Pain Relief CPG Flashcards
Care Objective Pain Relief CPG
To reduce the suffering associated with pain to a comfortable level
What is the preferred mode of analgesia? What does this mean?
Multimodal. It means giving smaller amounts of different drugs instead of a larger does of one to achieve better pain relief.
How do we determine the adequacy of analgesia?
Communication and conformation from the patient that their pain is under control. Assessing the signs and symptoms of pain can also be considered.
If a patient remains in pain, what should ALS paramedics do?
If max doses have been given the paramedic should consult with the clinician for further doses of pain medications.
If there is IV access and a patient in moderate pain what is the preferred combination of medications?
IV opioids and paracetamol
What is the preferred method of pain relief in elderly/frail patients and why?
IV route over the IN route as IN provides a more variable result in this population
IN can still be considered to extradite time to first dose or if IV access is unsuccessful or unavailable
When is IN ketamine/Fentanyl the preferred pain management approach for moderate pain?
IV access is non-available or not required
IV access is delayed or unsuccessful
When is IN ketamine the preferred approach to moderate pain?
IN Ketamine if first line opioids have little affect
IN ketamine is the preferred approach if the patient is tolerate to opioids, declines them or they are contraindicated
When should oral paracetamol be administered?
Always in conjunction with other pain medications if it is not contraindicated and the patient isn’t likely to need immediate or emergency surgery.
If a patient has moderate pain, when can you give IM morphine?
if IN fentanyl and ketamine are non-effective or contraindicated and you can’t gain IV access
When should methoxyflurane be used?
Preferred for procedural pain
As a their line pain management option
In conjunction with other pain management to optimise pain relief
What is there preferred approach to serve pain?
IV opioids and ketamin IN
There is no need to give only opioids first. Ideally wait 2-5 minutes to watch for patient reaction.
When can IV ketamine be used?
MICA- in preference to IN
ALS- after consult if initial IN is not adequate
What is moderate Procedural pain?
Pain due to splinting and reducing fractures, difficult egress and moving to stretcher
What is severe procedural pain?
Prolonged extraction or manipulation of severe musculoskeletal injury
What pain relief is suitable for cardiac chest pain?
IV opioids
IN fentanyl if IV unavailable
Morphine or Fentanyl IM if IV/IN not available with or without Methoxyflurane
When is fentanyl preferred to morphine?
Hypotension Respiratory depression Morphine contraindicated Short duration desirable Nausea/Vomiting Sevre Headache
Why should caution be taken if admin of ketamine to elderly/frail patients and adolescents?
There is greater side effects potential
Use IN fentanyl preferentially
Why should care be taken when administering ketamine to patients with a history of anxiety/psychosis?
Due to potential side effects
What populations should receive ketamine with extra caution?
- Elderly/frail patients
- Adolescents
- Pt with an Anxiety or psychosis history
How are side effects from medications managed?
Respiratory depression from opioids- IV naloxone
Hyper salivation from ketamine- Suction or MICA atropine
Emergence reactions- Midazolam
What is the mild pain action?
Paracetamol
What is the First line action for moderate pain?
IV access: Opioids
No IV access or delayed: IN fentanyl or ketamine
All: Paracetamol unless contraindicated
What is the second line action for moderate pain?
Ketamine IN
Morphine IM
what is the third line pain relief for moderate pain?
Methoxyflurane
What is the First line action for severe pain?
IV access:
Morphine or fentanyl IV and Ketamine IN after 2-3 does ketamine consult for IV
What is the second line action for severe pain?
IV access unsuccessful or delayed: Fentynal IN Ketamine IN Morphine IM Methoxyflurane
Paracetamol Dose
1000mg
Elderly/frail/<60kg 500mg
Methoxyflurane Doses
3ml repeat 3ml for max 6ml
Fentanyl doses
IV: 50mcg repeat at 5/60min consult after 200mcg
IN: 200mcg repeat 50mcg at 5/60 for a max of 400mcg or Elderly/frail 100mcg repeat at 5/60 for a max of 200 mcg
IM: 100mcg repeat 50mcg at 15/60 once or Elderly/frail 1mcg/kg single dose
Morphine Doses
IV 5mg repeat at 5/60 consult after 20mg
IM 10mg repeat 5mg at 15/60 once or Elderly/frail 0.1mg/kg single dose
Ketamine doses?
IN: 75 mg repeat 50mg @ 20/60 no max or Elder/frail 50mg repeat 25mg @ 20/60 no max dose
IV: Consult
can Ketamine be given IM?
Yes if IV and IN ketamine are unavailable or not adequate
What is the optimum volume for IN ketamine absorption? How you you achieve this?
0.3-0.5 millimetres is optimal, it might be good to consider doing a half dose in each nostril to obtain maximum affect
