Pain Management Strategies for Jugular Bulb Dehiscence Using Midazolam and Morphine in Resource-Limited Primary Emergency Services: A Case Report and Literature Review

Introduction: Jugular bulb dehiscence (JBD) is a rare otologic condition causing severe acute pain that typically requires specialized management. In resource-limited settings, primary emergency services face significant challenges managing such cases without immediate access to tertiary care facilities or otolaryngology specialists.  Objective: To describe a sedoanalgesia protocol using midazolam and morphine for acute pain management in JBD in primary emergency services with limited resources.  Methods: Clinical case of a 32-year-old woman with left JBD confirmed by CT, presenting with sudden hemicrania headache (VAS 9/10) and self-limited ipsilateral otorrhagia. The patient had primary adrenal insufficiency and history of PSVT treated with ablation. A protocol was implemented including hydrocortisone 100 mg IV, midazolam 5 mg IV and morphine 10 mg IV fractionated over 120 minutes, with continuous monitoring. Pain reduction, adverse events, hemodynamic stability, and sedation level were evaluated.  Results: The patient experienced gradual pain reduction (VAS: 9/10 to 2/10) over 120 minutes, without adverse events. Vital signs remained stable (initial HR 108 bpm, final 85 bpm; BP maintained within normal ranges; SpO2 >96%). No episodes of PSVT, hypotension, nausea, or vomiting were recorded. The patient was discharged with deferred referral to otorhinolaryngology.  Discussion: This case demonstrates that complex otologic emergencies can be effectively managed in resource-limited settings with careful patient selection, appropriate monitoring, and standardized protocols. The midazolam-morphine combination provided both anxiolysis and analgesia, addressing the multifactorial nature of pain in JBD.  Conclusions: The midazolam-morphine combination proved effective and safe for acute JBD pain management in emergency settings with limited resources, even in a patient with complex comorbidities. This approach provides a viable alternative when immediate tertiary care is unavailable. Studies with larger samples are needed to validate these findings.