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Opiates & the Acute Abdomen

trauma-list@trauma.org trauma-list@trauma.org
Fri, 11 Apr 2003 13:05:34 -0500

Narcan has its own problems. Few titrate Narcan effectively. When a
patient has been in pain, achieved some relief from the pain, then has
that relief eliminated in about a minute the effect is not pleasant.
Also, Narcan infrequently seems to bring on pulmonary edema.

The pain medication goal, as I understand it, is to decrease the pain to
a tolerable level - not eliminate the pain. Elimination of the pain
predisposes to narcosis (the patient is not just pain-free, but high). If
opiates are titrated properly the pain should be decreased from
moderate/severe to minor/moderate.

If you want accurate information about a chief complaint you would not
expect to obtain it from the stoned, pain-free patient. You also are
unlikely to receive accurate information from the patient who is in too
much pain to localize pain.

Another objection to medicating patients is informed consent to
treatment. You are in severe pain and they offer you pain medication if
you consent to surgical carte blanche. Is that informed consent? Not that
any of you are engaging in this; it is one other objection that comes up
with regard to pain relief prior to surgical evaluation.

For prehospital pain medication - should the patient be bounced all over
the place in the back of a truck (ambulances are trucks, nobody cuts
diamonds in the back of an ambulance) even at slow speeds, arrive at the
ED and then receive pain medicine to lie in a more comfortable bed that
is not moving? What training/continuing education/feedback is provided to
the paramedics about pain medication and how to decrease the pain, yet
stop short of having the patient want to sing?

Since this seems to be a subject on which reasonable people have strong,
divergent opinions, what studies are being done? Are there any that would
meet EVERYONE'S criteria for being prospective, large enough, randomized,
blinded, and placebo controlled?

Treating the patient without consideration of the long term outcome is
not something that anyone should be doing. I do not get the impression
that this is being advocated.

Tim Noonan.

On Fri, 11 Apr 2003 11:29:55 -0500, "Richard Buck"
<teotwawki@sbcglobal.net> said:
> In my admitted ignorance, I'm puzzled as to why Narcan can't be used to
> temporarily negate the effects of narcotic analgesics for the brief
> period when a surgeon needs to have the patient's true pain level
> present to accurately assess an abdominal injury. Isn't that win/win
> for patients who are in pain and must wait for attention (perhaps for
> hours) yet can present s/s faithfully to the diagnosing physician
> during the assessment (perhaps minutes)? Please educate EMT Trauma
> educator. My students and I await enlightenment.
> Rich
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