i am wondering how are headaches/migraines treated in your ers?
in our er docs mostly give narcotics and antiemetics. as an ex-neuro nurse i was very surprised by that, because our neurologists absolutely will not give narcs because it causes rebound headaches. upstairs we did mostly dhe protocol, caffeine, depakote, reglan loading protocol if all of the above didn't work, quiet room, icepacks, darkness, hydration and oxygen,etc.
the er docs explained to me that "we don't have time to do all that, we want to stop the pain and get the person home" (with a lortab prescription usually). none the less, the patients stay at least 4 hours even if they get narcotics, then they come back 2 days later because the pain is back and the neurologist can not see them this week.
Specializes in Case Mgmt, Anesthesia, ICU, ER, Dialysis.
Hello...I'm new here and don't want to make anyone mad, but I have been reading post for the past couple of days and this is the second time I've heard reference to Droperidol. I have given this drug before, and I'm not saying anything negative about anyone else that gives it. However, Droperidol was black boxed almost ten years ago. The reasoning behind the black box as irreversible cardiac arrythmias and death. Here's my question: If a physician orders Droperidol and you give it with negative consequences (death). Are you responsible? You gave the right drug, right dose, right route, right patient, right time, but you gave a black boxed drug. If anyone knows the answer to this question I would be grateful for the education.
I just recently had the privledge of hearing a lovely anesthesiologist give a talk on post-op nausea and vomiting, where droperidol is a Godsend. If you look at the incidences that landed it with a black box warning, they occured in extreme conditions, and the black box warning was highly lobbied for and advocated by the manufacturers of a rival drug trying to gain market share.
I'm not saying it shouldn't be given with caution, but always consider if there were other reasons, i.e., political, why something landed with a black box.
If you were following physician orders, and had clarified the ordered drug and dose, as well as documented that you had clarified the order, then I don't think you could be held liable. But if you are concerned about it, discussing with your hospital risk management department might be hepful.
Specializes in Med-Surg/Neuro/Oncology floor nursing..
For myself personally I am a chronic pain patient(just had a craniotomy to boot) so I get headaches a lot(got them before the crai, and now they are worse after the crani). I take narcotics already(have for three years, headaches aren't my reason for chronic pain, I have a few other issues) anyway if my headache isn't resolved by my oral fioricet or oral pain meds(or I am vomiting and can't keep my meds down) then and only then will I go to the ER(the ER my pain management doctor works at, this way if he is there he can come see me, or if he is in his office seeing patients, the ER doctors can call him a verify I am his patient and I am legit..the ER doctors usually take my word for it, if I was really a drug seeker why would i offer this man up along with my list of narcotics up on a silver platter). Some ER doctors will call my PM doctor to find out what they should give me and what would work, some doctors use their own judgment(and once they hear my doctors name..and I offer up his number they know right away I am not there to seek drugs, I only go to the ER if I am desperate, being a chronic pain patient I try to avoid going to the ER like the plague).
If I am vomiting my brains out; I get IVF, IV Zofran or compazine, A Imitrex, 1mg IV ativan and 1-2mgs dilaudid. I know this seems excessive, but like I said I am have been a legit chronic pain patient and have a high tolerance(most of the stuff given I take orally anyway). If I am NOT vomiting my guts out I asked for a quiet room, a couple of ice packs for my head and I get IM Dilaudid, Imitrex and Ativan. Sadly I've been through the ringer with the preventative meds(I just got off topamax and Neurontin...they make me loopy and tired and sadly my insurance only covers 6 imitrex pills a month(which I take and usually run out within a couple of weeks. I can't take toradol which actually really upsets me because I have an ulcer, gastritis and colitis. Which is why I can't take advil or motrin(though sometimes I do sporadically even though my gastro says NOT to touch NSAIDS, sorry tylenol just doesn't work a motrin or asprin here or there wont really kill me). Usually at home for my headaches(which I never got often before the crani...with the crani it's more of a head pain than your usual headache, I take the 6 imitrex I allotted a month(obviously not at the same time I try to save them as along as I can) or I take fioricet. Again I don't take these things everyday, and if those things don't work I move on to my pain meds which is rare(rebound headaches). Now the pain for the crani that isn't controlled at home involves IV dilaudid(sometimes morphine which doesn't work as well), a CT scan and a neurosurgery consult(which I usually ask for if they don't order it first), and if the pain doesn't resolve usually an admission for pain management(for the crani pain I go to the hospital where I had the surgery done, they also call their pain service down). Wow that was a book. Sorry about that.
My favorite kind of thread- A legit question, spiced up with a bit of humor. Thank you incensedandcerified. Now all we need is somebody with zero ER experience to be critical and call somebody heartless.
In answer to the original question: In my ER it is a total crap shoot. It depends on which doc is working. Could be any of the cocktails already mentioned. The real question is who gives narcs and who doesn't. All of the non-narcotic cocktails with a bolus seem to work pretty well for many.
Some patients come to the ER simply for narcotics. They know that their neurologist will not give them narcotics, as they are generally contraindicated for headaches. By the way, some have mentioned the need for education for ER docs who give narcs for headaches. ER docs are smart and well educated and are well aware that the consensus expert opinion is against narcs for headaches, yet they give them. Hence, the requests for narcs.
In the interest of customer service, I think we should post a board in the waiting room, indicating which doctor is on, and some basic stats on narcotic administration for headaches, chronic pain, and dental pain. This would save patients time, and, and potentially save the system a bunch of money. For example: Dr. A is on, and follows current best practices for headaches, which does not involve narcotics. Or, Dr B is on, and he gives narcotics for 90% of pain complaints. Or, Dr A and Dr B are both on, and we can't tell you which one will see you. Feeling lucky?
I know of one ER which has a sign posed in the waiting room: "We do not prescribe narcotics for dental pain." Not only a sound practice, but very considerate of patients who aren't going to take the ABX anyway, and just want the narcs. (I know this is unbelievable to some, but it has happened.) Imagine there are 2 hospitals in town, one with that sign, one without. Where do you want to work?
Another thought for anybody allergic to more than two non-narcotic analgesics. No medicine of any kind until a complete work up to find the cause of this tragic and statistically near impossible condition. (what do you figure the odds of being allergic to toradol and tramadol?) This workup would involve two large bore iv's. An IO and an EJ if access is questionable. Hang a couple of bags ready to go, and have at bedside epi, benadryl, pepcid and solumedrol. Then, slowly give the dreaded toradol. Think of it kind of like a stress test, where the heart is pushed to it's limits, but the team is there to prevent any damage.
This would be a tremendous benefit to many chronic pain pt's who believe they are allergic to these very effective medications. Chances are excellent, that they were simply confused about their allergy status, and this procedure would allow them to use much safer medications for their conditions.
Specializes in Emergency, Critical Care (CEN, CCRN).
Another vote for the 15L NRB fix. My dad gets cluster headaches, for which he actually keeps tanked O2 in the house. 3-5 minutes on the mask breaks the vasospasm and stops the headache. The one time he had to go to Emergency for a headache that would not quit, the doc tried snowing him with an absolute ton of opioids, in the well-intended but vastly misguided belief that he would be able to "sleep it off." (Over a four-hour period, he got two milligrams of Dilaudid, thirty-two milligrams of morphine, and two 325/10 OxyContin - this in a guy who's more or less opioid naive. Plus 50 mg of Benadryl and 25 of Phenergan, "slam" IV pushed. I was terrified the next "treatment" was going to be an ETT. And of course, it did not one thing for his headache. He was still wide awake and screaming, running a pressure of 220/118 from pain, and now delirious and combative from the meds. The headache eventually broke on its own, but by that point we had to sit in Obs for another four hours before he was safe for discharge. :flmngmd:)
Sub-Q triptans seem to be quite effective in aborting headaches in the emergency setting, and I'm hoping we see more of this in the future. (PO triptans, quite frankly, take way too long to kick in - they're something you send a patient home with to take as soon as symptoms start, not when the headache has been ongoing for hours already.) There's also a decent amount of research out now that supports the use of calcium-channel blockers in vasospastic-type headaches. Most of the work was done on verapamil, but if a patient can't tolerate its cardiac effects (already has bradycardia or an AV block), nimodipine is a bit more selective for cerebral vasculature. 60-125 mg of Solu-Medrol IVP followed by a tapered course of prednisone PO for home is also an effective "rescue" therapy for a refractive vasospastic headache. And, of course, IV hydration and nausea management.
Sadly, there are still plenty of MDs out there who go right to the narcotics on headache patients anyway. Sigh... more education needed!
There was an article in JAMA a few years ago about the treatment for migraines. It is shown that something like 80% of all migraines are caused by mild to moderated dehydration. the thought is give them hydration, than you will resolved migraine symptoms.
That being said. it depends on the doc. Some of our docs do Toradol/zofran. Otheres will load up on the big D and Zofran, IM phenergan ETc. Some will go with old faithful STadol, zofran.
We have a policy change and IVP Phenergan is only permitted in 20 gauge or bigger in the AC or higher.
Also lately, we have been on a "stop the abuse" wgon so the docs have been pulling pharm reports (Thank you Virginia Prescription Monitoring Program) and saying No.
Though I posted that most of the non-narcotic/bolus remedies seem to work pretty well, that is only for 1 kind of headache. The kind where the pt is light sensitive, noise sensitive, looks uncomfortable, doesn’t really wan to talk or eat. Often they have tried their prescribed migraine medications, without any relief. They look lousy even when it isn’t obvious you are watching them.
Then, there is the other kind of headache. It can involve talking, texting, watching loud tv, eating junk food. Pain is usually rated at least a 9. The signs of this headache are exacerbated by a set of scrubs. These headaches usually require narcotics.
Regarding Compazine: Don’t give it without Benadryl. I have seen several Compazine reactions, none with prior administration of Benadryl.
Though I posted that most of the non-narcotic/bolus remedies seem to work pretty well, that is only for 1 kind of headache. The kind where the pt is light sensitive, noise sensitive, looks uncomfortable, doesn't really wan to talk or eat. Often they have tried their prescribed migraine medications, without any relief. They look lousy even when it isn't obvious you are watching them.
Then, there is the other kind of headache. It can involve talking, texting, watching loud tv, eating junk food. Pain is usually rated at least a 9. The signs of this headache are exacerbated by a set of scrubs. These headaches usually require narcotics.
Regarding Compazine: Don't give it without Benadryl. I have seen several Compazine reactions, none with prior administration of Benadryl.
Yep those darn narcotic ha's They drive you crazy. Oh you forgot throw things and curse at the nurse if told "No"
Compazine I have seen work great for certain patient populations without the need of benadryl. I have seen more to Phenergan than Compazine.
Though I posted that most of the non-narcotic/bolus remedies seem to work pretty well, that is only for 1 kind of headache. The kind where the pt is light sensitive, noise sensitive, looks uncomfortable, doesn't really wan to talk or eat. Often they have tried their prescribed migraine medications, without any relief. They look lousy even when it isn't obvious you are watching them.
Then, there is the other kind of headache. It can involve talking, texting, watching loud tv, eating junk food. Pain is usually rated at least a 9. The signs of this headache are exacerbated by a set of scrubs. These headaches usually require narcotics.
hherrn You crack me up! "exacerbated by a set of scrubs". How true though.
I seen great results with reglan. Although I always mix it in a bag of 50ml of NSS and let it drip in. We also use benadryl, toradol, decadron, zofran, compazine, phenergan. Then of course you always have the pt who are "allergic" to nsaids, imitrex, tramadol and almost everything else that doesn't start with a "d". If it is a chronic pain pt our ED has a policy. We WILL medicate you but usually not their drug of choice. Supportive measures like IV hydration and antiemetics but no narcotics.
I try and accomodate the dark, quiet room the best I can but it is an ER and well not always the most tranquil and serene places to be but I do my best to offer supportive, non pharmacologic methods. Never utilized the O2 tx though. Makes perfect sense and will have to give it a whirl and try it.
Another thought for anybody allergic to more than two non-narcotic analgesics. No medicine of any kind until a complete work up to find the cause of this tragic and statistically near impossible condition. (what do you figure the odds of being allergic to toradol and tramadol?)
"Well let me put it this way, if you DO have an allergic reaction - you are IN an emergency department. The best place to go to if you have ANY kind of allergic reaction ... and you're already here!
NurseKitten, MSN, RN
364 Posts
I just recently had the privledge of hearing a lovely anesthesiologist give a talk on post-op nausea and vomiting, where droperidol is a Godsend. If you look at the incidences that landed it with a black box warning, they occured in extreme conditions, and the black box warning was highly lobbied for and advocated by the manufacturers of a rival drug trying to gain market share.
I'm not saying it shouldn't be given with caution, but always consider if there were other reasons, i.e., political, why something landed with a black box.
If you were following physician orders, and had clarified the ordered drug and dose, as well as documented that you had clarified the order, then I don't think you could be held liable. But if you are concerned about it, discussing with your hospital risk management department might be hepful.