Study of Respiratory Depression When Using a Hydromorphone Pain Protocol

This is a study about the efficiency and safety of a 1mg+1mg hydromorphone pain management
protocol for the treatment of long bone fractures in the Emergency Department. Appropriate
patients 60 years and older who present with a condition that causes moderate to severe
pain, according to the attending physician's judgment, in which the physician would order
the use of parenteral analgesia will be screened and randomized to one of two study arms,
"1+1" versus usual care group. Neither the research associate, nurse, or attending physician
will be blinded to the patients randomization. Patient pain score will be assessed at
baseline using VAS score. "1+1" patients will receive 1mg hydromorphone at "timepoint 0"
(baseline) followed by another 1mg after 15 minutes (along with repeat VAS pain score) if
the patient answers "yes" to "Do you need more pain medicine?" At 60 minutes, patient pain
will be assessed a final time and if patient needs more pain medicine, additional treatment
will be dictated by physician discretion. Usual care group patients will also have VAS pain
scores assessed at timepoint 0, 15 and 60 minutes and will have pain treated per the
discretion of the attending physician. Patients will be placed on capnometer for continuous
monitoring of respiratory status to guard against any opioid induced respiratory depression.
Respiratory status, vital signs, and pain scores will be monitor to assess the efficiency of
pain control as well as the safety of pain medicine administration in terms of respiratory
depression. We propose that the "1+1" hydromorphone protocol is easy to implement, as it
includes a set timeline, a standard question, and a set dosage of a potent analgesic. We
hypothesize that it will provide adequate analgesia in the majority of patients without
causing the anticipated level of respiratory depression.

Inclusion Criteria:

1. Any patient who presents a condition that causes moderate to severe pain, according
to the attending physician's judgment, in which the physician would order the use of
parenteral analgesia

2. Able to provide consent.

Exclusion Criteria:

1. Patient or family member unable to consent

2. Altered mental status

3. SpO2 less than 95 percent

4. Allergy to opiates

5. Hypotension (Systolic blood pressure less than 90 mmHg)

6. Chronic oxygen dependency or known CO2 retention

7. Acute ETOH or drug intoxication

8. History of chronic pain syndrome or chronic use of opiate narcotics

9. History of opiate/heroin addiction, past or current.

10. End stage renal disease/dialysis patient

11. Chronic metabolic acidosis

12. Physician feels that patient would be poor candidate for study

13. Weight less than 100 pounds, all patients will be weighted

14. Patients younger than 60 years of age