Analgesia and Sedation

Section 2 - PRIMARY CARE

2.04 ANALGESIA/SEDATION

"THE BELOW MEDICATIONS MAY ALL CAUSE A DECREASED LOC AND COULD COMPROMISE A PATIENT’S AIRWAY. JUDICIOUS USE IS A MUST! ALLOW AMPLE TIME FOR EACH DOSE TO TAKE EFFECT PRIOR TO ANY ADDITIONAL DOSES BEING ADMINISTERED."

PAIN MANAGEMENT: Moderate to severe pain is an “Emergency Medical Condition”, which historically has been undertreated in EMS. Moderate to severe pain can be described as pain greater than or equal to 6 on the 0-10 pain scale. Pain management should target the two components of pain: physiologic pain, pain receptors and psychologic, anxiety, fear, etc. The treatment of pain and anxiety can be accomplished with narcotic analgesics and benzodiazepines in a safe and reversible manner. The maximal effects of a IV or IO dose of a analgesic or anxiolytic occurs within seconds, not minutes.

Considering the above, a logical approach to pain management in an average-sized adult would be to titrate IV Morphine up to 10 mg then titrate Valium or Versed up to 10 mg. Complications can be reversed by administering Narcan or Romazicon.

PROCEDURE:

• The numeric rating scale will be used to measure pain on all patients. The numeric rating scale ranges from 0 (no pain) to 10 (unbearable pain).
• Non-pharmaceutical (BLS) interventions such as: immobilization of fractures; elevation of extremities; ice packs and padding of spine boards and splints should be attempted first, then re-assess the patient.
• If the pain is still significant (6 or greater) and the patient does not have a contraindication then follow the guidelines below.
• Vital signs are to be taken before and after the administration of the medication. Appropriate documentation is expected.

ANGINA / MYOCARDIAL INFARCTION:

• MORPHINE SULFATE 2 - 20 mg IV or IN, titrated to effect.
• NOTE: MORPHINE SULFATE is the preferred treatment of choice, if allergic to MS continue to the following:
• NITROUS OXIDE self-administered as needed for pain.
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect
• TORADOL (KETOROLAC) in suspected Pericarditis: Adult: 30mg (IVP) or 60mg (IM), > 65 or renal impairment: 15mg (IVP) or 30mg (IM). If dehydration suspected (dry or cracked lips or tongue, sunken eyes, decreased urine production) administer 250-300ml NaCL prior to administration of Toradol. Administer fluid cautiously in the cardiac patient.

ACUTE ABDOMINAL PAIN:

• NITROUS OXIDE self-administered.
• MORPHINE SULFATE 2 - 20 mg IV or IN, titrated to effect.
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect

ANXIETY:

• DIAZEPAM (VALIUM) 2 - 20 mg SLOW IVP or IM to desired effect.

BURNS: (with moderate to severe pain)

• MORPHINE SULFATE 2 - 20 mg IV, IO or IN, titrated to effect.
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect
• MIDAZOLAM (VERSED) 2 - 10 mg IV, IO or IN, titrated to effect.
• NITROUS OXIDE self-administered

COMBATIVE POST RESUSCITATION / HEAD INJURY:

• KETAMINE (KETALAR) 2 mg/kg IVP or IN OR 4 mg/kg IM x 1 dose
• MORPHINE SULFATE 2 - 20 mg IV or IN, titrated to effect

Note: Morphine should be considered first for combative head injury and suspected MI.

• MIDAZOLAM (VERSED) 2 - 10 mg IV or IN, titrated to effect
• DIAZEPAM (VALIUM) 2 - 20 mg SLOW IVP titrated to effect

FROST BITE:

• NITROUS OXIDE self administered, as needed for pain
• MORPHINE SULFATE 2 - 20 mg IV, IO or IN, titrated to effect
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect

MUSCULOSKELETAL PAIN / EXTREMITY PAIN:

• MORPHINE SULFATE 2 - 20 mg IV, IO or IN, titrated to effect
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect
• NITROUS OXIDE self administered, as needed for pain
• MIDAZOLAM (VERSED) 2 - 10 mg IV, IO or IN, titrated to effect
• DIAZEPAM (VALIUM) 2 - 20 mg SLOW IVP titrated to effect

FLANK PAIN/SUSPECTED KIDNEY STONES:

• TORADOL (KETOROLAC) 15mg – 30mg IV depending on hydration status
• MORPHINE SULFATE 2-20mg IV, IO or IN titrated to effect
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect

SICKLE CELL ANEMIA CRISIS:

• NITROUS OXIDE self administered, as needed for pain
• MORPHINE SULFATE 2 - 20 mg IV, IO or IN, titrated to effect
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect

PEDIATRIC PATIENTS:

• NITROUS OXIDE self administered, as needed for pain
• MORPHINE SULFATE, 0.1 mg/kg titrate small increments every 20-30 seconds for effect
• MIDAZOLAM (VERSED), 0.1 mg/kg refer to Handtevy System for dosage

PROCEDURAL SEDATION: Cardioversion, Pacing, Intubation

• MORPHINE SULFATE 2 - 20 mg IV, IO or IN, titrated to effect
• FENTANYL 1-2 mcg/kg IVP SLOW titrate to effect
• MIDAZOLAM (VERSED) 2 - 10 mg IV, IO or IN, titrated to effect
• DIAZEPAM (VALIUM) 2 - 5 mg SLOW IVP to desired effect

THE ABOVE MEDICATIONS MAY ALL CAUSE A DECREASED LOC AND COULD COMPROMISE A PATIENT’S AIRWAY. JUDICIOUS USE IS A MUST! ALLOW AMPLE TIME FOR EACH DOSE TO TAKE EFFECT PRIOR TO ANY ADDITIONAL DOSES BEING ADMINISTERED.

• These drugs may be given in combination for maximum effectiveness.
• Ensure that Pulse Oximeter is in place.
• Ensure that BVM, FLUMAZENIL (ROMAZICON) and/or NALOXONE (NARCAN) are readily available.