Pancreatitis:

• 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