Head Injury and Opioid Analgesia
54. M.C., a 24-year-old male hemophiliac, is admitted to the emergency department (ED) with several minor lacerations, contusions, and painful hemarthrosis secondary to a bicycle accident. Meperidine 50 mg IV was ordered and he was transferred to the medical ward for further evaluation. There, M.C. was given antihemophilic factor. He also was given meperidine 50 to 75 mg IV every 3 hours, as needed, for pain. What was the danger in administering an opioid to M.C. in the ED or shortly after he was admitted?
Opioid analgesics generally are avoided in patients with head injury for the following reasons: (a) opioid-induced pupillary changes, nausea, and general CNS clouding can mask or confuse the neurologic evaluation; (b) head injury potentiates the respiratory depressant effects of opioids; (c) opioids induce carbon dioxide retention, which in turn causes vasodilation of cerebral arteries and an increase in cerebrospinal fluid pressure that might already be elevated because of head injury180,181; (d) opioids in excessive doses can mask internal organ injury; and (e) morphine and meperidine can produce further hypotension in patients who have blood loss caused by trauma. These potential complications, however, should not preclude the use of a short-acting opioid, such as fentanyl, for pain control in emergency situations, especially when the patient's clinical condition and analgesic responses are monitored closely. If fentanyl is to be used, small but frequent IV doses are preferred over single, large boluses (see Table 8-5 for starting doses). The final dose is based on the patient's analgesic and toxic responses. It would be reasonable to start M.C. on fentanyl 25 to 50 mcg IV every 30 to 60 minutes followed by analgesic titration.
2 comments:
references 180-181. please specify?
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