) Acute issues resolved Escalating analgesic requirements Hydromorphone 7 mg po q4h scheduled Hydromorphone 1-2 mg IV q1h PRN “Switched-on” – Tachy/HTN/Febrile Reports of poor affect/motivation Severe, unremitting “10/10” abdominal pain Toxicologic AntidotesWhat’s pain got to do with it?

Questions on rounds 1.How can we reliably assess this patient’s pain? 2.Can we use his vital signs as an indication? 3.Are there other therapeutic options? 4.What about his mood? Toxicologic AntidotesWhat’s pain got to do with it?

Pain in the ICU

Nurse!! My back hurts!!!!

1.Jones et al., Intensive care medicine, 1979; 5: Gelinas, C. Crit Care Nurs, 2007; 23: Pain in the ICU

Pain the ICU

Pain in the ICU

Back to Case 1 37M, multiple gun shot wounds Persistent 10/10 abdominal pain “Unresponsive” to narcotics What worked for him? Scaled back regular hydromorphone to 2 mg q4h Stopped routine bowel care Aggressive mobilization Dramatic response to trial of methylphenidate (Ritalin®) Pain in the ICU

Toxicologic Antidotes Outline What’s pain got to do with it?

Mr. WF 41M, suicide attempt after romantic crisis Voluntary ingestion of 6500 mg bupropion XL, and self-injection of 3 epi-pens Acutely agitated, disoriented, aggressive Midazolam x 50 mg in ER and infusion in ICU Remained extremely agitated Physically restrained Toxicologic AntidotesWhat’s pain got to do with it?

Mr. WF Received bolus doses of propofol Settled in am after MDZ turned off Severe rhabdomyolysis CK > 45,000 Started isotonic fluid hyper-hydration Consequence? Complication? Toxicologic AntidotesWhat’s pain got to do with it?

Excited Delirium (ExDS)

Two sources Aggressive Chemical Sedadddtion

Excited Delirium (ExDS) Benzodiazpines Diazepam Midazolam Lorazepam Propofol (IMV) Failure of BDZ Extreme agitation Safer to put down Antipsychotics (Caution) QT prolongation NaC-blockade Anticholinergic Other Ketamine Dexmed

Toxicologic Antidotes Take home points 1.Pain assessment is far from objective 2.Protocolized use of pain scales is an effective trigger for pain assessment 3.Agitated delirium is a rare though lethal entity 4.All ICUs need to comfortable with the aggressive treatment required What’s pain got to do with it?