Safety and Efficacy of Rapid Titration Using 1 mg Doses of Intravenous Hydromorphone in Emergency Department Patients with Acute Severe Pain: The “1+1” Protocol[1]

Robert Kerr


AccessMedicine from McGraw-Hill 


The vast majority of patients seeking emergent medical attention do so for pain related complaints. A significant portion of these complaints are of a moderate to severe nature often necessitating use of opioid analgesics. Unfortunately oligoanesthesia remains a significant concern despite well-known studies showing pervasive under treatment of patient’s pain complaints in the emergency department setting.[2,3] There are numerous reasons for this. Underestimation of level of pain, concerns about over medicating,[4] delayed communication to physician of patient’s pain status, and concerns about drug seeking to list a few. Establishment of safe, effective, rapid, analgesic administration protocols, similar to the protocol evaluated in this study, have the potential to remove at least some of these barriers to obtaining adequate pain relief for patients in emergency departments.


Two hundred and thirty patients were enrolled in a prospective interventional cohort study. Enrollee’s were adult patients with acute pain (< 7 days duration) warranting intravenous opioid medication. Patients were provided an initial intravenous dose of 1 mg hydromorphone. Fifteen minutes later they were reassessed and offered an additional 1 mg dose, with subsequent reassessment of need for additional pain medication at 1 hour. Primary end point was elimination of need for further analgesic at the 15 minute or 1 hour assessment.


Two hundred and thirty patients met criteria for inclusion. Complete data to allow analysis was collected on 223 of these patients. Of these 172 (77%) did not desire additional medication at 15 minutes. Forty-four of the remaining 51 patients received an additional 1 mg of intravenous hydromorphone. At the subsequent 1-hour assessment, only 9 (4%) patients still desired additional analgesics.

Adverse affect profile showed 11/179 (6%) experienced oxygen desaturation <95% with 3/179 (2%) patients experiencing desaturation < 90. No patient required naloxone or assisted ventilation. 16/175 (9%) of patients experienced bradycardia(heart rate less < 50). All of these had heart rates of less than 60 prior to treatment.

Relevance to Emergency Medicine

The study does show that a rapid intravenous hydromorphone protocol can be safe and effective. However, lack of a matched controlled limb, utilizing routine treatment, does not address whether the rapid “1+1” protocol is superior to routine treatment. The study end point of patient’s perception of need for additional medication does make the study applicable to the real world emergency department setting. This study, hopefully, will encourage ED departments to establish similar type rapid intravenous opiate analgesia protocols, which would lower the barrier of tentative dosing for fear of respiratory compromise and allow rapid fixed time reassessment (and, if necessary, re-dosing), which would expedite analgesia.


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