Chapter 21: Multimodal Pain Management Strategies

PATIENT PRESENTATION

Chief Complaint

Motorcycle accident

History of Present Illness

US is a 41-year-old Caucasian male who presented to the emergency department (ED) 24 hours ago via EMS after suffering a motorcycle accident. According to bystanders, US hit a patch of loose gravel and was ejected from the motorcycle, landing on the pavement approximately 10 feet away. Upon presentation to the ED, US was found to have a Glasgow Coma Score (GCS) = 8 and a negative focused assessment with sonography in trauma (FAST) exam. Following a trip to the operating room for an open reduction, internal fixation (ORIF) of the left knee, US was transferred to the intensive care unit (ICU), intubated and sedated.

Past Medical History

Hypertension, hyperlipidemia

Surgical History

ORIF of left knee 12 hours ago

Family History

Unknown at present time

Social History

Unknown at present time.

Immunization History

Annual influenza vaccination, otherwise unknown at present time

Allergies

No known drug allergies

Home Medications

• HCTZ 25 mg PO daily

• Amlodipine 10 mg PO daily

• Atorvastatin 40 mg PO qHS

Current Medications

• Propofol continuous infusion, currently at 150 mcg/kg/min

• Hydromorphone continuous infusion, currently at 0.7 mg/h

• Hydromorphone 0.2 mg IV bolus PRN breakthrough pain—no doses received

• Cefazolin 1 gr IV q8h × 6 doses

• Gentamicin 5 mg/kg as a single dose—received in ED

• Heparin 5000 SQ q8h

• Lorazepam 1 mg IV q2h PRN agitation—no doses received

• Low level sliding scale insulin protocol—no doses received

• Electrolyte replacement protocol—no doses received

• Famotidine 20 mg PO bid

Physical Examination

Vital Signs

Tmax since admission 99.5°F, BP 108/92 mmHg, HR 86 bpm; RR 18 breaths/min; Ht: 180 cm, Wt: 112 kg

General

Intubated and sedated male patient.

HEENT

PERRLA; otherwise deferred.

Pulmonary

PRCV ventilation setting.

Cardiovascular

NSR.

Abdomen

Soft, nondistended, hypoactive bowel sounds.

Genitourinary

Foley catheter visualized, otherwise deferred.

Neurologic

GCS = 8 on admission, no changes appreciated. RASS = +1, CPOT = 2, CAM-ICU = negative.

Extremities

Significant abrasions appreciated on all four extremities; fresh incision, without purulence or erythema, visualized under dressing on left knee.