Pain Management Flashcards
Acetaminophen (Tylenol, APAP)
Class
Analgesic, Antipyretic
•Mechanism of Action
Inhibits prostaglandin E2 (PGE2)
Acts on a variant of the COX III enzyme- no effect on platelets
Elevates pain threshold
Readjusts the hypothalamic temperature regulatory center
No effect on inflammation so not classified as an NSAID
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Acetaminophen (Tylenol, APAP)
•Indications
Mild to moderate pain
Fever
•Contraindications
Hypersensitivity
Environmental Hyperthermia
Acetaminophen (Tylenol, APAP)
•Drug Precautions
1. Acetaminophen should be used with caution in patients with liver disease/failure.
2. The maximum adult daily dose of acetaminophen is 4,000 mg.
•Adverse Effects
1. Nausea/vomiting
2. Stevens-Johnson Syndrome (rare) –flu-like symptoms, rash, blisters
3. Toxic epidermal necrolysis (rare) –life-threatening skin disorder with blisters
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RI OEMS Protocols
•Dose and Administration
•2.07 Patient Comfort
For mild to moderate pain (scale of 1-6)
500- 1000 mg IV
Pediatric: For minor to moderate pain (scale of 1-6)
15 mg/kg IV (1000 mg max single dose)
RI OEMS Protocols
•2.15 Fever
Ketorolac tromethamine (Toradol)
Class
Non-steroidal Anti-inflammatory
•Mechanism of Action
Inhibits COX (cyclogenase) enzyme which is responsible for converting arachidonic acid into prostaglandin
Ketorolac tromethamine (Toradol)
Prostaglandins
1. Modulator of inflammation
2. Play a role in thermoregulation
3. Play a role in pain transmission
4. Play a role in platelet aggregation
5. Cause afferent arteriole dilation (without it GFR decreases)
Ketorolac tromethamine (Toradol)
•Indications
Mild to moderate pain
•Contraindications
Hypersensitivity or allergy to NSIADS
Asthma Renal Insufficiency Peptic Ulcer/Gi Bleeding
Pregnancy Hypovolemia Expected surgery (7 days)
Trauma (other than local extremity)
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Ketorolac tromethamine (Toradol)
•Side Effects
GI Bleeding Nausea/Vomiting Headache Drowsiness
Abdominal Pain Dyspepsia Diarrhea
•Special Considerations
Is not indicated for the treatment of abdominal or chest pain
Is not used for its antipyretic properties
Reduce dose by 50% for ages 65 and above due to the incidence of renal disease
Ketorolac tromethamine (Toradol)
•Dose
Adult- For mild to moderate pain (1-6 on pain scale)
15 mg IVP or 30 mg IM
Pedi- For mild to moderate pain (1-6 on pain scale)
.5 mg/kg IV/IM (Max 30 mg)
RI OEMS Protocols
•2.07 Patient Comfort
Morphine Sulfate
Class: Opioid
Made from the unripened seed capsules of the opium poppy
Morphine Sulfate
•Pharmacodynamics
Binds to opioid receptors that cause the blocking of nerve signals
from nociceptors to the spinal cord
Like other opioids, Morphine inhibits negative emotional response to pain and stimulates feeling of pleasure
Morphine Sulfate
•Indications
Pain Management
Sedation for cardioversion
Traumatic injuries (caution with burns)
ACS
•Contraindications
Known allergy to morphine
Bronchial asthma or upper airway obstruction
Respiratory depression in absence of resuscitative
equipment
Paralytic Ilieu (small intestine paralysis)
Morphine Sulfate
•Adverse reactions
Respiratory Depression -Inhibition of brain stem H+ receptors can induce apnea and lead to death
Dizziness, Nausea, Vomiting, and Constipation
•Special Considerations
Patient’s recovering from opioid addiction may refuse for fear of relapse (other pain management is available)
Do not have a false sense of security in thinking that the administration of naloxone can reverse the respiratory depression. It also takes away the pain relieving effect of the drug.
Morphine Sulfate
•Fentanyl is more potent but has an efficiency graph like morphine
Morphine Sulfate
•Drug Interactions
Cumulative with other opioids
•How Supplied
Varies: Usually 10mg/ml syringes/vials/ampules
Morphine Sulfate
•Dose
Adult: .1 mg/kg max 10mg
Pedi: .1 mg/kg max 5mg
RI OEMS Protocols
Ketamine (Ketalar)
Class: Dissociative Anesthetic
Pharmacodynamics: Blocks the N-methyl-D-aspartate (NMDA) receptor
on sensory neurons in dorsal horn (spinal cord)
Inhibits somatosensory processing of somatic pain
Dissociation effects resemble schizophrenia
Causes amnesia
Ketamine (Ketalar)
•Indications
Pain management
Chemical restraint for excited delirium
Sedation for cardioversion/intubation
• Contraindications
Hypersensitivity
Caution in eye injuries as it can increase interocular pressure
May increase myocardial oxygen demand
Ketamine (Ketalar)
•Adverse reactions
Emergence reaction- As higher doses wear off, hallucinations may occur
Laryngeal spasm (very rare)
•Drug Interactions
Increases responsiveness of opioid receptors without respiratory depression. Can be use alone or in conjunction with opioids
Ketamine (Ketalar)
•Dose and Administration
Adult Pain Control .3-.5 mg/kg IV/IO slow, may repeat 1x in 10 min or 1mg/kg IM/IN, may repeat 1x in 20 min
Adult Psych 4mg/kg IM max 400 mg IM
Pedi- Can be used but no protocol supports this (yet)
Ketamine (Ketalar)
•Duration of Action
Onset: Dissociation immediate
Duration: Short term depending on dose (good for EMS)
•Special Considerations
Good alternative to opioids especially with patients who have a hx of abuse
Known as “Vitamin K” on the street
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RI OEMS Protocols
•2.07 Patient Comfort
For severe pain (scale >6): 0.2 to 0.5 mg/kg IV or 0.5 to 1.0 mg/kg IM/IN (may repeat IV dosing x1 in 10 minutes and IM/IN dosing x1 in 30 minutes)
For patients requiring electrical therapy (cardioversion or pacing) or other procedure requiring sedation: 0.5-1 mg/kg IV or 2mg/Kg IM (must have continuous quantitative waveform capnography in place).
RI OEMS Protocols
•2.25 Excited Delirium
Ibuprofen (Advil, Motrin)
Class
Non-steroidal anti-inflammatory
•Mechanism of Action
Ibuprofen is a non-steroidal anti-inflammatory agent (NSAID) with analgesic effects, antiinflammatory, and antipyretic effects. NSAIDs are thought to exert their effects by inhibiting prostaglandin synthesis by inhibiting the cyclooxygenase (COX) enzyme, which catalyzes the conversion of arachidonic acid to prostaglandin and endoperoxide. Prostaglandins are a modulator of inflammation and are also involved in thermoregulation, pain transmission, and platelet aggregation. Ibuprofen should be avoided in patients with chronic kidney disease due to the risk of renal injury.
Ibuprofen (Advil, Motrin)
•Indications
Mild to moderate pain
Fever
•Contraindications
1. Known hypersensitivity
2. Allergy to any NSAID (including aspirin)
3. Asthma
4. Renal insufficiency
5. Peptic ulcer disease or GI bleeding
6. Pregnancy
7. Hypovolemia
8. Trauma other than isolated extremity trauma
9. Anticipated major surgery (within 7 days)
Ibuprofen (Advil, Motrin)
•Possible Side Effects
1. GI bleeding
2. Nausea/vomiting
3. Headache
4. Drowsiness
5. Abdominal pain
6. Dyspepsia (Upset stomach)
7. Diarrhea
Ibuprofen (Advil, Motrin)
•Duration of Action
•Special Considerations
Not indicated for the treatment of abdominal pain
RI OEMS Protocols
•2.07 Patient Comfort
For mild to moderate pain (scale of 1-6), consider: 10 mg/kg (typical adult 400-800 mg) PO
Pediatric: For mild to moderate pain (scale of 1-6), consider: 10 mg/kg (800 mg max) PO
RI OEMS Protocols
•2.15 Fever
If acetaminophen has been taken/administered in the last 4 hours and the body temperature is ≥ 100.4°F / 38°C, administer IBUPROFEN 400-800 mg PO.
Pediatric: • If acetaminophen has been taken/administered in the last 4 hours and the body temperature is ≥ 100.4°F / 38°C, administer IBUPROFEN 10 mg/kg PO (800 mg max) if patient is ≥6 months of age.
Naloxone (Narcan)
Class
Narcotic antagonist
•Mechanism of Action
Competitive inhibition at narcotic receptor sites
Reverse respiratory depression secondary to
depressant drugs
Completely inhibits the effect of opioids
Naloxone (Narcan)
•Indications
Opiate overdose
Coma
Complete or partial reversal of CNS and respiratory depression induced by opioids
Narcotic agonist
Morphine, heroin, hydromorphone (Dilaudid), methadone, Meperidine (Demerol), Paregoric, Fentanyl (Sublimase) Oxycodone (Percodan), codeine, propoxyphene (Darvon)
Narcotic agonist and antagonist
Butorphanol (Stadol) Pentazocine (Talwin)Nalbuphine (Nubain)
Decreased level of consciousness
Naloxone (Narcan)
•Contraindications
Use with caution in narcotic-dependent patients
Use with caution in neonates of narcotic-addicted
mothers
•Adverse Reactions
Withdrawal symptoms in the addicted patient
Tachycardia
Hypertension
Dysrhythmias
Nausea
Vomiting
Diaphoresis
Naloxone (Narcan)
•Drug Interactions
Incompatible with bisulfite and alkaline solutions
•How Supplied
0.02 mg/ml (neonate); 0.4 mg/ml, 1 mg/ml ; 2.0 mg/5
ml ampules; 2 mg/5 ml prefilled syringe
Naloxone (Narcan)
•Dosage and Administration
Adult: 0.4 - 2.0 mg IV, IM, SC, or ET (diluted); min.
recommended = 2.0 mg.; repeat at 5 minute
intervals to 10 mg maximum dose. (Medical
Control may request higher amounts). Infusion: 2
mg in 500 ml of D5W (4 mcg/ml), infuse at
0.4 mg / hr (100 ml/hour).
Pediatric: 0.1 mg/kg dose IV, IM, SC, ET (diluted);
maximum of 0.8 mg; if no response in 10
minutes, administer an additional 0.1 mg/kg
dose.
Naloxone (Narcan)
•Duration of Action
Onset: within 2 minutes
Peak effect: variable
Duration: 30-60 minutes
•Special Considerations
Pregnancy safety: Category B
Seizures without causal relationship have been
reported
Use caution when administering to narcotic addicts
(violent behavior, etc.)
Goal of administration is to regain respiratory drive
RI OEMS Protocols
•4.18 Toxicological Emergencies
For suspected opioid overdose, if NALOXONE has not been administered or if additive doses are required, administer NALOXONE 2 mg IN or 0.4 mg IV/IM every 3-5 minutes until adequate ventilation is restored or 10 mg is administered
RI OEMS Protocols
