Broken Bones and Pain Management

P_RN, ADN, RN · Mar 1, 2002

Morphine or Dilaudid is better for pain management in bone fractures/surgery.

Demerol is NOT. Plus Demerol has a nasty metabolite that can cause seizures.

Oxycodone with APAP.....

Tylenol #3

Darvocet-N 100

In that order.

kewlnurse · Mar 1, 2002

Demerol is useless, it does nothing for pain and makes old people goofy. Percocet or lortabs for po q3-4hprn ( I know sombody is going to say that is too much apap, but short term it wont hurt you.). darvocett n-100 is for headaches, seriously. Dilaudid PCA's are absolutly the first choice,.2-.3 mg q6 minutes with a 4 hour lockoutof 8-10 mg. if they are allergic, go to morphine. With either you can add 50-100 of vistaril and add either robaxin or valium for spasms, which are common. If it's a chronic issue add 100-300 of neurontin tid. Onycontin works great as long as you don't crush it up and snort it ( has been getting a bad rap in the press latly from poeple doing such) and add 5 mg of oxycodone q3-4 h for breakthrough pain. Very few MD's know anything about pain control, if you have any question ask an ortho or chemo nurse, and ortho md or an anesthiologist. Don't waste your time with a pmd or a non surgical resident. I once had a elderly lady admited form the er with a hip fx, admitted to div 1, which is teachjin service, don't know why she wasn't admitted to ortho, anywho i called the resident on call for pain meds, she said "give her apap 650 mg q 6 h", my reply was "if you do't give me some narcs for hewr, after i call you attending i will come donw to the er and kick you till YOUR hip is borken and give you apap and see how you like it", really, i am that big of a prick sometimes, she gave me percocet 1 tab po q 4 prn which suited this lady just fine. Sombody is going to bring up fentanyl, iv, it's great, patches are for chroninc pain only amd to tell ya the truth, they really don't work all that well. Torodol can be used as long as it isn't contraindicated by being pre op, and can't be used any longer that 72 hours. Nubane can be used in patients that have gone into narcotic psychosis ( i kinda miss that, it was entertaintin at times), but doesnt' do squat for pain, just makes ya not care your in pain.

P_RN, ADN, RN · Mar 1, 2002

Kewl I wish I'd been a fly on the wall when that resident said that!!!!

I've called many an attending and NEVER had one smart off at me.

With this gray hair the residents were kinda scared of ME.

I should have said the PCA and even the epidural ("epidermal") but I was focusing on the tib/fib and had a brain fart about the rest.

P

panda_181 · Mar 1, 2002

This is great guys, and keep it coming...but do you have any non-medication tips as well?

Amanda :)

MHN · Mar 1, 2002

panda ,I have seen PCA ,epidurals and even femoral nerve continuous infussion work well.

Learn acupressure points -works the same as acupuncture without needles ,or if you are the gypsy type you can buy the pain from the client-you do need to be convincing though you same as when you use any placebo. (check out the MASH episode when they ran out of morphine and the approaches and presentations of the placebo Great Example)

aus nurse · Mar 1, 2002

Can I just ask a quick question? Does anyone know Demerol's name in Australia? I think it is Pethidine. And do you have Tramadol (oral or IM) and what do you think of it?

We use Femoral block infusions, PCA's and oral stuff for our bone surgery.

JillR · Mar 1, 2002

Non-medication form of pain control for fractures include the obvious- ice, elevation, splinting. If it is not possible to elevate the extremity, help the patients get into the most comfortable position possible.

I once had an admission that had a fresh hip fx, not fixed yet and NOTHING ordered for pain. This person was fully clothed, so I had to undress her. I asked for something for pain for her and the doc told me that she had not been in pain in the ER. I just said, you guys didn't undress her, shes in pain now. Can you imagine? This is the same guy who wouldn't order anything for pain and then get angry when he was called at 2:00 AM for something for pain for a patient.

Patients usually need something a little stronger than Tylenol #3 in the first couple days. If there is a concern about the patient getting too much Tylenol, oxycodone is appropriate and effective.

Other forms of medication that can be a useful adjunct to opiates are NSAIDS, Torodol works well with musculoskeletal problem as an adjunct. Just remember that when giving NSAID's and tylenol, the patient can only get a maximum per day, depending on the medication. Opiates have no ceiling as long as you watch the patients respiratory status. Using adjucts can decrease the amounts of narcotics the patient requires, if that is a concern.

I agree that Demerol is useless, it really does nothing for pain and can be neurotoxic.

P_RN, ADN, RN · Mar 1, 2002

For Aus Nurse. Demerol(meperidine in the US) is Pethidine in the UK and Oz.

Tramadol is Ultram. I've taken it when I fx my ankle, and found it to be OK. I don't think it would handle a fx hip pain, at least initially.

semstr · Mar 1, 2002

For P-RN

Here Ultram (Tramadol) is called simply Tramal and it works pretty good for hips and total knees too.

We too give PDA's though.

Take care, Renee

kids · Mar 2, 2002

Two BIG things about Ultram that a lot of DOCS don'teven know...

Be very cautious if the parient is taking an SSRI (Paxil, Zoloft, etc) it can cause EPS (have had it happen to my Mom and at least 6 patients >60 yrs old.

Also please don't give it with or alternated with narcotic pain meds...they cancel each other out-Ultram will act as an antagonist I found this out the hard way-I was 2 weeks post op from a spinal fusion with pedicle screws and thought I would reduce my narcotic load by substituting some 'left over' Ultram. Ended up back in the hospital for 24 hours on a MS PCA and then back on the Tylox.

Also from personal experience-fx femor in 95- hydrocodone/APAP (vicodin, lortab) was more effective on the deep inside bone pain than was anything with codeine.

Rob_FL · Mar 2, 2002

I have been in Ortho for about 3.5 years now at a major hospital in Orlando. I work in the clinic (post op) so I dont see people in the hospital so I am not to sure what they use for pain management in house.

I will tell you that I write about 50 scripts a day for patients and I have only written for tylenol w/ codeine about 3 times. (dunno why really but that is the truth)

Mainly we write for Oxycontin 20 (or greater) q 12 and Oxy IR 5 q4-6 prn breakthrough. Once they wean them off of that stuff we go to vicodin (which I like cause I can call em in instead of writing em).

We dont use darvocet that often either, I agree with whoever stated they work better for headaches.

Elevation is key in pain and swelling obviously but I am guessing nothing beats a good narcotic painkiller, I would not know personally since I managed to make it through 15 years of baseball and 6 of football without a single fracture. Lucky me!

I am not an RN but I figured I would post what I have done at my work. I love my job since it is a teaching hospital and I have learned alot along with all the new docs in the program. They love to teach and I like to listen.

Night!

Röb