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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Jonathan C. -

I have to questions: at what level of low phosphorus should be treated in SI unit IV or oral? Can patients be discharged on oral phosphorus supplement and for how long.

In the section on peripheral line in central vein, do you worry about the plastic part breaking of causing embolus ( li).

Joseph V. -

I'd love to do rebuttal to the Italian Stallion's rant on opioids this month.
I sit on our department's analgesic committee, so think a lot about pain...
Opioid-only ED (which, at it's extreme, is almost what Al suggests) is not the response to an opioid-free ED.
What we should be doing is the Most painless, most addictionless ED (I know, it doesn't really trip off the tongue).
Which means maximizing non-opioid options where appropriate, and then turning to opioids to help out (not carry all the analgesic burden alone).
So, to summarize:
1) Opioids should rarely be used alone. Combine with acetaminophen/ibuprofen (if using oral) or ketoralac (if parenteral).
2) Increasingly impressive evidence that the best analgesic combination is acetaminophen/ibuprofen. Opioids can always be added if needed.
3) If the patient has moderate pain, and has not taken any analgesic at home, start with non-opioid meds. Add opioids if it isn't enough.
4) Parenteral analgesics don't work better, just faster. And they are titratable. But for moderate, longstanding pain, these factors are less advantageous.
4) If you think the patient is going to be going home (such as sciatica, acute back strain, non-surgical fractures), don't give parenteral analgesics, give oral. Max out your analgesics: Acetaminophen 1 gm, ibuprofen 600mg, hydromorphone 2mg, all at once. It may take a bit longer, but when the patient is going home, you can tell them... "this is the best I can make you feel. Always take the APAP/Ibuprofen, and then you have some narcotics to back you up if you need them. But remember the side effects, addiction, etc..."
5) Maximize non-narcotic, non-nsaids when applicable. Buscopan for GI cramps, nerve blocks for dental pain, finger injuries, etc. And always use more bupivicaine than lidocaine when suturing, because who wants their pain to come back in 30 mins?
6) Don't use crappy po opioids. Skip the Tramadol and Codeine, go straight for morphine and hydromorphone. The only things the crappy drugs give you is more side effects and less beneficial effects. Use what works.
End of Rant Rebuttal

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