No more Toradol

[EMEDPA]

I've given a lot of IV phenergan in the past as well but a few years ago the hsopital said IV phenergan is no longer an option. a quick check of the internet for phenergan complications found this:

 

Although deep intramuscular injection into a large muscle is the preferred parenteral route of administration, product labeling states that the drug may be given by slow IV push, which is how it is typically given in most hospitals. However, due to the frequency of severe, tragic, local injuries after infiltration or inadvertent intra-arterial injection, ISMP recommends that the FDA reexamine the product labeling and consider eliminating the IV route of administration. Severe tissue damage can occur regardless of the route of parenteral administration, although intravenous and inadvertent intra-arterial or subcutaneous administration results in more significant complications, including: burning, erythema, pain, swelling, severe spasm of vessels, thrombophlebitis, venous thrombosis, phlebitis, nerve damage, paralysis, abscess, tissue necrosis, and gangrene. Sometimes surgical intervention has been required, including fasciotomy, skin graft, and even amputation.

 

source: http://www.ismp.org/newsletters/acutecare/articles/20060810.asp

[fireguy]

We've been short on Compazine, Reglan, and now Toradol as well. Seems like all of the good Non-narcotic meds are in shortage, which is frustrating. I don't like using Phenergan IV as there has been known cases of tissue necrosis.

 

BTW, has anyone has any experience with Ofirmev, acetaminophen IV injection. Perhaps this may be another option to treat mild-moderate pain the way we use Toradol.

 

we have had no compazine, caffeine, or ativan for several months now. We have toreador though intermittently.

 

A colleague of mine from europe told me that IV acetaminophen works very well, that the drug seeking patients there come in asking for IV acetaminophen. When I inquired about using it in my ED, I was informed that it was not available, because it was super expensive.

 

We have been using IV ibuprofen for those with migraines or severe musculoskeletal pain when toradol is short. Seems to work fairly well.

[NoClinic4Me]

I've never used inapsine. Will have to give it a try (if we have it).

Thanks,

Pat

[mainiac]

we are also having intermittent zofran shortages leaving only phenergan....(or inapsine but then you have to deal with nurses demanding ekg's, 30 min of cardiac monitor, etc)

 

We're out of compazine... bummer

[Hemegroup]

Too bad there isn't a shortage of Oxycontin or Vicodin?

I work a lot in Pain Mgmt ... I don't think there's a national shortage, but pharmacies are often out of the 'higher' narcs, either due to rarity, prescription overload, or some just not wanting to carry it. As for zofran and phenergan, I haven't had a red flag yet.

[EMEDPA]

I actually had to give inapsine last night to a pt still vomiting after zofran and phenergan. we are out of reglan and compazine.

inapsine 25 mg/bendryl 25 mg and all the problems(including her bad attitude) went away.

[andersenpa]

I actually had to give inapsine last night to a pt still vomiting after zofran and phenergan. we are out of reglan and compazine.

inapsine 25 mg/bendryl 25 mg and all the problems(including her bad attitude) went away.

 

I know it has a black box as well but do you ever try droperidol?

[True Anomaly]

I know it has a black box as well but do you ever try droperidol?

 

Inapsine is the trade name of droperidol

[andersenpa]

Inapsine is the trade name of droperidol

 

hilarious. our EMR is entirely generic....I never use trade names anymore.

so I guess the answer is yes....

[EMEDPA]

yup. but I don't use propofol because it scares folks due to the michael jackson death....I use diprivan.....:)

[skyblu]

I'm frustrated with our recent shortages.

 

In the last 3 months, we've been low on or out of: toradol, IV Valium, Reglan, compazine, Protonix, and now we just got an email asking us to conserve Dilaudid (!!!) as we are running low!

 

So basically, anyone in pain who can't take PO gets morphine or fentanyl. If they get nauseous with morphine, I pray Zofran helps them as it is the only thing we have other than phenergan, which we are not allowed to give IV because of the tissue necrosis warning.

 

I guess I should be grateful I don't practice in my home country, where there is a severe shortage of insulin!

[True Anomaly]

So some places really DO run out of Dilaudid....I thought this was a happy myth

 

I heard a couple new ones today at one of the hospitals we cover while I was working: Marcaine and Maalox. When the nurse called up to the pharmacy to ask if there was any Marcaine up there, the pharmacy person said "Well don't you have lidocaine? It's the same thing". If the nurse hadn't have handled that one on her own, I was jumping at the bit to call the pharmacy back and educate them on their own medications :)

[surgblumm]

There are now scores of mefications, which when they became generic, were decreased in production by the pharmaceutical industry. It has been my partner and my habit to order IV Mephyton prior to starting an elective case that has a potential for bleeding. We have had forty years of success with this or placed them on the oral version which suddenly did the disappearing actband now costs patients almost two hundred dollars for ai five day supply. I. Hate to say that this is America but abuses in the system are running rampant because government has no control.

Bob

[surgblumm]

I still need to be educated on how to start a thread as I have areas of discussion that are worthy of the minds on this great forum. Help.

Bob

[True Anomaly]

I still need to be educated on how to start a thread as I have areas of discussion that are worthy of the minds on this great forum. Help.

Bob

 

Bob- there's a button on the left-hand side of each forum labeled "Post New Topic"- just click it and go from there. You have to be in a forum to have the button show up

[surgblumm]

Thanks. I'll check it out now. bob

[ventana]

 

So basically, anyone in pain who can't take PO gets morphine or fentanyl. If they get nauseous with morphine, I pray Zofran helps them as it is the only thing we have other than phenergan,

 

 

the nausea from morpphine is from a histamine release - give 25 - 50 of benadryl BEFORE giviing morphine and Ta Da no more nausea (and they get tired so you can document that their pain must be better as they are sleeping comfortably.)

Learned this from EM:RAP a few years ago and it has repeatedly served me incredibly well - -

 

Benadryl first, then morphine - no need to repeat dose the benadryl after the first dose, just titrate morphine for pain relief and no nausea!

[surgblumm]

You may consider the new IV Acetaminophen which is given 1000 mg q6h and then a small amount of an opioid. The N&V is greatly reduced and this is highly successful on some of your more painful procedures , such as orthopedics.

Bob

[skyblu]

Ventana and Surgblumm, thanks for the tips!

 

My institution doesn't have parenteral Tylenol, but I will try the trick with Benadryl.

 

Thanks again!

[chiaroscuro27]

the nausea from morpphine is from a histamine release - give 25 - 50 of benadryl BEFORE giviing morphine and Ta Da no more nausea (and they get tired so you can document that their pain must be better as they are sleeping comfortably.)

Learned this from EM:RAP a few years ago and it has repeatedly served me incredibly well - -

 

Benadryl first, then morphine - no need to repeat dose the benadryl after the first dose, just titrate morphine for pain relief and no nausea!

 

What great advice! I'll be sure to remember this one. Gotta love EMRAP.

[True Anomaly]

Our frequent sickle cell patients taught me that one

 

the nausea from morpphine is from a histamine release - give 25 - 50 of benadryl BEFORE giviing morphine and Ta Da no more nausea (and they get tired so you can document that their pain must be better as they are sleeping comfortably.)

Learned this from EM:RAP a few years ago and it has repeatedly served me incredibly well - -

 

Benadryl first, then morphine - no need to repeat dose the benadryl after the first dose, just titrate morphine for pain relief and no nausea!

[fuma102]

what if youre giving benadryl IM? Iv got a few sicklers who continuously itch from dilaudid or morphine despite sometimes up to 200mg of benadryl IM over 4 hours. I know its an excessive dose, but my attendings are quite ok with this, and sometimes we've tried pepcid PO as well with mixed results.

 

should we give benadryl like 20-30 minutes first before pain meds to prevent histamine release earlier and then only have to do 1 dose rather than 2/3/4 ?

 

anyone else have this problem?

[surgblumm]

Hi Fuma 102

I have been engaged in surgery and emergency medicine for forty years and I have experience some of your problems. In our private practice we always give Benadryl 50 mg 30 minutes pre-op as it has the two fold effect of lowering the histamine telease,acting as an adjunct to an antiemetic and then as a third, it sedate the patient to a degree. this makes the patient more comfortable pre-op and post-op. As far as 200 mg within four hours, if i were examining this treatment plan as a expert witness, I would do an extensive literature search as this is not a treatment plan that is approved in the PDR for Benadryle and therefore is "off label" use and is up for targeting by a plaintiff's attorney. Your Doc's being OK with this means spit in a court of law as they are among the most fallible.

Bob

[primadonna22274]

YES, give your Benadryl preemptively and it will work a lot better. I am wary of 200mg+ doses as well...anticholinergic excess is not a good thing and even worse with a sick sickler.

 

what if youre giving benadryl IM? Iv got a few sicklers who continuously itch from dilaudid or morphine despite sometimes up to 200mg of benadryl IM over 4 hours. I know its an excessive dose, but my attendings are quite ok with this, and sometimes we've tried pepcid PO as well with mixed results.

 

should we give benadryl like 20-30 minutes first before pain meds to prevent histamine release earlier and then only have to do 1 dose rather than 2/3/4 ?

 

anyone else have this problem?