Sedation and Pain Management

Question 1

Adverse reactions to Ketamine

Answer 1

▪ Hypersalivation: Administer ATROPINE 0.5mg IV/IM/IO.
▪ Laryngospasm (Stridor): Try the following interventions in the order of: High flow O2, BVM, rapid sequence intubation.
o Laryngospasm is uncommon and is usually selflimiting. It almost always resolves with high flow O2 or brief ventilation via BVM.

Question 2

Important management after Ketamine administration

Answer 2

▪ Continuously monitor and maintain patient’s SpO2 at 95 % and EtCO2 between
35-45mmHg.
▪ Obtain IV access.

Question 3

When and how do you cool a patient in need of chemical sedation?

Answer 3

TEMPERATURE OF GREATER THAN 103 DEGREES F
▪ Apply ice packs to axilla and groin area.
▪ COLD NORMAL SALINE: (If available) 1L NS IV/IO, assess lung sounds and blood
pressure every 500mL. Maximum 2L.
▪ SODIUM BICARBONATE 50 mEq IV/IO, each amp administered slow over 2
minutes

Question 4

Special Consideration for Ketamine

Answer 4

** FOR THESE PATIENTS GIVE 200 MG IM KETAMINE
▪ Over 65 years of age
▪ Head trauma
▪ <50 kg
▪ Other sedatives on board (Benzodiazepines or alcohol)
May repeat 3 x prn in 5 min intervals to gain control of the patient

Question 5

Chemical Sedation Procedure

Answer 5

▪ The decision to use Ketamine is the sole discretion of Fire Rescue personnel
based on strict adherence to protocol
▪ KETAMINE: 200-400mg IM. May repeat 1x prn. Max single dose 400mg.
▪ Allow patient to hyperventilate.
▪ Do not hold the patient in a prone position or allow the patient to be handcuffed
with hands behind back.
▪ Once calm, physical restraints may be unnecessary, but may be used as an added
precaution.

Question 6

Management after Ketamine administration

Answer 6

▪ Continuously monitor and maintain patient’s SpO2 at 95% OR GREATER and
EtCO2 between 35-45mmHg.
▪ Obtain IV/IO access.
▪ Repeat DOSE OF KETAMINE as needed to treat Excited Delerium
▪ BE PREPARED FOR RESPIRATORY DEPRESSION AND HYPOTENSION.
▪ Obtain and document a temperature early into treatment and monitor the temperature throughout transfer of care.

Question 7

Pain Management Information

Answer 7

When administering pain medications continuously monitor the ECG. Maintain the SpO2 at 95 % and the EtCO2 between 35-45 mmHg. Monitor patient’s blood pressure and respirations prior to and after administering Fentanyl and/or Ketamine. Pain management can be administered to all patients complaining of pain with the exception of pregnant women near term (32 weeks or greater) or in active labor.

Question 8

Adult Pain Management

Answer 8

▪ Fentanyl is the front-line medication for pain; however, Ketamine is preferred for
hypotensive patients or patients who have opiate contraindications (allergy, history of abuse, etc.)
FENTANYL: 100mcg slow IV/IO/ IM/IN. May repeat once AFTER 5 minutes prn. Max total dose 200mcg.
o Monitor patient for respiratory depression.
o Discontinue if patient becomes drowsy.
o To reverse respiratory depression or chest wall rigidity: NARCAN -as per protocol
o Administer Zofran 4mg for treatment of nausea and vomiting secondary to Fentanyl.
▪ ZOFRAN: 4mg IM, or slow IV/IO/PO over 2 minutes prn nausea/vomiting secondary to Fentanyl administration. Max dose 4mg.
FOR CONTINUED PAIN MANAGEMENT
>12 YEARS OLD
▪ Ketamine should be given after Fentanyl max dose for severe pain.
▪ KETAMINE: 25 MG IV/IO/IM. May repeat 2x every 5 minutes prn. Max total dose 75mg..

Question 9

IO infusion Pain Management

Answer 9

LIDOCAINE: 40mg IO over one minute (FOR PT GREATER THAN 20KG). Allow
Lidocaine to dwell in IO space for one minute and flush with NORMAL SALINE 10mL.
May administer additional LIDOCAINE: 20 mg IO over one minute prn.
Morphine Sulfate: (Secondary – if primary is on back order): 4mg IV/IO/IN/IM. May
repeat 1x prn.

Question 10

Pediatric Pain Management

Answer 10

▪ FENTANYL: 1mcg/kg slow IV/IO OVER 2 MIN May repeat every 5 mins prn.
Max single dose 100mcg. Max total dose 200mcg.
▪ FENTANYL: 1.5mcg/kg IN/IM. May repeat every 5 mins prn. Max single dose
100mcg. Max total dose 200mcg.
▪ ZOFRAN: 0.1mg/kg, IM, or slow IV/IO/PO over 2 minutes prn nausea/vomiting
secondary to Fentanyl administration. Max dose 4mg.
o Monitor patient for respiratory depression.
o Discontinue if patient becomes drowsy.
o Contraindicated in age-appropriate hypotension.
o To reverse respiratory depression or chest wall rigidity, administer NARCAN
0.5mg IV/IO/IM or 1mg IN every 2-3 minutes prn. Max total dose 2mg.