Nitrous oxide was widely available in emergency departments 20 to 30 years ago in North America, but it fell out of favor for two reasons: misuse by staff and variable effectiveness in patients. Both of those problems were the result of trying to make use of a 50/50 mixture (nitrous and oxygen). Use of the 70/30 mixture has provided solutions to both problems: the stronger mixture does not lead to euphoria but rather unconsciousness, making it rather evident who might be trying to misuse it! Analgesic effectiveness is almost 100 percent with the 70/30 mixture, and it is widely used in Australia as a result. It is almost omnipresent in Canadian pediatric EDs as well. Current regulations already in place in the United States for other procedural sedation medications should allow a relatively easy process to reintroduce nitrous oxide into emergency departments. Indications for nitrous oxide’s use rapidly come to mind because of its rapid-on, rapid-off effect. They include catheter placement in cognitively impaired children, casting a pain fracture, and disimpaction, to name a few.
Explore This IssueACEP Now: Vol 34 – No 02 – February 2015
In Europe, where experience now exceeds three years, IV acetaminophen is used routinely in acute pain management as part of a multi-medication approach.
The introduction of IV acetaminophen in the past two years has provided yet another option for acute pain management. In studies to date, 1 g IV of acetaminophen appears to have an analgesic impact almost equivalent to 10 mg morphine. Of course, the same was also said of ketorolac when it was introduced to the market. In Europe, where experience now exceeds three years, IV acetaminophen is used routinely in acute pain management as part of a multi-medication approach. Start with acetaminophen except in obvious severe pain (polytrauma, fractures, etc.) and add an opioid if required. Even in patients requiring opioids, acetaminophen is used, if only to minimize initial dosing of all medications, thus minimizing adverse events from any one agent. Evidence about the safety of repetitive doses of IV acetaminophen does not yet exist. Evidence suggests that 2 g by mouth as a one-time dose would probably be just as effective.
The use of regional anesthesia will be discussed in a future article because it, too, can play an important role in pain management of fractures and in procedures.
Concern over opioid misuse is at its highest when discharge prescriptions are written. First consideration should be to avoid prescribing the opioid most misused in your community. Each community chooses its opioid. Within a 60-mile radius of where I have worked, patients have told me that “only idiots” abuse any opioid other than “fill in the blank.” Heroin, oxycodone, meperidine, hydromorphone, fentanyl, dextromethorphan—they all have been abused, but usually only one is abused in any given community. This is primarily due to control of the drug scene by one gang or another. If opioids do have to be prescribed, limit dosing to three to four days maximum because follow-up for persistent pain is essential.