Pain Management with Dr. Sergey Motov

EMRA*Cast

Do you ever get overwhelmed with all the ED analgesic options? Dr. Sergey Motov from Maimonides Medical Center in Brooklyn helps breaks down ED pain management. We cover everything from topical NSAIDs to ketamine infusions. Curious which opioid to go with or what dosing? Look no further.

Key Points:

1. Remember to set appropriate pain management expectations. The goal is to make the pain tolerable, not to eliminate it. The more you include your patient in your decision making, the more in control they will feel.
2. NSAIDs are a go-to first option. If a patient doesn’t respond to one class, try another. And don’t forget about topical NSAIDs like diclofenac! Reasons to avoid this class would be history of GI bleed or CAD.
3. Ketamine is a great option for acute pain. 0.3mg/kg in a bolus over 30 minutes followed by 0.1mg/kg/hr during their ED stay. Use these slow infusions to avoid dysphoric reactions. Don’t be afraid to use ketamine in combination with other analgesics for optimal pain management.
4. Neuropathic pain is difficult to manage. Options include antidepressants, lidocaine infusion, gabapentin.
5. Nerve blocks are amazing. From a greater occipital nerve block for migraine to serratus anterior block for rib fractures. There are so many more applications. “If there is a nerve, it can be blocked.” Shout out to my favorite: a hematoma block!
6. Opioids are dangerous but they have a definite role in acute pain management. Morphine is less associated with euphoria and is a good start if choosing to treat with opioids. Oxycodone and hydromorphone are weaker alternatives and have a higher risk of substance abuse; avoid them if possible.

Resources and References:

• https://www.emra.org/books/pain-management/painmgtguide/
• http://www.painfree-ed.com/