Clinical question: What are the efficacy and safety of a simplified “1+1” pain protocol using 1-mg IV hydromorphone followed by an optional repeat dose at patient request 15 minutes later in patients with acute pain?

Background: ED patients receive inadequate treatment of pain. Previously studied protocols utilized weight-based dosing, complex pain scales, and frequent nurse contact to assess and treat pain, making them less useful in a busy ED. A 2-mg single dose hydromorphone protocol provided pain relief, but was associated with oxygen desaturation.

Study design: Prospective interventional cohort study.

Setting: Adult, urban, academic ED with an annual census of approximately 89,000.

Synopsis: Participants included 223 ED patients ages 21 to 64 years old presenting with acute pain (<7 days duration) of sufficient severity to warrant use of IV opioids. Notable exclusion criteria included use of opioids within the past seven days, history of chronic pain, room air saturation <95%, systolic blood pressure <90 mm/Hg, or contraindication to hydromorphone; thus, findings are applicable to a limited set of ED patients presenting with acute pain. The hydromorphone protocol achieved patient expectations of pain relief (defined by decision to forgo additional opioid medication) in 77% of patients within 15 minutes and 96% of patients within one hour. 5% of patients dropped their oxygen saturations to <95%, but all increased promptly with 4L nasal cannula. Only 1% of patients dropped their respiratory rate to <12 breaths/minute and systolic blood pressure to <100 mm/Hg; none required naloxone use.

Limitations include lack of comparison group, unblinded design, and findings from a single urban center (in which participants were 60% Hispanic, 29% black, and 65% female). While there were no serious adverse events, the sample size is not large enough to identify rare events.

Bottom line: In nonelderly adult ED patients without a history of chronic pain or recent opioids, a pain protocol of 1-mg IV hydromorphone repeated in 15 minutes if needed is effective and safe, assuming typical ED monitoring for hypoxia and respiratory depression.

Citation: Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225.

Reviewed for TH eWire by Bhaskar Arora, MD, Thomas Barrett, MD, MCR, FHM, Honora Englander, MD, Stephanie Halvorson, MD, Alan J. Hunter, MD, David Kagen, MD, Blake Lesselroth, MD, MBI, Portland Veterans Affairs Medical Center and Division of Hospital Medicine, Oregon Health & Science University

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