Manejo del dolor agudo en urgencias

Dolor Agudo DR. Alejandro Saez Ceballos. Becado de M. Urgencia

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197-205. Jones JS, Johnson K, Mcninch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med. 1996;14(2): 157-160 Introducción

[object Object],[object Object],[object Object],[object Object],[object Object],(Asociación Internacional para el Estudio del Dolor; Pain 1979;6:249-252) Dolor

Def. relacionadas con el dolor

Neurofisiología del dolor ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Consecuencias fisiológicas

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sedación

Niveles de Sedación ,[object Object],[object Object],[object Object],[object Object],Sedación disociativa

Sedoanalgesia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Preparación ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

La (ASA) incluye 5 categorías del estado físico preoperatorio ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Equipamiento y Monitorización ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Enfrentamiento ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Medición ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Evaluación Clínica ,[object Object],[object Object],[object Object],No existe ningún método de valoración del dolor, que sea absolutamente fiable, y la elección de uno u otro dependerá de las posibilidades de que se disponga, así como del tipo de dolor y las características del paciente a evaluar.

Escala Visual Análoga ,[object Object],Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain. 1997;72:95-7.

Escala de Campbell Erdek MA, Pronovost PJ. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care. 2004;16: 59-64

Reevaluación del dolor ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Adicción Dependencia Tolerancia

Fármacos ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Analgésicos Sistémicos Vías de administración ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

AINES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Glucocorticoides ( Bloquean la expresión de ARNm) Acido Araquidónico COX-1 (Constitutiva) COX-2 (Inducible) Estómago Intestino Riñón Plaquetas ,[object Object],[object Object],[object Object],[object Object],(–) (–) AINEs Mecanismo de Acción (–) IECOX2

AINES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],AINES Efectos indeseables

Analgésicos no opioides ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Opiáceos ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Opiáceos

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Opiáceos

Receptor Efecto Clínico Agonistas μ Analgesia supraespinal( μ -1). Depresión respiratoria( μ -2). Dependencia física. Morfina Met-encefalina* B-endorfina* κ Rigidez muscular. Sedación. Analgesia espinal. Fentanil Morfina Dinorfina* δ Analgesia. Conductuales. Oxicodona Leu-encefalina* B-endorfina* σ Epileptogénico. Disforia. Halucinaciones Estimulación respiratoria. Nalorfina Ketamina?

RAM y manejo ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Droga Vía Dosis Duración (horas) Morfina IV IM, SC oral peridural 0.05 mg/kg -1 0,1 mgxkg -1 0,3 - 0,5 mgxkg -1 3-5 mg (*) 3 3 - 5 4 8 - 12 Codeina oral 0,5 - 2 mg/kg -1 3 - 4 Metadona IM, SC 0,05 - 0,1 mg/kg -1 6 - 8 Meperidina IV 0,5 mg/kg -1 1 - 2 Fentanil IV 1-2 ug/kg -1 0,5 Tramadol IV, IM, SC 1-1,5 mg/kg -1 6 - 8 Naloxona IV 1 mg/Kg. 0.5-1 Características clínicas de los analgésicos narcóticos

Morfina (10 mg/1 ml) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fentanyl (0,1/2 cc // 0,5 mg/10 ml)

Meperidina ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tramadol ,[object Object],[object Object],[object Object],[object Object],[object Object]

Naloxona (0,4 mg/ 1 ml) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tto escalonado OMS 1990 ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],PCA Limita circuito de demanda de analgésico ( dolor-----enfermera-----médico----- enfermera------ medicación------analgesia)

Ketamina (500 mg/ 10 ml) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Propofol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],200 mg/10ml

Etomidato ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Barbitúricos

Benzodiazepinas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diazepam ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Amp. 10mg/2ml

Midazolam (5-15 mg/ ml) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Midazolam (5-15 mg/ ml)

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lorazepam

[object Object],[object Object],[object Object],[object Object],Recuperación y Alta

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sugerencias

Analgesia multimodal: Recomendaciones ,[object Object],opiodes IV + AINEs analgesia epidural con anestésicos locales + opiodes + AINEs IV Procederes más agresivos y pacientes de mayor riesgo (ASA III y IV) Pérez Hernández y cols .

Manejo del dolor agudo en urgencias

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Manejo del dolor agudo en urgencias