Minimizing pain with local anesthesia

‘Wow doc! That freezing hurt more than the cut did in the first place!”

It’s common knowledge among our patients that the ‘freezing’ we give them as we prepare a wound for closure is often worse than the initial injury. We tell our patients that it will only hurt for a second, or that the momentary discomfort is for good reason. ‘Ouch!!’ they still yell as we inject the lidocaine and get ready to suture ‘That stuff hurts!’

Are our patients just wimps? Should they just suck it up and deal with the pain?

If you think the answer to these questions is yes then here’s a little experiment for you. Go get some 1% lidocaine and a 22 gauge needle. Now inject 1 ml into yourself, it doesn’t matter where really but for the sake of the experiment choose somewhere sensitive like your volar forearm. Okay, how did that go?  Yes, it hurts, but don’t worry we did the experiment for a good reason.

How can we minimize our patients discomfort during administration of local anesthesia? Most of us already know how to do this, but we aren’t. Perhaps we are desensitized to pain issues, but more likely we worry it will take too much time. In reality there is very minimal time requirement, and patients will be grateful. In fact, if they have had ‘freezing’ before and you do this well they will automatically think you are an amazing doctor!

  1. Minimize your patients anxiety. Tell them in a reassuring voice that you are going to minimize their pain.
  2. Consider alternatives to injected local anesthetic. Will topical anesthetic work? Should the patient have procedural sedation?
  3. Choose 2% lidocaine. High volume injections are more painful, so choose to inject a smaller volume of more concentrated lidocaine. 1% solutions are best used for large wounds where we need to get good anesthesia but are constrained by maximum doses, so need more dilute solution.
  4. Put your anesthetic somewhere warm. Warm anesthetic hurts less. I like to put a few ampules of 2% lidocaine in my scrubs pocket, or under the desk light at a work station.
  5. Buffer your lidocaine. Lidocaine has a pH of 7.4, and injection hurst less when it is buffered. Use a ratio of about 10 parts lidocaine to 1 part sodium bicarb.  I usually draw up 0.5ml of 8.4% sodium bicarb from an amp then fill the rest of a 5ml syringe with lidocaine, invert several times to mix and voila!
  6. Provide a distracting counter-sensation prior to injection. Rub the patients skin proximal to the injection site.
  7. Use a small gauge needle.
  8. Infiltrate directly into the wound rather than through intact skin.
  9. Inject the anesthetic slowly.
  10. Allow time for the anesthetic to work. Lidocaine works fast, but you need to allow a minute or two for it to take full effect.

Once we decide that providing a maximally pain free experience for our patients is important the rest is easy. These steps will become second nature to you, and patients will think you’re the best doctor ever, because ‘It didn’t hurt a bit!’

Your Next Patient: A 62 Year Old Man With Advanced Lung Cancer

It’s 9PM in your busy emergency department when an ambulance arrives with a 62 year old man who appears to be very short of breath. His wife explains that he has advanced metastatic lung cancer and has been waiting for a bed at a local hospice, but none have been available. They have been trying to manage at home but he has been getting worse rapidly today. Tonight he is struggling to breathe and in pain. He has been unable to take his medications because of breathlessness so they called the ambulance.

You review the patients records and find that he is a long-time smoker and has COPD. About one year ago he developed lung cancer. It was metastatic at the time of discovery and unresponsive to chemotherapy. Currently the cancer is widely metastatic in both lungs with invasion into the left chest wall causing severe pain. The patient has been followed by palliative care and has a do not resuscitate order in place.

On examination the patient is a cachetic man in overt respiratory distress and moaning in pain. His vital signs are: HR 120, RR 30 (shallow/laboured), BP 100/60, O2 80% on room air. Examination reveals the following positive findings: bilateral firm fixed supraclavicular adenopathy, no audible air entry on the left lung field with dull percussion tone, poor air entry on the right lung field, with a palpable right lateral chest wall mass. Heart sounds are noted to be tachycardic and diminished and jugular venous distension is present. Abdominal examination reveals an enlarged hard liver edge, suspicious for metastatic disease.

The patient has respiratory distress, diminished heart sounds and JVD. This raises a number of diagnostic possibilities familiar to most emergency physicians. In our patient, with advanced cancer, there are some additional important considerations.

  • Pericardial tamponade
  • Tension pneumothorax
  • Massive pulmonary embolism
  • Superior vena cava syndrome
  • Tension hydrothorax
  • Lobar collapse/lobar atelectasis
  • A complex combination of more than one of these possibilities

This is a complex question. A do not resuscitate order in it’s most basic form is only useful when the patient arrests and it does not provide any other guidance for the patients medical care. The presence of a do not resuscitate order may allow the physician to focus on treatment goals that have short term positive benefits.

Some patients may have detailed advanced directives that spell out the patients wishes in specific circumstances but this is rare. In the case of our patient he has a signed and witnessed document that states ‘In the event of death please do not resuscitate, please allow a natural death.’

It is also important to note that a DNR order can be revoked or changed at any time by the patient.

Like all other care decisions the physician must discuss options with the patient. In this case the patient is experiencing an uncomfortable natural death and available options aimed at relieving that suffering should be offered.

Our patient has severe dyspnea and pain due to tumor invasion of the chest wall. He has been unable to take his medications due to breathlessness.

The cornerstone of initial management is parentral opioids. In this case an opioid medication will provide both pain relief and relief of dyspnea. Either intravenous or subcutaneous medication is acceptable and medication should be titrated to symptom relief. Medications with a long interval to onset of action, such as transdermal fentanyl patches, should be avoided for acute symptom management.

Severe dyspnea can cause anxiety in many patients. In some patients anxiety resolves as the symptoms are controlled, while others require specific treatment with benzodiazipines.

Our patient receives hydromorphone 0.5mg IV q5minutes x 3 doses (1.5mg total) and has good relief of both his pain and dyspnea. His anxiety is also greatly reduced and he is offered lorazepam 0.5mg sublingual but he declines.

The doctrine of double effect (DDE) is a philosophical principle (probably first discussed by Thomas Aquinas). The principle is that harms are sometimes a side effect of actions intended to bring about a good result, and that these unintentional harms are ethically permissable.

In our case the doctrine of double effect is important. Some physicians are reluctant to treat palliative patients with opioids or benzodiazipines for fear they will hasten their death. This doctrine permits the treatment of palliative patients pain and suffering, even if that same treatment also hastens their death.

(In fact proper pain treatment has never been shown to hasten death, but this myth persists and is worth addressing.)

Our patient initially decides he might consider interventions that would improve his symptoms and some investigations are undertaken. A bedside ultrasound shows a moderate sized pericardial effusion. A CT scan shows diffuse metastatic lung cancer with a high disease burden, there is a massive left effusion with some mediastinal compression and diffuse liver metastases are now apparent. The patient is anemic with a hemoglobin of 71, and has metabolic derangement with a creatinine of 425, BUN 25 and K 6.0.

You discuss the results with the patient and offer interventions likely to improve symptoms, in particular left thoracocentesis. You discuss the difficulty of managing severe anemia and hyperkalemia in the face of renal failure. The patient decides that he does not wish to have any interventions except medications for pain control as he has had good results with the IV hydromorphone. You admit him to the hospital to wait for a bed in hospice but the hospital is over full so he remains in your emergency department.

Four hours later you are approached by the patients wife. She tells you that the patient is deeply sleeping with shallow and slow respirations. She is concerned because he has a loud gurgle in his throat and wonders if there is anything that can be done about this?

  • Glycopyrolate 0.1-0.2mg SC q2-4h
  • Scopolamine 0.3-0.6mg SC q3-6h
  • Atropine 0.1-0.4mg SC q2-4h

The patient is treated with glycopyrolate with good result. He dies 2 hours later still in our emergency department having never been admitted to a hospital bed or hospice due to overcrowding.

Palliative care seems on face as far out of the realm of emergency medicine as can be. However, with chronic overcrowding, hospital and hospice congestion and boarded patients a fact of life in most emergency departments, means that the provision of palliative care is becoming an important consideration for many of us.

Your Next Patient: A 35 year old with disproportionate pain

A 35 year old, somewhat rough looking, man arrives in your emergency room around midnight under his own power. He is complaining of 10/10 severe left arm pain. He says the pain started 5 hours earlier and has gotten worse every hour. The pain is mainly about the elbow and forearm. There pain began around 19:00 while he was watching TV. There is no history of trauma or injury. The pain does not radiate. there is no chest pain or shortness of breath. The patient is right handed.

The patient has no past medical history. He works as a roofer, and he drinks 6 beers per day and smokes a pack a day, he denies drug use.

On exam the patient is screaming and rolling around the stretcher, examination is difficult because every time you touch his arm he begins screaming and swearing. His arms are both heavily muscled, and his left forearm is slightly larger in girth than the right. The patient refuses to move the wrist. The pulses are present at the wrist, and sensation over the hand is intact.

The patient receives 10mg of IV morphine but his pain is unchanged. After a further 10 mg of morphine the patient is somewhat sleepy but says his pain is unchanged.

The nurse taking care of the patient asks you ‘Come on, are you buying this?’ and rolls her eyes.

The primary job of the emergency doctor is to consider the possibility of serious and dangerous diagnoses. Judging patients who present with disproportionate pain to be symptom magnifiers, malingerers, or drug seekers is a pitfall to be avoided.

Severe pain in the absence of compelling physical findings has a number of serious life and limb threatening causes. Premature closure, or mislabelling of the patient in these cases can have dire consequences. When confronted with disproportionate pain in a limb I like to consider if the patient could have:

  1. Vascular catastrophe
  2. Compartment syndrome
  3. Necrotizing soft tissue infection

With the patient now in a near somnolent state you re-examine the arm. The area of maximal tenderness seems to be the proximal volar forearm, and there are perhaps some subtle parasthesias over the palm. The patient wakes with agonized screams with passive ranging of the wrist or elbow.

The real answer is no, this patient has a surgical forearm (in the same way a patient with a rigid abdomen has a surgical belly). The patient requires immediate surgical consultation.

Getting a surgeon to attend the patient without ancillary testing is another matter…

If you have the equipment available a measured compartment pressure is the best test in this case to help differentiate among possible causes. An excellent review of the use of the Stryker pressure monitor can be found at emedicine.com

Blood tests are unlikely to be useful in this case. The white blood cell count will likely be elevated regardless of cause, the CK may be elevated in either necrotizing myofasciitis or compartment syndrome. Serum lactate may be elevated but is non-specific.

A CT scan of the arm may be useful. Contrast enhanced images including aortic imaging should be obtained if vascular catastrophe is suspected. An edematous compartment may be visible, and signs of necrotizing infection may be apparent.

A pressure of > 30 mmHg is considered diagnostic of compartment syndrome. However, it is probably more useful to consider the issue of compartment perfusion pressure (in the same way we think about cerebral perfusion pressure). Patients with low perfusion states, such as the trauma patient with hypovolemic shock, are at risk of compartment syndrome at lower absolute  compartment pressures.

In this case a Stryker monitor was not available. The patient’s bloodwork was notable for an elevated CK at 13,000, and a WBC of 18 (worthless) and a lactate was normal. A CT scan showed edema of the volar compartment of the forearm.

The patient was taken to the OR for fasciotomy of the volar forearm, and made a good recovery. In retrospect the patient had been using a heavy impact drill in the left hand the previous day and this was thought to have precipitated the compartment syndrome.

  • Pain out of proportion to physical findings should make the emergency physician very wary.
  • Be reluctant to define a patient as a symptom magnifier, malingerer or a drug seeker.
  • Vascular catastrophe, compartment syndrome and necrotizing skin infection can all present with disproportionate pain and subtle or no physical findings.
  • A swollen painful limb with any neurovascular findings represents a surgical emergency.

Opioid related deaths and emergency room prescribing

Today the United States Centre for Disease Control issued an early release of an article to be published in it’s Morbidity and Mortality Weekly Review (MMWR). The title is Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States 1999 – 2008, and the content is startling. Overdose deaths due to prescription opioid pain relievers are almost as common as deaths due to motor vehicle collision (36,450 vs 39,973 for 2008).

You heard correctly, your cause of death is now equally likely to be from either a motor vehicle collision or an overdose of prescribed narcotics. If you worry about dangerous drivers on the roads, you should also worry about dangerous prescribers in the hospital.

In the emergency room we are faced with a difficult dilema, confronted with acute pain, but uncertain of risk to the patient when we prescribe narcotic pills. This is risky business. My own feeling is that we should be very aggressive about the control of acute pain within our departments. When we send patients home with narcotic pain pills we should send them with a very small supply, and instructions for close follow-up with a provider they know who can follow them along over time.

There are ways to assess the risk to patients when they commence on opioid medications. Dr. Douglas Gourlay’s paper Universal Precautions in Pain Control is a must read for anyone who ever writes for opioid medications. However, with even the best of training and the best of intentions our interactions with patients in the emergency department are fleeting. We have no capacity to follow patients along, to assess their risk and response over time. As prescribers of opioids medications pills that flowed from our pen have killed people. We must be cognizant of this, reduce the risk for our patients and confine our prescribing to agressive relief of acute pain within our department, and short bridging therapy until the patient can be reassessed by their own family physician. To do otherwise exposes our patient to unacceptable risk.

Otitis Media: How to treat your patients right and do the right thing

In a busy emergency department nothing is as wonderful as a simple and straight forward case. Otitis media used to be that case; a child is crying, the ear is sore and red, hand over a prescription for penicillin and the job was done. Happy parents, happy doctor, happy child….oh wait, the child was still unhappy but 2 out of 3 isn’t bad.

Mounting evidence and experience in European countries has shown us that immediate treatment of otitis media with antibiotics is probably not warranted. In a modern immunized society the majority of cases of OM are essentially benign self limited illnesses that don’t require treatment. In many North American emergency departments physicians have slowly been backing off of antibiotic treatment for OM. This past January 2 separate studies were published in the NEJM that have again shifted us back towards antibiotic prescribing for OM. Separate studies by Tahtinen and Hobermen both seemed to show a benefit in treating children less than 2 with a 10 day course of amoxicillin-clavulanate. There was much analysis of these studies, perhaps the best is by Dr. David Newman, and in the end it seems that perhaps there is a small reduction in symptoms when children are treated with antibiotics at a cost of significant antibiotic associated side effects, most commonly diarrhea.

Physicians are confused, we don’t know what to do, we try to read the parent and sense what they want and do what we think will make them happy. Parents are confused, sometimes doctors tell them their kids need antibiotics, sometimes they withhold antibiotics, it doesn’t make sense to them. What was once a lovely and brief encounter is turned into an emotionally turbulent episode of hand wringing, half explanations and crying children; a doctor who is unsure what to do, and a parent who is aggravated by the seeming randomness of the situation and a conflict around antibiotics.

The problem with ear infections is that they hurt, they hurt in the same way it hurts when a sadistic dentist blows compressed air onto a freshly drilled tooth (why do they do that!?). Adults with an ear infection want a shot of morphine, kids get a pat on the head and an ‘it’ll be okay buddy’. The only reason that anyone takes a marginal reduction of symptoms in an OM study seriously is because the symptoms are terrible and because we don’t treat the symptoms. It seems ridiculous that we are willing to accept a 15% risk of diarrhea with amoxicillin-clavulanate for 12 hours less of symptoms, particularly when the symptoms can be treated (if only we decide to treat them).

Here’s what I’ve found helpful in turning otitis media back into a great emergency department encounter:

  1. When I walk in the room and see a crying child with a bright red and bulging TM I say Wow! That looks really sore, we need to do something to get you feeling better right away!
  2. I always carry a couple of sterile ampules of 2% lidocaine in my breast pocket, and as long as there is no allergy I put 2-3 drops in the ear (there are commercial products designed for this, but they are expensive and single use lido works just fine). Then I tell the parents, just to keep him still for a minute while I go get a sticker to distract the child.
  3. When I get back into the room no one wants to talk about antibiotics because the child is now happy and smiling. What they want to talk about is the magic pocket drops and where they can get some of their own.
  4. I then give the child 15mg/kg of po acetaminophen.
  5. Then I say to the parents; Now that he’s feeling better we can talk about what to do. These days in children who are immunized ear infections are not dangerous and get better with time, people sometimes worry that they might turn into meningitis but I can reassure you that that is not going to happen. The biggest problem is that ear infections are painful so the first thing we need to talk about is how to control the pain…I give them a talk on using proper weight based doses of acetaminophen or ibuprofen and a topical agent like the lidocaine drops or a commercial alternative and that typically symptoms last 5 to 7 days…When it comes to antibiotics the studies that are out there don’t show a lot of benefit and they do show a lot of children getting side effects like diarrhea, so I like to start with getting the child feeling better with pain control. I’m not dogmatic about antibiotics though, if you are worried he is not getting better we are always happy to see him again and reassess the situation or if you would like I will even write you a prescription for antibiotics you can fill in a couple of days if things are not getting better.
Almost no one takes the delayed antibiotics script, and often when they bring in another child for an ear infection the parents decline antibiotics and ask for pain control options instead. The whole encounter takes about 5 minutes. It is much faster and easier to control the pain and explain the options than to have a tense antibiotic associated stand-off to the tune of a screaming child.
And ahhhhhhhhh, that’s the sound I remember from the old otitis media visits, happy parents, happy doctor and happy child, oh wait this time we are 3 out of 3….