Agree +++ with giving analgesia to abdo pains. I keep a copy of the
relevnt article (you know the one, analgesia doesn't mask the diagnosis,
tends to improve diagnostic accuracy if anything) in A&E, to wave under
the nose of any surgical SpR who cares to argue the toss with me. I've
stopped bothering to ask them if they would mind if I gave some
analgesia while they were waiting to be seen - the answer was always:
"No, rather you didn't, old chap, we'll be there in a minute anyway".
Three hours later and still waiting.... Now I give them analgesia 1st,
refer the patient 2nd and discuss it with the surgeons later.

>Morphine. I'm fairly mean with anti-emetics in younger people as the
>incidence of dystonic reactions is rather high. I tend only to give
>them to those who are very nauseated or have actually vomited.

I've never seen a dystonic reaction at any age after a single shot of
metoclopramide, and I routinely use it in everyone I give morphine to
(irrespective of age or sex). That's not evidence, but it is my
experince. I await the list's combined anecdotal evidence to the
contrary with fevered anticipation.

The BNF/data sheet states that dystonia is more likely in young females,
but doesn't go so far as saying its contra-indicated for this reason.
One of the "allowed" indications for metoclopramide in the young is as a
"pre-med" (to increase gastric emptying). I have always taken the view
that the cautions in the data sheet etc. are aimed mainly at disuading
regular dosing of metoclopramide in the young, and quite rightly too.
Personally I think the potential benefits of reducing the risk of
aspiration related to an urgent GA for, say a kinky wrist #, outweigh
the small risk of dystonia which, though unpleasant, is not life-
threatening, is easily and quickly reversed and is pretty rare (I
reckon) after a single dose. That's quite apart from the humanitarian
aspect of reducing nausea and vomiting, whether induced by pain or
morphine.

If the kid still needed morphine on the ward later, I would be very
reluctant to continue metoclopramide. I think our kids ward uses
domperidone supposotries, if needed.

Any one got any hard facts (to educate my clinical impression) on:
1) incidence of vomiting post-morpine in kids
2)      "       "       "       "       "     if given anti-emetic too
3)      "       dytonic reactions after 1 dose of metoclopramide.

===========================================================================
Goat
(e-mail: [log in to unmask])
Sussex, U.K.
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To err is human, to forgive is not management policy
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