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.

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….

Aggressive Pain Control

A 35 year old man presents with a kidney stone, or an 85 year old woman presents with a broken hip, or an 8 year old boy presents with an open lower leg fracture. All these patients have fairly straight forward and very painful medical problems, but in the average emergency room none of them will get prompt pain control.

How long is it okay for a patient to wait for pain control? How about if it’s your 85 year old mother with a hip fracture, your 8 year old child with a leg fracture or you with a kidney stone. Now you know the correct answer, pain control should be prompt, it should come shortly after making sure patients are not about to die and don’t need an immediate intervention. Our patients know this, if we do everything right, no matter how complex, but ignore their pain they don’t think we did a good job. Pain is why they came to see us in the first place.

The EMCrit podcast has a practice changing lecture on acute pain control in the emergency department by Dr. Edward Gentile. The idea is simple, the patient is the one who knows when they have had enough pain medicine and a one size fits all approach is appropriate in the emergency department.

The protocol is simple (with credit to Dr. Gentile); For patients in moderate to severe acute pain and who have no allergies:

  1. Give 0.1mg/kg morphine IV push (0.05mg/kg for patients older than 55) along with 0.05mg/kg of diphenhydramine (since most of the adverse effects of morphine are histamine mediated).
  2. 7 minutes later ask the patient ‘Would you like more pain medicine?’
  3. If the answer is yes give 0.05mg/kg morphine IV push.
  4. Repeat every 7 minutes until the patient’s pain is controlled.
If your emerg is like mine some doctors and nurses you work with probably believe that 10mg of IVP morphine is a lethal dose. The benefit of controlling pain using a one size fits all approach is that everyone gets used to it. After a while all of the nurses have given a 100kg man with pancreatitis 10 mg of morphine as an IV push and 30mg over an hour, and the patient didn’t die and didn’t need naloxone.
I will admit that I used to think it was normal to spend hours and hours getting peoples pain under control. Since I’ve started using a protocolized approach to pain I have happier patients, happier nurses and I feel like I’m doing a better job. We see patients with acute severe pain everyday, it is absolutely a patient priority in the ED and it should be a priority for us too.

Shove it up your nose

A 35 year old man arrives at your emergency room, he’s a construction worker and he’s put a large spike right through his forearm with a nail gun. Ouch! He’s freaking out, screaming and writhing around. ‘Stay still!’ the nurse is yelling, ‘I can’t help you until I get this IV in!’ The ambulance crew is trying to hold him flat, the patient is screaming, crying and can’t stop moving.

I hate this kind of messy situation, I like my emerg to be a well oiled machine and this situation is like the sound of metal shavings in the gears. What can you do? Obviously this patient needs analgesia, but in the current situation establishing IV access is proving difficult.

Intranasal fentanyl is the trick shot that can get you out of this situation. Estimate the patients weight, draw up 0.5mcg/kg of fentanyl into a 3ml syringe. If you have an atomizer device use it, if not just make sure the patients head is tilted back. Walk over to the patient and say “Sir I am going to give you some pain medication, do you have any allergies?’ then, shove it up his nose.

Ah, silence my favourite sound. Intranasal fentanyl is directly absorbed, bypasses first pass metabolism and rapidly accesses the brain to provide analgesia. It burns a little in the nose, but in the patient with severe pain they never seem to notice. A minute after giving the med you can take a history, do your examination and establish your IV in a cooperative, if slightly altered patient.