Flipping EM: Procedures and Analgesia

Welcome to Flipping EM, our flipped classroom case-based learning conference activity! Prior to each session, we will post clinical cases for your consideration and each learner level (PGY1, 2, 3) will be asked to answer a question about the cases. In order to aid your response, links to journal articles will accompany each question. You will be responsible for reading the articles for your level’s assigned questions and developing an answer to the questions (feel free to seek out other resources as well!). During our scheduled conference time, we will break up into small groups of 6-9 residents (2-3 residents per level in each group) with a faculty facilitator. Each level of learner will discuss their question and corresponding articles and teach the rest of the small group what they learned with the other group members adding their input. Below you will find the cases for this edition which focuses on Procedures and Analgesia. Please be prepared to discuss your articles and questions by conference on 7/27/17!

In order to set the scene for this edition’s cases, it is vital to have an understanding of the current issues surrounding opioid misuse and our role as Emergency Physicians. To begin, please listen to this podcast from Emergency Medicine Cases that discusses these issues: Opioid Misuse in Emergency Medicine1

Case #1

25 F with no significant PMH p/w low back pain since yesterday. The patient first noted the pain while at work where she works on a construction site. She denies any acute trauma but does note she frequently performs heavy lifting as part of her job. The pain is bilateral and isolated to her low back. It does not radiate. The patient denies fever, focal numbness/weakness, change in bowel or bladder habits. VS: T= 37C BP=110/65, HR=95, R=18, O2=98%. On exam, there is no spinal tenderness and the neurological exam is normal. The patient’s urine HCG is negative and she has no known drug allergies. The patient is asking for something to treat her pain.

PGY 1: You suspect that the patient’s low back pain is musculoskeletal in etiology and recall that generally NSAIDs are recommended as first line agents to treat musculoskeletal back pain. You order Naproxen 500mg PO. You remember seeing your senior order diazepam in the past for similar patients for muscle relaxation. Is there a benefit to giving diazepam in addition to NSAIDs for treatment of acute low back pain?

PGY 2: You decide against giving diazepam but wonder should you give a different muscle relaxant such as cyclobenzaprine? Or what about oxycodone/acetaminophen as an adjunct to control your patient’s pain?

PGY 3: Feeling like you should be doing more for your patient, you wonder whether corticosteroids might be of benefit for patients with low back pain. Is the patient likely to see improvement after administering corticosteroids? What about for patients with radiculopathy?

Case #2

45 M h/o nephrolithiasis c/o severe L flank pain x1 day. Pain was acute onset and is non-radiating, constant, and colicky. The patient has had similar pain in the past due to kidney stones. The patient denies fever, dysuria, hematuria, n/v/d, cp, sob. The patient is requesting something to help his pain.

VS: T: 37C, BP: 150/90, HR: 95, RR: 16, O2: 100%

PGY 1: You suspect the patient is suffering from renal colic. Your senior suggests that you start by ordering the patient a dose of ketorolac. What is the optimal dosing strategy for ketorolac that will maximize analgesia and minimize side effects?

PGY 2: After receiving a dose of ketorolac,  the patient reports mild improvement but is still in significant pain. You consider ordering morphine but would like to avoid opioids if there are suitable alternatives that may help the patient’s pain. Your attending suggests trying IV acetaminophen. How does IV acetaminophen compare in terms of efficacy to morphine in patients presenting to the ED with pain?

PGY 3: The patient reports his pain is improving but still moderate in intensity and asks if there is anything else you could give him to help control the pain. Again wanting to avoid opioids, you remember seeing a senior use ketamine for analgesia once and wonder whether that would be a good option for your patient. How does subdissociative dosing of ketamine compare to morphine for analgesia and what is the optimal method to administer it?

Feel free to utilize additional resources to support your responses and further the discussion of the topics raised in the cases! Please leave any questions or comments below. Thanks!

Episode 74 Opioid Misuse in Emergency Medicine. Emergency Medicine Cases. https://emergencymedicinecases.com/opioid-misuse-emergency-medicine/. Published December 15, 2015. Accessed July 18, 2017.
Friedman B, Irizarry E, Solorzano C, et al. Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain. Ann Emerg Med. January 2017. [PubMed]
Friedman B, Dym A, Davitt M, et al. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015;314(15):1572-1580. [PubMed]
Eskin B, Shih R, Fiesseler F, et al. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med. 2014;47(1):65-70. [PubMed]
Balakrishnamoorthy R, Horgan I, Perez S, Steele M, Keijzers G. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial. Emerg Med J. 2015;32(7):525-530. [PubMed]
Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. December 2016. [PubMed]
Sin B, Wai M, Tatunchak T, Motov S. The Use of Intravenous Acetaminophen for Acute Pain in the Emergency Department. Acad Emerg Med. 2016;23(5):543-553. [PubMed]
Motov S, Rockoff B, Cohen V, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015;66(3):222-229.e1. [PubMed]
Motov S, Mai M, Pushkar I, et al. A prospective randomized, double-dummy trial comparing intravenous push dose of low dose ketamine to short infusion of low dose ketamine for treatment of moderate to severe pain in the emergency department. Am J Emerg Med. March 2017. [PubMed]
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

Jay Khadpe MD

Associate Professor of Emergency Medicine
Associate Residency Director
University of Florida College of Medicine – Jacksonville

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