Pain, Procedural Sedation and RSI

Question 1

What is the average amount of IV morphine needed to relieve a patient’s pain?

Answer 1

-10 mg to control an average patient’s pain (correct for age, weight, drug abusers)
(Nurses don’t like to give 10 mg at one time, they usually do 2mg, so it’s not necessarily the best choice).

Question 2

What is the equivalent dose of Dilaudid compared to Morphine?

Answer 2

Dilaudid 1 mg = 8 mg Morphine = 4 hour duration

Question 3

What is the equivalent dose of Fentanyl compared to Morphine? When should you use it?

Answer 3

Fentanyl 100 μg = 10 mg Morphine = 35 min duration (short-acting)
• Used for pain that you don’t know the cause of.
• Once pain source is clear, use longer acting med for control

Question 4

How do you know how much to give (what do you want pain level to be)?

Answer 4

Titrate pain level to 0 to 3

Question 5

What should you use for children to speed time to pain relief?

Answer 5

Intranasal (IN) fentanyl.
• Use 1.5 microgram/kg for children 1-15 years presenting with acute pain
• Time cut from 60 min for IV morphine to 30 min for IN fentanyl

Question 6

What is Procedural Sedation (formerly known as conscious sedation)?

Answer 6

Used for any painful procedure (dislocation reduction, complex lacerations, painful abscesses, chest tube placement, cardioversion)

Question 7

What drugs should you use for procedural sedation? Give some examples.

Answer 7

Pain meds and amnesiacs (don’t want to remember procedure).
• Analgesic (fentanyl) + benzodiazepine (midazolam, Ativan)
• Ketamine (solo agent) = pain reduction + amnesia (May use in combo w/ propofol (i.e. ketofol))

Question 8

What is Rapid Sequence Intubation (RSI)?

Answer 8

Used to paralyze a conscious person to allow easier intubation of the trachea and securing the airway.
• Paralyze patient to allow for better visualization and easier passage of tube through the vocal cords
o Render patient amnesic (no recall) – patient won’t want to remember being paralyzed

Question 9

What drugs can be used for RSI?

Answer 9

Anxiolytic/sedative (no recall) drugs (use any of these three):

1. Etimodate 0.3mg/kg IV (may suppress adrenal gland function)
2. Propofol 2mg/kg IV (may induce hypotension, so use ½ dose in elderly) (milk of amnesia)
3. Ketamine 2mg/kg IV if dealing with sepsis or hypotension

Paralytic drugs (Neuromuscular blocking agents):

1. Succinylcholine 1.5-2.0mg/kg IV
2. Rocuronium 1 mg/kg IV (lasts 30 min, competes with ACh for receptors, nondepolarizing agent) – possible allergic rxn.

Question 10

What paralytic agent is associated with malignant hyperthermia? What is the antidote? What other SE does it have?

Answer 10

Succinylcholine!
(Depolarizing agent, lasts 2-10 minutes)
***Do not use with neuromuscular disorders, beware malignant hyperthermia – rapid rise in temperature {treat with dantroline})
SE: may increase K → arrhthymia; avoid in renal failure, crush injuries, burns, eye trauma.