#EMConf: Pearls from Conference Day


  • The pancreas is a retroperitoneal organ so description and location of pain can be variable! Not always "epigastric."
  • 75% of cases of acute pancreatitis are caused by gallstones and ETOH abuse. 15% of cases are idiopathic. 
  • Significant alcohol use over a long period of time is required to cause pancreatitis, typically 8 or more drinks/day for more than 5 years. Only 10% of alcoholics get pancreatitis.
  • ALT >150 is more suggestive of gallstone pancreatitis over ETOH abuse.
  • Stop with the scorpion bites! Scorpions only in Trinidad and Brazil have been associated with pancreatitis. And only in case reports! 
  • Think about hypertriglyceridemia if your nurse tells you the patient's blood was "yellow." Send a triglyceride level! TG needs to be >2000 to be diagnostic, >1000 to be suggestive.
  • 5% of ERCP will cause acute pancreatitis.
  • BISAP Score is best score to use in the acute setting of the Emergency Department. A score >2 carries a 7x risk of organ failure and a 10x risk of mortality! Think about Critical Care consults for these patients.

Non-opiate, Alternative Pain Control Therapies

  • Lidocaine:
  • IV Lidocaine for pain from nephrolithiasis in patients who failed pain control with to toradol, recovering addicts, etc. 
  • IV Lidocaine originally studied for oncological pain. Moderate support from Cochrane Review. RCT showing lower pain scores compared to morphine in nephrolithiasis  
  • Dose: IV 1.5 mg/kg, max 200mg, infused over 10 minutes. Drug is antiarrythmic, don't forget cardiac monitor. 
  • Trigger Point Injections:
  • Useful for point-tender, muscular spasm/pain  
  • Dose: 0.5% bupivicaine, 1-2 cc intradermal injection
  • Can bill as procedure!
  • Ketamine:
  • Indicated for chronic pain disorders.
  • Think NSAID + Tylenol, Gabapentin, Valium, Flexeril first.
  • Dose: Sub-dissociative dosing. IV 0.3 mg/kg loading over 10 minutes followed by 0.1 mg/kg/hour IV infusion. 
  • Dose: 0.5 mg/kg intranasal with atomizer. Max dose 50 mg. Max 1 cc per nare. Safe in kids!
  • Nitrous Oxide:
  • Anxiolytic and analgesic! Fast onset of action.  
  • Can use in adjunct with local analgesia for procedural pain control in kids
  • Contraindicated in COPD/asthma, sinusitis, otitis media, bowel obstruction, altered mental status, pregnancy, B12 deficiency