Pain Management in Long Bone Fractures

[widi96]

For those who have protocols for pain medication in (actual and potential) long bone fractures - what do they look like? What medications are you using? What contraindications are listed in the protocol for administering the medication?

We are looking to add pain medication to our protocol and want to see what others are doing. Wanting to see if there are better options or something we aren't thinking of.

[DayDreamin ER CRNP]

In the ER, I don't really think a protocol would necessarily work, so to speak. Every patient is different and even if you have two identical femur fractures, you could have two very different patients and scenarios.

For pain control, we use Morphine, Fentanyl, ketamine, and that one that starts with a D.

We also throw in some zofran or other anti-emetic. It all depends on the physician, MOI, and presentation. In my opinion, we grossly under medicate these injuries and very few of our docs like to dole out a lot of meds. I also don't think a protocol would even fly with our docs. They ALL have their own ideas of what works and what doesn't.

I'm not saying attempting a pain protocol isn't a good idea but I just think there are so many variables that factor into what I would decide to order. I will be interested in seeing what other folks answer.

[offlabel]

Why has "protocol" become the default fall back position when something is being handled poorly? There are people that specialize in acute (and chronic, for that matter) pain, but everyone has to reinvent the wheel. If the physicians in the ER have their way of treating severe, acute musculo-skeletal pain and they do it poorly, there isn't a lot the nursing staff can do about it.

[DayDreamin ER CRNP]

Why has "protocol" become the default fall back position when something is being handled poorly? There are people that specialize in acute (and chronic, for that matter) pain, but everyone has to reinvent the wheel. If the physicians in the ER have their way of treating severe, acute musculo-skeletal pain and they do it poorly, there isn't a lot the nursing staff can do about it.

We don't see protocols as something in place when things are handled poorly at all. Our ER utilizes nurse-driven protocols that our ED docs have agreed to sign if the nurse initiates the set of orders appropriately. It saves significant time and the patients see that we are getting things started before the MD/NP ever enters the room. We have protocols for CP, abdominal pain (upper and lower), asthma, suspected volume depletion, hip fractures, extremity fracture, diabetic complications, etc. I think we probably have about 20 or so. Most do not include meds but a few do. None include pain meds, however,

Our hip fracture protocol does include a battery of labs, X-rays, foley, EKG, etc. We have been using these for over 10 years and we tweak them from time to time but they work really well for us.

[widi96]

We currently only have one protocol that includes pain medication and that is flank pain for possible kidney stone and we can give IV Toradol after a negative preg test.

I don't believe it is our physicians that are causing this problem - this is much more of a ED size issue. We've added more rooms and still have 4+ hour wait times frequently for our level 3s. We're trying to get things started in triage prior to seeing a physician. The pt who complains about a twisted ankle that is doing ok may have to wait awhile then find out they have a non-displaced fracture vs the patient with obvious deformity who would go right back. We're trying to improve the situation until they can get to see the provider.

[CX_EDRN]

We have a ton of nurse driven protocols but not one specifically for long bones. Our trauma protocol uses fentanyl initially and we give it pretty freely, although I do agree these patients are undermedicated. Kids are especially under medicated.

[nightbrightener]

I am seeing a big push to go IV acetaminophen first, and quickly, with the elderly with long bone fractures due to increased dementia and agitation with narcotics. This was suggested by our ortho floors and seems to generally go well. We still usually will add a chaser of 2-4mg morphine if needed but often the tylenol is enough for the elderly with femur or hip fractures in my experience and their perception. Now open humeral fracture on a 20 year old, break out the fentanyl and dilaudid.

[jdub6]

Our problem is our pain protocols use po Tylenol or Motrin. for some things this is fine but if they need more after being seen now they are less likely able to get toradol or ofirmev. but if we don't offer the p.o. in triage we get dinged. rock and a hard place in my opinion.