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Thursday, June 19, 2014

For better pain control, add a benzo? (Part 1 - Trauma)

If a patient is in pain, should we also be treating their anxiety more aggressively? Some medical practitioners feel strongly that we should be.  In part 1, I'll discuss the evidence for using "benzos" (e.g. midazolam, lorazepam) for traumatic pain. The (forthcoming) part 2 will discuss using benzos to treat the pain of cardiac ischemia. 
Bourbon, for example, can treat the anxiety of MI.
Source: Not the NEJM
Trauma, pain, and benzos
Many paramedics believe that they could control traumatic pain better, and reduce morphine or fentanyl dosing, if they were allowed to add a benzodiazepine, like midazolam or Ativan. Different reasons are offered for this approach, such as the role of anxiety, the spasming of muscles in trauma, or the difficulty in controlling pain quickly with just opioids. An interesting new EMS study adds some evidence to this discussion.

The French authors of  "Does midazolam enhance pain control in prehospital management of traumatic severe pain?" enrolled patients who had a traumatic injury, and who described their pain as at least a "6" on a 10-point scale. 

All of the patients got morphine, and good doses too! The first dose was 0.1 mg/kg, and then repeat doses of 3 mg PRN every 3 minutes were administered, until the pain was down to a “3.” 

Half of these patients also received 0.04 mg/kg IV of midazolam at the same time as the initial dose of morphine, while the other half received a placebo injection.


So, did adding the benzo help? It appears not. Surprisingly, the patients who received midazolam had about the same pain relief as the placebo group. 



Unsurprisingly, they also had much higher rates of sedation: 44%, versus only 7% for the placebo group. They also found a strong trend for more hypoxia in the benzo group: 13% versus 2% for placebo. Lastly, there was no difference in the total doses of morphine given.


So, unless you're looking to "snow" more patients, this isn't a good approach!


How does this agree with other studies?

Pretty well. For example, an ED study done with kids with fractured arms also looked at morphine ± midazolam for pain control. Similar to the present study, they found no advantage in pain control, but more "drowsiness." (In the graph, "VAS" means pain level.)



The Bottom Line
When I interviewed medics for a study I did a few years ago, I was surprised to hear that many medics, from both rural and urban locations across New England, felt strongly about giving benzos for acute traumatic pain.  Here's a sample quote from one of the subjects:


Ref.

Despite having personally worked as a medic at a few of the places I visited, I was surprised to hear this perspective. Adding benzos for pain control is not common (or usually even permitted) in the emergency departments where these medics trained. 

Unless we are trying to sedate a patient, severe pain is probably best controlled with opioids only.

54 comments:

  1. Maybe they should try a study where they give Versed to the EMS crew instead of the patient.

    ReplyDelete
    Replies
    1. Your point, while ostensibly humorous, likely gets at the truth of the matter.

      Anxiety in a patient, or at least the perception of it, is highly uncomfortable for medical caregivers. We just don't have the same reflex to treat a patient's pain, while addressing the anxiety is often seen as a priority.

      (And fever. Gotta treat fever!)

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    ReplyDelete
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  30. Hello Am From The UK , I want to write a little testimony about the good work of doctor Oyagu who cured me from Hsv 1 and 2 for just 2 weeks with his herbal medicine, I never believe I can be normal again and have a good life like others I always regretted the day I got diagnose with the virus, I was lost of hope when my doctor told me there is no cure for it but I keep thinking and thinking about my future, if I can have kids of my own well I am so grateful for my helper who get me cured with his herbal medicine, I go online in search of anything that can help me because I can’t deal with it forever so I found this doc Oyagu email on a blog of someone who was cured by him I quickly contact him for help and explain all my pain to him, he told me not to worry about it there is cure for real, I never believe until he send me the herbal medicine when I order for it and I have it within 4 days that is how I took the medicine for 2 week and the following week I go for test just to confirm I was 100% cured from this sickness what a miracle in my life I am so happy right now, you can also get in contact with him if you have such sickness through email address oyaguherbalhome@gmail.com or text him on what's app, phone number +2348101755322 Dr Oyagu also has remedy to others disease like COLD SORES,HIV/AIDS,DIABETES.CANCER,HIGH BLOOD PRESSURE AND MANY MORE. I oblige everyone to contact this powerful herbalist Dr Oyagu and be free from suffering.

    ReplyDelete
  31. Hello everyone, Words cannot describe how happy i am today after been cured from the herpes disease that i have be suffering from over 2 years now. I was infected with herpes and i have be living in shame and hiding it, but it became worse that i was searching for cure from different means so desperate until i met with a lady online who was testifying about this herbal doctor called Dr Iyoha. Who said she get her herpes disease cured with the use of Dr Iyoha herbal medicine. I never believed but i have to give a try because i was desperately in need of cure to the deadly disease that i have been living with. So i contacted him and we discussed how to get the cure and Dr Iyoha told me he cured with herbal medicine which i will order for and it will be delivered to me. Which i did what he wanted and to my greatest surprise the herbal medicine was delivered to me at my address which i gave to him, with instruction on how to apply was also given to me by Dr Iyoha. Then i started to use the herbal medicine, so after 3 weeks of using the herbal medicine, i saw physical changes and went for test at two separates hospitals and i was totally cured, i am here to say thanks to you again Dr Iyoha for saving me from the deadly herpes disease. Anyone with such disease can also contact Dr Iyoha through his EMAIL: driyohasolutiontemple@yahoo.com. You can also call him on +1 407 337 9869.

    Dr IYOHA CAN AS WELL CURE THE FOLLOWING DISEASE:-
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    13.YOU NEED YOUR WIFE OR HUSBAND BACRK
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    ReplyDelete
  32. A big Thanks to you doctor Just confirm am completely cure free from hsv with the help of his wonderful herbs medicine, may God continue to bless you and your wonderful herbs medicine thanks so much Dr Abubaka anyone looking for any herbs medicine should kindly contact Dr Abubaka to place your order for his lovely herbs medicine Via email: DrAbubaka@gmail.com or WhatsApp: +2349051703820

    ReplyDelete
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    ReplyDelete
  34. I Want To Appreciate Dr. momoh for his great deeds, I Was Diagnosed With Herpes Virus Last 2018, And i Was Looking For Solution To Be Cured Luckily I Saw Testimonies On How Dr. momoh Cure Herpes Virus I Decided To Contact Dr. momoh I Contacted Him He Prepared A Herbal Medicine Portion And Sent It To Me,I Started The Herbal Medicine For My Health.He Gave Me Step By Step Instructions On How To Apply It, When I Applied It As Instructed, I Was Cured Of This Deadly Herpes Within 2 weeks, I Am Now Herpes Negative.My Brother And Sister I Know That There Are So Many People That Have The Same Herpes Virus Please contact Dr momoh To Help You Too, And Help Me To Thank Dr. momoh For Curing Me, I’m Cured By Dr. momoh Herbal Medicine, His Contact Email:(dr.momoh9@gmail.com) Or Cell Whatsapp Number  +234 708 372 4098   thank you so much DR.momoh. He can also cure other diseases/infections

    ReplyDelete
  35. DR Abubaka herbal medicine is the best remedy for Herpes and HIV/AIDS, I was a carrier of Herpes and I saw a testimony on how Dr. Abubaka cure Herpes, I decided to have a contact with him and asked him for solutions and he started the remedy for my health and prepare the herbal cure for me which i use to cure myself. Thank God, now everything is fine, I'm cured by Dr. Abubaka herbal medicine, I'm very thankful to Dr. Abubaka and i will not stop publishing his name on the internet because of the good work he did for me, You can reach him on his email: DrAbubaka@gmail.com or WhatsApp: +2348075551672

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    ReplyDelete
  37. I am very happy today to share this amazing testimony on how Dr. AFRID the herbal doctor was able to cure me from my Herpes Virus with his herbal medicine. I have been a herpes patient for almost 8 months now and have tried different methods of treatment to ensure that I am cured of this terrible disease, but none worked for me, so I had to leave everything to God to handle as I was a Christian who had faith that one day God would intervene in my life, yet I felt so sad and desperate as I was losing almost everaything due to my illness, A few months ago while I was surfing the internet I saw different recommendation about Dr AFRID on how he have been using his herbal Medicine to treat and cure people, these people advice we contact Dr. AFRID for any problem that would help immediately, I contacted Dr AFRID and I told him how I got his contact and also about my disease, after some time Dr. AFRID told me to have faith that he would prepare for me a medication of herbal herbs, he told me I would take this medicine for a few weeks and also asked my home for home address so as possible for him to submit the drug for me, so my good friends after all the process and everything Dr AFRID actually sent me the medicine, I took it as I was directed by Dr. AFRID, after a few weeks passed, while on Dr. AFRID medication I began to experience changes in my body, I had to call my doctor at the hospital for some blood test, after test my hospital doctor told me that I was no longer with the herpes virus and my blood is pretty good, I can not even believe this, Friends well today i am Herpes Free and i want everyone to know that there is a cure for herpes for those who will contact Dr AFRID after reading my testimony, you can kindly contact Dr. AFRID in (DRAFRIDHERBALHOME@GMAIL.C OM) or whatsApp him +2349057260738, God bless you all  

    ReplyDelete
  38. I’m very excited to inform everyone that I’m completely cured from HSV1&2 recently.I have used Coconut oil, Acyclovir, Valacyclovir, Famciclovir, and some other products and it’s really help during my outbreaks but I totally got cured from HSV1&2 with a strong and active herbal medicine ordered from a powerful herbalist called Dr Iyoha and it completely fought the virus away my nervous system and I tested negative after 14 days of using the herbal medicine. I’m here to let everyone know that herpes virus has a complete cure, I got rid of mine with the help of Dr Iyoha and his herbal exploit. Contact him via email: driyohasolutiontemple@yahoo.com or Call him at +1(407) 337 9869 . He have the herb to cure difference cure for any sickness (1) HERPES, (2) DIABETES, (3) HIV&AIDS, (4) URINARY TRACT INFECTION, (5) HEPATITIS B, (6) IMPOTENCE, (7) BARENESS/INFERTILITY (8) DIARRHEA (9) ASTHMA... once again emial him via driyohasolutiontemple@yahoo.com

    ReplyDelete
  39. I’m very excited to inform everyone that I’m completely cured from HSV1&2 recently.I have used Coconut oil, Acyclovir, Valacyclovir, Famciclovir, and some other products and it’s really help during my outbreaks but I totally got cured from HSV1&2 with a strong and active herbal medicine ordered from a powerful herbalist called Dr Iyoha and it completely fought the virus away my nervous system and I tested negative after 14 days of using the herbal medicine. I’m here to let everyone know that herpes virus has a complete cure, I got rid of mine with the help of Dr Iyoha and his herbal exploit. Contact him via email: driyohasolutiontemple@yahoo.com or Call him at +1(407) 337 9869 . He have the herb to cure difference cure for any sickness (1) HERPES, (2) DIABETES, (3) HIV&AIDS, (4) URINARY TRACT INFECTION, (5) HEPATITIS B, (6) IMPOTENCE, (7) BARENESS/INFERTILITY (8) DIARRHEA (9) ASTHMA... once again emial him via driyohasolutiontemple@yahoo.com

    ReplyDelete
  40. The doctors said Herpes virus do not have medical cure because the virus is capable of hiding within the human cells, it remains protected from your immune system. Herpes isn’t a special virus – your immune system has the tools to fight it back. But because it is able to lay dormant in protected cells, your immune system is unable to remove it from your body,But with strong reactive herbal medication is capable of getting rid of the virus gradually and totally from your body without damaging any of your cells,natural herbs kills the virus totally not just reducing the out break. Get natural herbs cure Email DR. VOODOO at voodoospelltemple66@gmail.com Add Dr voodoo on whatsApp +2348140120719

    ReplyDelete
  41. Excellent and Amazing service on how to get back your ex, You need a honest and trustworthy man called Dr Isikolo (https://isikololovetemple.com)
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    ReplyDelete
  42. I started on COPD Herbal treatment from Ultimate Health Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 4 months, it reversed my COPD. My severe shortness of breath, dry cough, chest tightness gradually disappeared. Reach Ultimate Health Home via their website www.ultimatelifeclinic.com I can breath much better and It feels comfortable!

    ReplyDelete
  43. I started on COPD Herbal treatment from Ultimate Life Clinic, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 4 months, it reversed my COPD. My severe shortness of breath, dry cough, chest tightness gradually disappeared. Reach Ultimate Life Clinic via their website www.ultimatelifeclinic.com . I can breath much better and It feels comfortable!

    ReplyDelete
  44. I was having Herpes Simplex Virus then i came across a review of people saying that they got treated from Herpes Simplex Virus by Dr VOODOO., So i gave a try by contacting him through his email and explain my problem to him. He send natural medicine herbs to me and told me all the things I need to do and also give me instructions to take the medicine, which I followed properly. Before I knew what is happening after two weeks the HERPES SIMPLEX VIRUS that was in my body got vanished . so if you are also heart broken by any deadly diseases like HERPES HIV, shingles,low sperm count or bringing back your ex lover, this great man is extremely the best in which I have seen if you also need a help, you can also email him at voodoospelltemple66@gmail.com Add Dr voodoo on whatsApp +2348140120719

    ReplyDelete
  45. I want to share this great testimony to the world on how Dr. Kham cured me from HSV1&2 with his herbs, I was nervous when i first contact him about the cure for HSV but i decided to give him a try because i was desperate to get cured and be free from HSV. Dr. Kham prepared the cure and sent it to me through UPS,which I use just the way Dr. Kham instructed me and thank God today I am a beneficiary to this cure and I went back to the hospital after two weeks of taking the herbs and I tested HSV1&2 Negative. So I will tell you all who are looking for a cure to his/her HSV1&2 that Dr. Kham took research before he could finally get the solution to it and a lot of people are benefiting from him right now. He also cured my friend from HPV. Dr. Kham heals with natural herbs. Please I urge you to contact him now through his email address: dr.khamcaregiver@gmail.com or call and WhatsApp him on +2348159922297. His website is drkhamherbalhealingcenter.wordpress.com/   and he is capable of curing HIV/AIDS, HERPES, HPV, HSV1&2, CANCER of all kinds,DIABETES and so many other infections.  

    ReplyDelete
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