Pain Relief

Question 1

1. When is Fentanyl preferred to Morphine?

Answer 1

1. C/I to morphine
2. Short duration of action desirable
3. Hypotension
4. N/V
5. Severe headache

Question 2

2. Rx for Mild pain?

Answer 2

1000mg Paracetamol or 500mg for <60kg, frail, elderly, malnourished or liver disease

Question 3

3. Rx for Moderate pain?

Answer 3

• Morphine up to 5mg, repeat at 5min intervals, consult after 20mg
• OR Fentanyl up to 50mcg, repeat at 5min intervals, consult after 200mcg

IV access delayed, not required or unsuccessful:

• IN Fentanyl 200mcg, repeat up to 50mcg at 5mins, max 400mcg; 100mcg for weight <60kg, frail/elderly, repeat up to 50mcg at 5mins, max 200mcg
• IN Ketamine: 75mg, repeat 50mg @20mins, no max dose; or 50mg (<60kg/frail/elderly), repeat 25mg @20mins, no max dose

All pt unless C/I - Paracetamol

IN Ketamine - if min response to opioids
IM Morphine - if opioid not already administered

• Methoxy 3mL, repeat 3mL if required (max 6mL)

Question 4

4. Rx for Severe pain?

Answer 4

• First line: Morphine or Fentanyl IV and Ketamine IN - 3-5mins between medication to assess effectiveness - Consult for Ketamine IV if pain remains severe following 2-3 doses
• Second line: Fentanyl IN, Methoxy, Morphine IM 10mg IM (if opioid not already administered), repeat 5mg after 15mins (once) or 0.1mg/kg (single dose) for weight <60kg, frail/elderly

Question 5

5. When is Prochlorperazine not to be used in Headache guideline?

Answer 5

Unlikely to offer clinical benefit for intracranial haemorrhage or SAH - many patients will have signs of CNS depression

Question 6

6. What are the warning signs of intracranial pathology - headache?

Answer 6

Thunderclap headache - increases intensity within seconds to mins of onset

1. Abnormal neurological findings or atypical aura
2. New onset headache in older patients (age >50) or those with Hx of Cancer
3. Altered LOC or collapse
4. Seizure activity
5. Fever and or neck stiffness

Question 7

7. Rx for Cluster headaches?

Answer 7

High flow oxygen if pt can confirm their diagnosis

Question 8

8. What is the Rx for Headache of any severity?

Answer 8

• Paracetamol 1000mg or 500mg for <60kg/elderly/frail, malnourished or liver disease
  With or Without
• Prochlorperazine 12.5mg IM (pt≥21)
  If after 15mins headache remains severe, and Tx remains >15mins, treat with IV or IN or IM Fentanyl to reduce pain to <7

Question 9

9. What is the pain relief consideration for Cardiac chest pain?

Answer 9

• Ketamine not to be administered for chest pain in suspected ACS
• IN Fentanyl can be used when no IV access, otherwise IM Morphine or Fentanyl

Question 10

10. Ketamine considerations:

Answer 10

• Use with caution for pt with Hx of anxiety/psychosis
• Use with caution for adolescent, elderly and frail
• Effective for non-traumatic pain such as renal colic
• Ketamine IM using IV dose may be considered where IV and IN route not available
• All IN doses require an additional 0.1mL to account for atomiser dead space