Analgesia and Nausea Vomiting Flashcards
Analgesia Medical Directive
What are the INDICATIONS?
How can we interpret pain? Types of pain
Pain
Nociceptive Pain - Typically the result of tissue injury
Inflammatory Pain - An abnormal inflammation caused by an inappropriate response by the body’s immune system
Neuropathic Pain - Pain caused by nerve irritation
Functional Pain - Pain without obvious origin, but can cause pain
Analgesia Medical Directive
What is Acetaminophen? + Generic Name
What is Ibuprofen? + Generic Name
Drug to treat mild to moderate pain, commonly known for its analgesic and antipyretic effects - acetaminophen does not disrupt or inhibit platelet aggregation.
Tylenol
NSAID – non-steroidal anti-inflammatory drug, shown to
have properties for management of pain (analgesia), fever (antipyretic), and inflammation (anti-inflammatory)
Advil
Analgesia Medical Directive
What is Ketorolac? + Generic Name
An non-selective blocker of prostaglandin synthesis NSAID that’s used to treat moderate pain
Toradol
Analgesia Medical Directive
What are the CONDITIONS for Acetaminophen?
Why is liver disease important?
What are the CONTRAINDICATIONS?
≥ 12 years
Unaltered
it’s metabolized in the liver i.e. disease implies poor metbolization
Allergy or sensitivity to acetaminophen
Acetaminophen use within previous 4 hours
Hx of liver disease
Active vomiting
Unable to tolerate oral medication
Suspected ischemic chest pain
Analgesia Medical Directive
Why is 4h important as a contraindication for acetaminophen?
Because it’s dosing interval is 4-6 hours - all of the receptors are occupied
Analgesia Medical Directive
What are the CONDITIONS for Ibuprofen?
What are the CONTRAINDICATIONS?
≥ 12 years
Unaltered
Allergy or sensitivity to ASA or NSAIDs
NSAID use within previous 6 hours
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Active vomiting
Unable to tolerate oral medication
Suspected ischemic chest pain
Analgesia Medical Directive
What would happen if the patient were on anticoagulation medication/therapy and you were thinking of giving ibuprofen?
Why is 6h important as a contraindication for ibuprofen?
Why is pregnancy relevant?
Don’t give it because it’s known to slow down blood clotting which would cause further complications.
Because it’s dosing interval is 6-8hours
Ibuprofen can pass the placental barrier and is excreted in breast milk which can be toxic for the fetus
Analgesia Medical Directive
Why is renal impairment important as a contraindication for ibuprofen?
Ibuprofen is removed by the kidneys i.e. impairment would result in a buildup of the medication in the body
Analgesia Medical Directive
What are the CONDITIONS for Ketorolac?
What are the CONTRAINDICATIONS?
≥ 12 years
Unaltered
Normotension
Allergy or sensitivity to ASA or NSAIDs
NSAID use within previous 6 hours
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Suspected ischemic chest pain
Analgesia Medical Directive
Why is normotension a condition for ketorolac?
How should you administer it?
Why is hx of peptic ulcer disease or GI bleed a contraindication?
becasue administration can cause severe reboud bradycardia - BUT hypertension is more common
You should push slowly
because the medication can be hard on the tissue that lines the stomach (already not good if theres a hx of peptic ulcer disease or GI bleed)
Analgesia Medical Directive
What is the ROUTE, and TREATMENT PLAN for Acetaminophen for a pt who is ≥12 years to < 18 years?
What is the ROUTE, and TREATMENT PLAN for Acetaminophen for a pt who is ≥ 18 years?
ROUTE - PO
Dose - 500-650mg
Max. Single Dose - 650mg
Dosing Interval - N/A
Max # of Doses - 1
ROUTE - PO
Dose - 960 - 1,000mg
Max. Single Dose - 1,000mg
Dosing Interval - N/A
Max # of Doses - 1
Analgesia Medical Directive
What is the ROUTE, and TREATMENT PLAN for Ibuprofen?
ROUTE - PO
Dose - 400mg
Max. Single Dose - 400mg
Dosing Interval - N/A
Max # of Doses - 1
Analgesia Medical Directive
What is the ROUTE(s), and TREATMENT PLAN for Ketorolac?
The vial is supplied in 30mg/1mL
How much volume will you need to draw up if you’re looking to give 10mg? AND 15mg?
ROUTE - IM/IV
Dose - 10 – 15 mg
Max. Single Dose - 15 mg
Dosing Interval - N/A
Max # of Doses - 1
.333mL AND .5mL
Analgesia Medical Directive - clinical considerations
Can you administer more than one pain medication at the same time?
IV in this directive means what?
What should suspected renal colic patients be considered for?
Yes, try to co-administer acetaminophen and ibuprofen (but not ibuprofen and ketorolac)
only to PCPs authorized for PCP Autonomous IV can administer ketorolac
Ibuprofen and ketorolac
Analgesia Medical Directive
When would you go IV over IM?
Can ketorolac and ibuprofen be taken together?
In preperation for more the potential for more meds or fluid therapy
NO - they have similar effects and targeted receptors therefore toxic buildup and/or increased adverse effects will occur
Analgesia Medical Directive
Can we make clinical judgements on which pain medication to give the patient?
Compare oral administraion to parental
The 1st line analgesia for patients who can tolerate oral administration are?
Yes - it’s encouraged
Oral is as effective and is less invasive than parenteral analgesia
Acetaminophen and ibuprofen
Analgesia Medical Directive
Why should suspected renal colic patients be routinely considered for NSAIDS?
i.e. ketorolac and ibuprofen
What is the only advantage of parenteral ketorolac over oral ibuprofen?
NSAIDS inhibit prostaglandin (cause chronic pain and inflammation when bulit up) production.
NSIADS also produce anti-inflammatory and smooth muscle relaxant effects that reduces the glomerular filtration rate which reduces renal pelvic pressure and stimulation of the stretch receptors therefore reducing the pain
the ability to administer the NSAID despite vomiting (even if they’re vomiting)
Analgesia Medical Directive
Is an external trauma that has been dressed and controlled an active bleed?
Is occult bleeding considered active bleeding? i.e. hematuria/GI bleed
If the pt has suspected renal colic AND trace blood in the urine, is that considered active bleeding?
NO
YES
NO
Nausea/Vomiting Medical Directive
What are the INDICATIONS?
Nausea
OR
Vomiting
Nausea/Vomiting Medical Directive
What is Ondansetron (Zofran)?
What’s preferred meds for an elderly (65y) pt with nausea or vomiting?
What is Dimenhydrinate (gravol)?
An antiemetic that blocks the 5-HT3 serotonin receptors (in central AND peripheral NS) used to treat nausea/vomiting due to stimulation of the vagus nerve.
Ondansetron because dimenhydrinate causes confusion and somnolence/sleep
An antihistamine H1 receptor antagonist used to treat motion sickness, nausea, or vomiting and is known to have anticholinergic effects
Nausea/Vomiting Medical Directive
When do you consider ondansetron?
When do you consider dimenhyDRINATE?
chemotherapy, alcohol, cannabis, or illicit drug interaction causing nausea or vomiting
taking diphenhydrAMINE, anticholinergics or tricyclic
antidepressants (TCAs) causing nausea or vomiting
head trauma (less risk of ICP)
elderly patients
motion sickness or vertigo
upset stomach due to food ingestion
hyperemesis for a pregnant patient
best for people on SSRIs
avoid with head injuries (increases ICP)
Nausea/Vomiting Medical Directive
What are the CONDITIONS for Ondansetron?
What does the addition of Ondansetron allow us to use?
What are the CONTRAINDICATIONS?
≥ 25 kg
Unaltered LOA
our clinical judgment in terms of medication selection
Allergy to ondansetron
Prolonged QT syndrome (known to
patient)
Apomorphine use (used for parkinson’s - is a D2 dopamine agonist)
Nausea/Vomiting Medical Directive
Why is Apomorphine Contraindicated for ondansetron?
What patient population are you most likely to see Apomorphine usage in?
Is a 12-lead needed to assess for long-QT syndrome before administration of ondansetron?
It may precipitate profound hypertension
used for pts with Tremor, Huntington, Parkinson
No - because it should be known to the pt however if you were to look for it, you’d need a 12-lead to confirm, as 4-leads won’t show a long-QT
Nausea/Vomiting Medical Directive
What are the CONDITIONS for Dimenhydrinate?
What are the CONTRAINDICATIONS?
< 65 years old
≥ 25 kg
Unaltered LOA
Allergy or sensitivity to dimenhydrinate
OR other antihistamines
Overdose on antihistamines OR
anticholinergics OR tricyclic
antidepressants
Co-administration of diphenhydramine
Nausea/Vomiting Medical Directive
Why would this particular
overdose (TCA or anticholinergics) be relevant to dimenhydrinate administration?
AND
What does an anticholinergic overdose look like?
Why is co-administered with diphenhydrAMINE contraindicated?
they have similar effects and targeted receptors therefore toxic buildup and/or increased adverse effects will occur
Increased HR
Dry, hot, flushed
Altered mental staus
Dilated Pupils
the combined effect can lead to anticholinergic side effects, and over-sedation
Nausea/Vomiting Medical Directive
What is the WEIGHT, ROUTE, and TREATMENT PLAN for ondansetron?
ROUTE - PO
Dose - 4mg
Max. Single Dose - 4mg
Dosing Interval - N/A
Max # of Doses - 1
Nausea/Vomiting Medical Directive
What are the ROUTE(s), and the TREATMENT PLAN for a pt that is ≥25 kg to < 50 kg for dimenhydrinate?
IV in this directive means what?
What are the ROUTE(s), and the TREATMENT PLAN for a pt that is ≥ 50 kg for dimenhydrinate?
ROUTE - IV or IM
Dose - 25mg
Max. Single Dose - 25mg
Dosing Interval - N/A
Max # of Doses - 1
only to PCPs authorized for PCP Autonomous IV can
ROUTE - IV or IM
Dose - 50mg
Max. Single Dose - 50mg
Dosing Interval - N/A
Max # of Doses - 1
Nausea/Vomiting Medical Directive
How do you administer dimenhydrinate via the IV route?
Do you dilute IM medication before administering?
Can you co-administer Zofran and Gravol?
Dilute it with saline to facilitate a slower AND less painful administration.
Based on a supply of 50 mg in 1 ml, either dilution method of 5 mg/ml (diluted with 9
ml of NaCl) or 10 mg/ml (diluted with 4 ml of NaCl) is acceptable.
NO!!
In either administration of medication, if the patient has no relief of their nausea & vomiting symptoms after 30min then you can administer the other medication - still in accordance with it’s conditions and contraindications
Nausea/Vomiting Medical Directive
Why is pregnancy risky but not a full contraindication for ondanstetron?
Can you give dimenhydrinate to pts ≥65?
Because it can pass the placental barrier and is excreted in breast milk
it’s still considered for pregnant pts in hyperemesis but dimenhydrinate is more likely than not the most approriate choice
only if ondansetron is not available
