IV Therapy

RN&mom · Jul 10, 2013

You will never get rid of a true migraine with po meds if its gotten to the point they're in the ER... Unless you've had a migraine you might want to be careful with the "drama queen" bit as well. I was in the ER myself not too long ago for a migraine and endure 31 injections of Botox every 3 months in my head & neck just to keep my migraines manageable. The pain is very much real, trust me! And maybe this girl was being dramatic (I obviously wasn't there) just be careful what you're saying because it sounded like you were dismissing migraine headaches as nothing. They are awful, I go through a lot to try to keep them away and when I get them I still only go to the ER when I feel like my head is going to explode and I can't stop vomiting (with zofran)... All I'm saying is please take migraines seriously, offer a cold cloth to cover the eyes while you start the IV :)

FL ER Nurse · Jul 11, 2013

It depends on the pts symptoms as well as the MD working that night. Some docs work everybody up. Some are minimalists.

IrishErin · Jul 11, 2013

It depends on the pts symptoms as well as the MD working that night. Some docs work everybody up. Some are minimalists.

This! We also have regulars that come in and have their own "care plans", so to speak. One might always get a litre bolus with some morphine and maxeran. Another gets an IM of morphine and gravol. One woman gets a shot of solumedrol into the joints in her neck!

Each headache is different, and each doctor may treat them differently.

Ciale · Jul 11, 2013

You will never get rid of a true migraine with po meds if its gotten to the point they're in the ER... Unless you've had a migraine you might want to be careful with the "drama queen" bit as well. I was in the ER myself not too long ago for a migraine and endure 31 injections of Botox every 3 months in my head & neck just to keep my migraines manageable. The pain is very much real, trust me! And maybe this girl was being dramatic (I obviously wasn't there) just be careful what you're saying because it sounded like you were dismissing migraine headaches as nothing. They are awful, I go through a lot to try to keep them away and when I get them I still only go to the ER when I feel like my head is going to explode and I can't stop vomiting (with zofran)... All I'm saying is please take migraines seriously, offer a cold cloth to cover the eyes while you start the IV :)

No no, definitely not dismissing migraines as nothing. The lay in bed, no sound, no light and sensation of someone stepping on your head while simultaneously stabbing it. Yup. I used to get them often. There's way too many details that would prove my point regarding the "queen" comment but none of them are relevant to my actual question about when to go ahead and start an iv.

I guess just assume the worst? Headache think aneurysm?!?! I dunno...everyone keeps saying "it will come with time" but I'm really looking for black and white answers.

Ciale · Jul 11, 2013

This! We also have regulars that come in and have their own "care plans", so to speak. One might always get a litre bolus with some morphine and maxeran. Another gets an IM of morphine and gravol. One woman gets a shot of solumedrol into the joints in her neck!
Each headache is different, and each doctor may treat them differently.

Aaah yeah, gotcha. Thanks!

SweetMelissaRN · Jul 11, 2013

Although you may feel like being told "it will come with time" is a blow off answer, but it's the truth...

With that said, there are certain chief complaints which will just about ALWAYS get a work up: chest pain, nausea/vomiting (in adults), ams, seizure, sob, stroke-like symptoms, flank pain in males (not women bc it's usually just a UTI).... Each hospital and doctor vary so it takes time to learn who they like to work up and what not..

You'll get it, I promise!

Altra, BSN, RN · Jul 11, 2013

For your migraine example, here are things I would have assessed:

1. Does the patient have a hx of migraines? If s/he has never had one before, or has been well-controlled for a long time but then suddenly has a whopping migraine -- that's likely going to get worked up.

2. Any trauma?

3. Fever or other recent illness?

4. PERRL?

5. Any other neuro deficits or s/s?

In other words ... the differential diagnosis rules out other big & bad stuff before concluding that it's "just" a migraine. The old ER adage: "prove to me that you're not sick". (in some patients, this takes only 15 seconds )

Having said all that -- migraines are unlikely to respond to p.o. meds. If there are no red flags in the differential (see above) nearly all are going to get 500mL or 1 liter IVF and your provider's cocktail of choice such as Benadryl/Reglan/Toradol. Hoping you don't work with a provider who has been sucked into giving narcotics for migraines -- the chance of a rebound headache is very high, and it's a very problematic road to go down.

Exceptions to the above would be: "I ran out of Maxalt and all I really want is an Rx for 5 days or so until I can get in to see my doctor."

OR

The "migraine" whose s/s don't really match the migraine profile. It's not for me to say whether or not you have a headache ... but if you're noisily crunching away on Cheetos or potato chips ...

OR

The frequent flyer migraine patient (and yes, I'll say it, there is a subset of these that include symptoms of "drama") who has not managed to follow up with neurology as previously directed.

A strong suggestion for you, OP -- listen to the docs' assessment of patients. You'll learn a great deal about differential diagnosis that way.

Adenosine6 · Jul 11, 2013

In general for ER's you have some "standard guidelines"

Example:

ER (A), Line and lab all urgent patients (ESI 3,2,1)

ER (B), Line and lab, place orders: Chem 7, CBC, Lft's, Meds: I.e Zofran (docs will then co sign)

ER (D), If you have an old-school doctor that rarely orders much, then wait...

Best thing to do as a new-grad who is unfamiliar with treatment in the ER; as your fellow coworker "Hey, should I line and lab him?"

Ciale · Jul 12, 2013

For your migraine example, here are things I would have assessed:
1. Does the patient have a hx of migraines? If s/he has never had one before, or has been well-controlled for a long time but then suddenly has a whopping migraine -- that's likely going to get worked up..

Oh yeah. Good point and thanks for all the input. Will listen to doc's differential dx. Also, I didn't know that about narcs for migraines causing rebound headaches. So far I've had mostly orders for morphine/dilaudid (+benandryl and antiemetic). Hm. I have seen Toradol as well but not as often.

RN&mom · Jul 12, 2013

Narcotics should definitely NOT be given for migraines! Anyone who has had migraines long term knows this and as a pt generally refuses them (or should). The best "cocktail" for migraines, mine and everyone I've talked to is compazine, Benadryl, toradol. I'm sure other things work but any doctor handing out morphine for a migraine is a fool and the pt is a bigger fool!! And yes lots of IV fluids, 1000mL, sometimes 2000, depending on my headaches... Thanks for understanding my previous post. I definitely wasn't trying to pick on you but I know a lot of people don't understand migraines or think sufferers are drug seekers when most migraine sufferers never touch narcotics at all...

psu_213, BSN, RN · Jul 12, 2013

Narcotics should definitely NOT be given for migraines!

First, let me state that I suffer from occasional migraines, but, thankfully, I have never had to go the ER for treatment. From working in the ER, I see how bad they can get and usually is relieved with a migraine cocktail (some combination of IVF, reglan, compazine, benadryl, toradol, zofran, etc...the exact mix depends on the individual doc). There are a few (definitely the minority) migraine sufferers who demand a narcotic (i.e. "dilaudid is the only thing that works for my migraine") and that is when warning sirens go off in my head. It is these individuals who give a "bad name" to the majority--those with a true migraine who want nothing more than some measure of relief.