Click HERE to see full infogram
The above algorithm is taken from the BJA Education article, here.
NB: Regional techniques offer high levels of non-narcotising pain relief, such as intercostal blocks and s.anterior blocks +- catheters. (You will all know I am an advocate of the CERTA concept of pain relief, with non-opioids and RA techniques used whenever possible). With all the best will in the world, it is hard to find a trained individual to site or perform such regional techniques in an acute setting 24/7 and in a timely fashion, let alone have a service on the ward that is happy to look after different pumps/complications/troubleshooting etc. This is why this guide will focus on pharmacological management +- Thoracic Epidural where indicated/available. It is also worth noting that non-catheter blocks wear off at various rates depending on local analgesia used, so you still need to be aware of pharmacological management and the step-wise pain pathways. Should 24/7, quick-access Regional Anaesthesia be available in your hospital; this is a great asset and should be used in conjunction with your own local policies.
Rib fractures can be difficult to manage with respect to adequate pain relief and maximised chest safety. There is a high risk, in more complex fractures, of pneumothorax, haemopneumothorax, flail chest and great vessel injury. One of the most significant problems to prevent, (after PTX etc) is the acquisition of an atelectasis induced chest infection, particularly in those with concomitant chest disease and advancing age. You must be able to rapidly and safely control pain levels.
We also know that a lot of patients can be managed on the ward with good nursing, physiotherapy and analgesia and that many are not admitted to ICU. It is worth noting that an HDU/ICU admission may be required if pain is not controlled and breathing becomes an issue - you should involve the pain and ICU teams early, but this should not substitute or preclude the admitting team & ED actively trying to control pain using the algorithm above. It will be useful to the acute pain teams to see which, if any, analgesia worked.
All patients with rib fractures may not be admitted, but those who are sore enough to should have basic care (mentioned in the infograph) commenced IMMEDIATELY in A&E.
Good regimes of escalating pain regimes must be in place from A&E and admission teams and NOT just wait for a pain team review, which can be after a busy weekend or the next working day.
It may be nice to allow all patients to have a thoracic epidural sited, but this is not pragmatic in a busy NHS hospital; it will often be the next day or 'after the weekend'. They are also not required for every rib fracture patient. NEVERTHELESS, thoracic epidurals DO have benefit for those who have complex disease processes, fractures and advancing age. They probably should not be inserted due to inadequate attempts to control pain with more conventional pharmacological methods in most patient groups.
Surgical wards are used to dealing with PCA's so they often become the first stop of acute pain management. Wards are often not set up to facilitate IV lignocaine/ketamine infusions; if your wards are - you should contact your local pain team to see whether these interventions might be utilised in your place of ward in lieu of a morphine PCA. Do not forget to write up emergency naloxone if using opioids alongside an anti-emetic regime.
Here is the best BJA Education Article for scoring rib fractures with advice on pharmacy etc.
A final note on pharmacy; PLEASE check the BNF for contraindications of medications in your patient. Renal function is also important with respect to opioids, NSAIDs and Gabapentin etc.
Kudos to David Halliwell - Paramedic who spoke at SMACC DUB in 2016, delivering this wonderful topic
Resus.org.uk has all the latest guidelines on Cardiac Arrest and Advanced Life Support
You can watch (free) David Halliwell's amazing SMACC Talk here.
He talks about 'sneaky helpful ventilations' - so beware of over ventilating the patient in cardiac arrest!
by Dr. David Lyness & Mark Dornan
Lack of sleep is a major problem in hospitals across the world. Hospitals are NOT quiet places; we all know this. Working together we can help patients get better sleep in order that they might have better outcomes, better hospital experiences, more energy and less complications during their stay.
I would have to say, I am a massive advocate of the eye masks and ear plugs. They are cheap, simple interventions that can be supplied by the ward or bought by patients for a nominal fee. Wholesale, these can be bough for pence and likely reduce vastly more costly complications associated with sleep deprivation. The caveat being, they can really only be used by patients who are well enough to take them off (this is common sense).
It's also a strange practice to give patients caffeinated drinks before bed-time. Coffee & Tea are both caffeinated and stimulate an awake state. Decaf options should be available for the patients who 'cannot cope' without a bed-time cuppa! Fruit-like 'herbal' teas should also be brought in by patients or supplied by the ward. It is furthermore an even stranger practice to give people caffeinated drinks along with their insomnia medications like zopiclone etc. Red Bull and other highly caffeinated drinks such as coke, lucozade and sports drinks really should be limited too.
Mark also raises the excellent point of caffeinated drinks and continence in the elderly. Caffeine drinks further disturb sleep by increasing the production of urine and therefore frequency of micturition - waking patients up to urinate further deteriorates sleep quality.
Considerate nursing and medical practice is key to helping patients sleep well.
Share your thoughts on twitter @gas_craic :-)
Above is a 'cheat sheet' or, full data list for the sympathomimetics commonly encountered in medicine, particularly anaesthetics, ICU and emergency medicine. Broadly divided out into alpha, beta, dopamine agonists and phosphodiesterase inhibitors. It is key to understand the actions that each receptor causes; there is often overlap. There is a PDF above for a HD copy of the sheet.
Adapted from a St. George's Hospital London, Anaesthetic Department Poster.
** Clear fluids including water, pulp-free juice and tea or coffee without milk.
There honestly is no such thing as 'fast from midnight' any more. One has FEWER complications, length of stay and hunger issues if you are allowed to drink clear fluids up to 2 hours pre-op. We should be challenging practices from ward-based patients where they are sometimes fasted up to an inch of their life! No-one from the anaesthetic team will mind being spoken to about fasting times.
This is for an elective cohort of patients. This is unlikely to be a suitable mantra for most emergency operations that include a rapid sequence induction.
Existe el concepto errado de que #FOAMed es sólo para personas interesadas en la medicina de Urgencias y Prehospitalario. Es cierto que grran parte del movimiento está dedicado a estas especialidades, pero existe una inmensa variedad de otras especialidades que utilizan #FOAMed para difundir, discutir y desarrollar ideas y mejorar sus competencias.
Esta guía es para todos ustedes, allá afuera, que buscan una pequeña ayuda para descubrir el movimiento #FOAMed. Quizás quieres involucrarte en el ciclo 24/7 de novedades en tu especialidad o quizás quieres contribuir. En el 2016, esto no podría ser más fácil.
1. Entra a twitter. Crea una cuenta gratuita y usa la etiqueta #FOAMed para descubrir a quien seguir
2. Instala twitter en tu teléfono. Verás las actualizaciones de los que sigues en tu especialidad.
3. Crea una lista (marcadores) de tus blogs o páginas web favoritas que utilizan #FOAMed
4. Googlea #FOAMed y tu especialidad para ver los resultados
5. Usa el sitio LinksMedicus para encontrar las páginas #FOAMed de tu especialidad como también otros sitios increíbles!
6. Involúcrate en conversaciones utilizando en hashtag #FOAMed en twitter
7. Inicia conversaciones acerca de cualquier tema médico utilizando el hashtag #FOAMed junto a #Radiologia, por ejemplo
8. Invita a tus colegas a hacer lo mismo- caras amigas con mucho que aportar.
9. Pon tus presentaciones online utilizado Slideshare o alguno similar, es gratis. Puedes linkearlo a twitter!
10. Si tienes un montón de material o presentaciones, crea un blog gratuito en Wordpress o similares y publícalos online!
Aquí hay algunas herramientas de búsqueda #FOAMed
Melatonin - considered by some to be a 'herbal myth' and others as a useful adjunct to help sleep in ICU patient and adults >55 years old. There is biological plausibility that melatonin could be a useful adjunct to aid restful and efficient sleep in those who could be deplete in melatonin.
Overall - a meta-analysis here in 2013 showed that there was some evidence to say that it could work in some cohorts. Given its relatively safe profile, it could be useful to trial in patients with a sleep disorder. Particularly it could be of use in ICU, but, the evidence is currently out - awaiting a larger RCT. It's a cheap drug and even cheaper in the USA where it is available OTC. In patients who are restless or unable to sleep in a busy ICU, perhaps it has a role in being a first drug of choice before considering more 'heavy' sedative alternatives given it is a non-narcotic.
The studies mentioned below are indeed rather small and a few are single-centre analyses, so we cannot say for certain whether there is true efficacy, but many practitioners would agree, it's certainly worth a go providing there are no obvious contraindications in your local formulary (primarily, not to use in patients with autoimmune conditions) and the person does not require heavy sedation for other reasons.
Outside ICU, the drug is quite popular with GP's and could even be used more frequently as a first line alternative to Z-drugs or benzodiazepines in a hospital cohort. Sleep deprivation, it will come as no surprise, is rife in hospitals - I think we can all agree, that any adjunct to promote restful sleep without being profoundly 'sedating' could be a useful drug. I look forward to seeing more definitive studies in the future.
Dr. Sergey Motov (USA Emergency Medicine) & Dr. David Lyness (UK/IRE Anaesthetics)
Originally put on this website in July 2016
Taken from Dr Motov's work on a CERTA regime.
This is published in conjunction with the CERTA concept explanation here.
We can all provide superior analgesia by using medication and techniques other than just opioid medications.
This is NOT a definitive list and in all cases, local policies and protocols should be followed. Check your local formularies.
This is NOT a prescribing guideline - it is for information ONLY.
We do not dispute the role of opioids in many spheres of practice, including emergency medicine, ICU and anaesthetics, rather we wish to highlight the pandemic of high opioid and opiate use. There are many medications available to reduce the amount of opioids used.
You may find, when considering your analgesia regimes that opioids are not always the best options for emergency pain issues.
We would advocate the use of nerve blocks in the first instance to control acute pain, when feasible.
With respect to alternatives listed for non-radicular back pain, it has been brought to our attention that a new study was presented in 2017 which showed that "diazepam has no benefit when added to naproxen vs placebo" in acute low back pain. See here.
This document is for review in 2018 - so please contact us if you have anything to add!
References in document below...
I have collaborated with Dr. Sergey Motov from New York, USA to bring a series of infographs on a great new concept of CERTA pain relief with the hope of reducing opiate use. This is the latest line in thinking about MULTI MODAL pain relief and characterises the ideas behind multiple analgesic combinations to reduce pain, reduce sedation and provide maximal analgesia to patients in acute pain. Part one below describes the MAIN concepts of CERTA. It should be food for thought to all...
Channels, Enzymes, Receptor Targeted Action!
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