Author: V. Dimov, M.D.
A 25-year-old Caucasian male (CM) with quadriplegia after a motor vehicle accident (MVA) is at a long-term rehabilitation facility on a ventilator. During his 4-month hospital stay, he developed a stage III sacral decubitus.
The pain management team was consulted.
The patient complained of two types of pain:
-"in my butt" - nociceptive pain from the sacral decubitus
-"shooting, burning pain in my right leg" - neuropathic pain
What are his current pain medications?
Dilaudid 2 mg IV q 4 hr PRN pain
Acetaminophen (paracetamol, Tylenol) 650 mg PO q 6 hr PRN pain
What can be done better?
He needs around the clock pain medications. PRN only is not adequate.
The treatment for these two types of pain is different.
Acetaminophen (paracetamol, Tylenol) 650 mg PO q 6 hr (i.e. not PRN)
Duragesic (Fentanyl Transdermal) patch 25 mcg/hr q 72 hr
Dilaudid (hydromorphone) 4 mg IV q 4 hr PRN pain
Gabapentin (Neurontin) 400 mg PO qhs x 3 d
400 mg po BID x 3 d
400 mg PO TID
The patient reported that his sacral pain decreased from 10/10 to 4/10 the next day, after adjusting therapy.
It took a week for the gabapentin (Neurontin) to start working for the neuropathic pain.
What did we learn from this case?
Always evaluate all the places where the patient is feeling pain. Pain may be of different origin in different places, e.g. nociceptive vs. neuropathic and may require different treatments.
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