pharmacology case!!please answer to this post

[kapil]

A 45-year old woman was found outside her car after hitting a tree.The car appeared severly damaged.There is no evidence as to how the woman escaped from the car.It is thought that she was able to open her door and then fell from the car.When she was discovered,she was conscious but disoriented and complaining of severe pain of multiple origins.While in way to the emergency department,her pain increased in intensity.
which medication (NSAIDs or opioids)might be used to ease her pain immediately upon her arrival at the hospital???


please share your knowledge...

[Spencer Wells]

Look up the analgesic ladder, but note that you can jump in at a higher level if you think it appropriate.
Watch any episode of ER and you're sure to see someone coming in from a RTA, they're all given "5mg morphine iv push stat."
And do your own homework.

[Matt641]

Off the top of my head, in a nutshell, 5mg morphine slow IV, titrate as necessary + an antiemetic. That is the standard 99.9% of the time, but you can also go with NSAIDs if you are concerned about keeping her score up (obv possible loss of eye signs with morphine). This is fairly straightforward for a clin student, do you not have an Oxford Handbook?

[kapil]

so which one is the best among those 2? someone tell me NSAID is best for this case.......i dont have enough knowledge for this......with my little knowledge,i think that it should be opioid because of severe pain of multiple origin...directly acts on CNS to relieve pain...but my friends tell me its NSAID....
can u tell me the exact reasons for selecting (5mg morphine slow IV)! just focusing on this case..

[Spencer Wells]

With NSAIDs you have to wait for them to be absorbed from the gut. This leaves the patient in pain for some time. i.v. opiates have a faster onset of action, and so would seem more appropriate for this case.

[M Clayton]

Just to muddy the waters somewhat, what about parenteral NSAIDs?

[Spencer Wells]

There's always one
If memory serves, they're more expensive than morphine (which at 2p per vial is pretty damn cheap).

[Varied A]

Originally Posted by Matt641

Off the top of my head, in a nutshell, 5mg morphine slow IV, titrate as necessary + an antiemetic. That is the standard 99.9% of the time, but you can also go with NSAIDs if you are concerned about keeping her score up (obv possible loss of eye signs with morphine). This is fairly straightforward for a clin student, do you not have an Oxford Handbook?

Current thinking where I work and in the literature seems to be that we shouldn't really be giving routine anti-emetics with opiates/opioids, but rather prescribing them on a prn basis; as a sizeable majority of patients don't actually require them, and (particularly in the case of metoclopramide) they can have quite nasty side effects.

Agreed on the necessity for titrated IV morphine in this situation, though!

[yazoo]

Disorientation + high speed car injury (badly damaged car) = risk of head injury. Thus, I believe ideally not morphine in this situation (as risk of sedation and central respiratory depression - try NSAID & paracetamol first).

Anti-emetics are still routinely given with morphine in patients who are opioid naive. In my trust, anyway. We write them up prn (as with the morphine, but they get given at the same time...)

[Michael]

I was gonna type what yazoo said. Until you rule out HI, clear the cspine and rule out other deceleration injuries it wouldn't give a clear clinical picture of her GCS popping her on morphine, plus if her neurological status decreased before or on arrival then the morphine is only going to muddy the waters, could try giving ketorolac in the meantime.