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Pain Management and Dosing Guide Updated Updated April April 2016 2016 Pain Management and Dosing Guide Includes: 1. Principles Principles of of Pain Pain Management, Management, Discharge Discharge and and Patient Patient Safety Safety 1. Considerations, Analgesic Ladder Considerations, Analgesic Ladder 2. Non-opioid Analgesics, Opioid Opioid Prescribing Prescribing Guidelines Guidelines and and 2. Non-opioid Analgesics, Equianalgesic Chart, Chart, Opioid Opioid Cross-Sensitivities, Cross-Sensitivities, Intranasal Intranasal Equianalgesic Medications Medications 3. Nerve Blocks, Neuropathic Neuropathic Pain Pain Medications, Medications, Muscle Muscle Relaxer Relaxer 3. Nerve Blocks, Medications, Ketamine Ketamine Indications Indications Medications, 4. Topical and Transdermal Transdermal Medications Medications 4. Topical and 5. Procedural Sedation and Analgesia (PSA) (PSA) Medications Medications 5. Procedural Sedation and Analgesia 6. Stepwise Approach to to Pain Pain Management Management and and PSA PSA 6. Stepwise Approach http://pami.emergency.med.jax.ufl.edu/ http://pami.emergency.med.jax.ufl.edu/ https://goo.gl/4Yh1cB https://goo.gl/4Yh1cB Send your your feedback feedback on on all all PAMI PAMI materials materials and and how how you you Send use them them to to improve improve patient patient safety safety and and clinical clinical care. care. use you would would like like to to adapt adapt this this guide guide for for your your IfIf you institution or or have have recommendations recommendations contact contact PAMI PAMI at at institution [email protected] or or 904-244-4986. 904-244-4986. [email protected] Disclaimer Disclaimer ThePAMI PAMIdosing dosingguide, guide,website, website,learning learningmodules, modules,and andresources resourcesare arefor foreducational educationaland andinformational informationalpurposes purposesonly onlyand andare arenot notintended intendedas asaasubstitute substitutefor forprofessional professionalmedical medicaldiagnosis diagnosisor or management management The byaaqualified qualifiedhealth healthcare careprofessional. professional.PAMI PAMIisisnot notresponsible responsiblefor forany anylegal legalaction actiontaken takenby byaaperson personor ororganization organizationas asaaresult resultof ofinformation informationcontained containedin inor oraccessed accessedthrough throughthis thiswebsite websiteor orguide guidewhether whether by such information is provided by PAMI or by a third party. As new research and clinical experience becomes available, patient safety standards will change. Therefore, it is strongly recommended that such information is provided by PAMI or by a third party. As new research and clinical experience becomes available, patient safety standards will change. Therefore, it is strongly recommended that physicians, nurses and other healthcare professionals remain current on medical literature and national standards of care and structure their treatment accordingly. As a result of ongoing medical advances physicians, nurses and other healthcare professionals remain current on medical literature and national standards of care and structure their treatment accordingly. As a result of ongoing medical advances and developments, developments,information informationon onthis thissite siteisisprovided providedon onan an“as “asis” is”and and“as “asavailable” available”basis. basis.Patient Patientcare caremust mustbe beindividualized. individualized.The Theuse useof ofinformation informationobtained obtainedor ordownloaded downloadedfrom fromor orthrough throughthis thiswebsite, website, and module,or orproduct productisisat atthe theuser’s user’ssole solediscretion discretionand andrisk. risk. module, Funding provided provided by by Florida Florida Medical Medical Malpractice Malpractice Joint Joint Underwriting Underwriting Association Association (FMMJUA) (FMMJUA) and and University University of of Florida Florida College College of of Medicine-Jacksonville, Medicine-Jacksonville, Department Department of of Emergency Emergency Medicine Medicine Funding Principles of Pain Management Establish realistic realistic pain pain goals goals Establish Will vary vary depending depending on on patient patient and and type type of of Will pain -- goal goal of of zero zero may may not not be be feasible feasible pain Analgesic Ladder Ladder and and Treatment Treatment Basics Basics Pain Management Considerations Analgesic Type of of pain: pain: nociceptive, nociceptive, neuropathic, neuropathic, inflammatory inflammatory ••Type Acutevs. vs.chronic chronicvs. vs.acute acuteon onchronic chronicpain painexacerbation exacerbation ••Acute Pain medication medication history: history: OTC, OTC, Rx Rx and and herbal herbal ••Pain Patient factors: factors: genetics, genetics, culture, culture, age, age, previous previous ••Patient pain experiences, experiences, comorbidities comorbidities pain Verify dosing dosing for for << 66 mo mo and and >> 65 65 yo yo ••Verify Treatment Options Options Treatment Educate patient/caregivers patient/caregivers on on pain pain Educate management goals and regimen management goals and regimen Pharmacotherapy: systemic, systemic, topical, topical, transdermal transdermal -••Pharmacotherapy: nerve blocks blocks nerve Non-pharmacologic modalities modalities ••Non-pharmacologic Refer to to pain, pain, palliative palliative or or other other specialists specialists for for ••Refer advanced treatment treatment advanced Consider pharmacologic pharmacologic and and Consider non-pharmacologic treatment treatment options options and and non-pharmacologic initiate therapy therapy initiate Continually reassess reassess patient’s patient’s pain pain Continually and monitor monitor for for medication medication efficacy efficacy and and and side effects effects side same scale scale to to reassess reassess pain pain ••Use Use same scale that that isis age age and and cognitively cognitively appropriate appropriate ••Use Use scale no improvement, improvement, adjust adjust regimen regimen ••If If no Step 1: 1: Mild Mild Pain Pain Step and counsel counsel regarding regarding falls, falls, driving, driving, work work ••Assess Assess and safety, and and medication medication interactions interactions safety, regimen for for opioid opioid induced induced constipation constipation ••Bowel Bowel regimen signs and and oral oral intake intake before before discharge discharge ••Vital Vital signs all pain pain medications medications administered administered and and ••Document Document all response at at time time of of discharge discharge or or disposition disposition response OTC and and non-pharmacologic non-pharmacologic options options ••Consider Consider OTC patient implement implement pain pain management management plan? plan? ••Can Can patient -- insurance insurance coverage, coverage, transportation, transportation, etc. etc. Non-Opioid Analgesics* Analgesics* Non-Opioid (Brand) (Brand) Adult Adult Pediatric Pediatric (<12yo) yo) (<12 325-650mg mg 15mg/kg mg/kg 325-650 15 Acetaminophen Acetaminophen POqq4-6 4-6hh POqq4-6 4-6hh PO (Tylenol®) Max:PO (Tylenol®) Max:90 90mg/kg/d mg/kg/d g/dor or11qq44hh Max: Max: 44g/d <50kg kg <50 Acetaminophen Acetaminophen IV qq 66 hh 15mg/kg mg/kgIV IVqq66hh 11 gg IV 15 IV (Ofirmev®) (Ofirmev®) Max: IV or12.5 12.5mg/kg mg/kg g/d or or 650 650 or 44 g/d Use only only ifif not not Max: Use IV q 4 h prn pain mg q 4 h prn pain IV q 4 h prn pain tolerating PO PO mg q 4 h prn pain Max: tolerating 75mg/kg/d Max: 75mg/kg/d 100-200 mg mg 100-200 >2 yo yo Celecoxib >2 Celecoxib PO daily daily to to qq 12 12 hh 50 mg PO BID BID (Celebrex®) PO mg PO (Celebrex®) Max: 400 400 mg/d mg/d 50 Max: 10mg/kg mg/kg 10 400-800 mg mg 400-800 Ibuprofen POqq66to to88hh Ibuprofen PO PO qq 66 to to 88 hh Max: PO (Motrin®) 40 mg/kg/d (Motrin®) Max: 40 mg/kg/d Max: 3200 3200 mg/d mg/d or 2400 Max: mg/d or 2400 mg/d 1-2 mg/kg mg/kg 1-2 25-50 mg mg PO qq 66 to to 12 12 hh 25-50 PO Indomethacin Indomethacin PO qq 66 to to 12 12 hh >6 mo mo PO >6 (Indocin®) (Indocin®) Max: 200 mg/d Max: 4 mg/kg/d Max: 200 mg/d Max: 4 mg/kg/d or 200 200 mg/d mg/d or 0.5-1 mg/kg/ 0.5-1 mg/kg/ 15-30 mg mg IV/IM IV/IM 15-30 dose IM/IV IM/IV dose Ketorolac† Ketorolac† qq 66 hh 66 hh (Toradol®) Max: 120 120 mg/d mg/d Max:qq15-30 (Toradol®) Max: mg Max: 15-30 mg xx 55 dd qq 66 hh xx 55 dd 250-500 mg mg PO PO mg/kgPO PO 250-500 55mg/kg Naproxen Naproxen to 12 12 hh 12hh qq 88 to qq12 (Naprosyn®) Max: (Naprosyn®) 1500 mg/d mg/d Max: Max:1000 1000mg/d mg/d Max: 1500 7.5-15mg mgPO POdaily daily Meloxicam 7.5-15 Meloxicam — — Max: 15 15 mg/d mg/d (Mobic®) Max: (Mobic®) *Doses can can be be scheduled scheduled or or PRN PRN pain. pain. Avoid Avoid NSAIDs NSAIDs inin renal renal *Doses dysfunction, PUD, PUD, CHF, CHF, and and ifif << 66 mo mo of of age. age. Use Use with with caution caution dysfunction, elderlypatients. patients. ininelderly †Forpatients patients<<65 65yo, yo,60 60mg mgIM IMor or30 30mg mgIV IVxx1, 1,followed followedby by30 30 †For mgIV/IM IV/IMqq66hhPRN PRNup upto toaamax maxdaily dailydose doseof of120 120mg mgfor for55days. days. mg For patients patients >65 >65 yo, yo, <50 <50 kg, kg, and/or and/or with with renal renal impairment, impairment, 30 30 For mgIM IMor or15 15mg mgIV IVxx1, 1,followed followedby by15 15mg mgIV/IM IV/IMqq6h 6hPRN PRNup upto to mg maxdaily dailydose doseof of60 60mg mgfor for55days. days. aamax Step 2: 2: Moderate Moderate Pain Pain Step Step 11 Strategy Strategy ++ Intermittent Intermittent Dose Dose of of Opioid Opioid Step Analgesics (PO, (PO, IV) IV) +/+/Analgesics Interventional (Blocks (Blocks & & Procedures) Procedures) Interventional Non-pharmacological modalities modalities Non-pharmacological Splinting, distraction, distraction, hot/cold hot/cold therapy, therapy, Splinting, exercise, massage, massage, imagery, imagery, and and others others exercise, Discharge and and Patient Patient Safety Safety Considerations Considerations Discharge Generic Generic Step 3: 3: Severe Severe Pain Pain Step Step 11 and and Step Step 22 Strategies Strategies +/+/- Scheduled Scheduled Step Opioid Analgesics Opioid Analgesics Non-opioid Analgesic Analgesic (APAP, (APAP, NSAIDs, NSAIDs, COX-2 COX-2 Non-opioid Inhibitors) +/+/- Local/Topical Local/Topical Anesthetics Anesthetics Inhibitors) Ladder Basics Basics Ladder 1.Use oral route route when when possible possible 1. Use oral 2.Give analgesics at at regular regular intervals intervals 2. Give analgesics 3.Prescribe according to to pain pain intensity intensity 3. Prescribe according 4.Dosing must be be adapted adapted to to individual individual 4. Dosing must 5.Analgesic plan must must be be refined refined and and 5. Analgesic plan communicated with with patient patient and and staff staff communicated Opioid Prescribing Prescribing Guidelines Guidelines and and Equianalgesic Equianalgesic Chart Chart Opioid Onset (O) (O) and and Onset Duration (D) (D) Duration Oral IV Oral IV Generic (Brand) (Brand) Generic Recommended STARTING STARTING Approximate Recommended Approximate Equianalgesic Dose Dose dose for for ADULTS ADULTS Equianalgesic dose Oral IV Oral IV Oral IV Oral IV O:30-60 30-60min min O: O:5-10 5-10min min 30 mg O: Morphine (MSIR®) (MSIR®) [CII] [CII] 30 mg Morphine D:3-6 3-6hh D:3-6 3-6hh D: D: O: 30-90 min Morphine extended release O: 30-90 min Morphine extended release — 30mg mg — 30 (MS Contin®) Contin®) [CII] [CII] D:8-12 8-12hh (MS D: O:15-30 15-30min min O: O:15 15min min 7.5 mg Hydromorphone (Dilaudid®) (Dilaudid®) [CII] [CII] O: 7.5 mg Hydromorphone D:4-6 4-6hh D:4-6 4-6hh D: D: Hydrocodone/APAP 325 325 mg mg Hydrocodone/APAP O:30-60 30-60min min O: — 30mg mg (Norco 5, 5, 7.5, 7.5, 10®) 10®) [CII] [CII] — 30 (Norco D:4-6 4-6hh Hycet (7.5 (7.5 mg/325 mg/325 mg mg per per 15 15 mL) mL) D: Hycet Transdermal Transdermal Fentanyl[CII] [CII] Fentanyl O:immediate immediate O:12-24 12-24hh O: O: (Sublimaze®Duragesic®) Duragesic®) — (Sublimaze® — D:72 72hhper per D: D:30-60 30-60min min Patchfor foropioid opioidtolerant tolerantpatients patientsONLY ONLY D: Patch patch patch O:30-60 30-60min min Methadone (Dolophine®) (Dolophine®) [CII] [CII] O: Methadone D:>8 >8hh — Variable D: — Variable Opioid tolerant tolerant patients patients ONLY ONLY Opioid (chronic use) (chronic use) Oxycodone5,5,15, 15,30 30mg mg(Roxicodone®), (Roxicodone®), Oxycodone O:10-15 10-15min min Oxycodone5,5,7.5, 7.5,10 10mg/ mg/APAP APAP325 325mg mg O: Oxycodone — 20-30mg mg — 20-30 (Percocet®), D:4-6 4-6hh (Percocet®), D: ER=Oxycontin®[CII] [CII] ER=Oxycontin® O:11hh O: — 300mg mg Tramadol (Ultram®) (Ultram®) [CIV] [CIV] — 300 Tramadol D:3-6 3-6hh D: Codeine* 15, 15, 30, 30, 60 60 mg/APAP mg/APAP Codeine* 300 mg mg 300 O:1-2 1-2hh O: D:4-6 4-6hh D: — — 200mg mg 200 Recommended STARTING STARTING Recommended dose for for CHILDREN CHILDREN (> (> 66 mo) mo) dose Oral Oral IV IV 0.1mg/kg mg/kg 0.1 2-4hh qq2-4 0.5-2mg mg 0.5-2 2-4hh qq2-4 0.3mg/kg mg/kg 0.3 qq44hh 0.3-0.6mg/kg mg/kg 0.3-0.6 12hh qq12 0.06mg/kg mg/kg 0.06 qq44hh 0.015mg/kg mg/kg 0.015 qq44hh 5-10mg mg 5-10 qq66hh — — 0.1-0.2mg/kg mg/kg 0.1-0.2 4-6hh qq4-6 — — 100mcg mcg 100 (0.1mg) mg) (0.1 Transdermal Transdermal 12-25mcg/h mcg/h 12-25 72hh qq72 50mcg mcg 50 1-2hh qq1-2 Transdermal Transdermal 12-25mcg/h mcg/h 12-25 72hh qq72 1-2mcg/kg mcg/kg 1-2 1-2hh qq1-2 (max50 50mcg/dose) mcg/dose) (max Variable Variable 5-10mg mg 5-10 8-12hh qq8-12 — — 0.7 mg/kg/d mg/kg/d PO/SC/IM/IV PO/SC/IM/IV divided divided 0.7 4-6 hh prn prn severe severe chronic chronic pain pain qq 4-6 — — 0.05-0.15mg/kg mg/kg 0.05-0.15 4-6hh qq4-6 — — 1.5mg mg 1.5 15-30mg mg 15-30 2-4hh qq2-4 15-30 mg mg 15-30 12 hh qq 12 2-4mg mg 2-4 qq44hh — — 10mg mg 10 10mg mg 10 — — — — — — 5-10mg mgqq66hh 5-10 ER10 10mg mgqq12 12hh ER 2-10mg mg 2-10 2-4hh qq2-4 — — — — 50-100mg mgqq66hh 50-100 Max:400 400mg/d mg/d Max: — — — — — — 30-60mg mg 30-60 qq44hh — — 0.5-1mg/kg mg/kgqq66hh 0.5-1 or3-6 3-6yo yo==12mg 12mg or 7-12yo yo==15-30mg 15-30mg 7-12 — — *Codeineisisoften oftenineffective. ineffective.Use Usefor forcough coughand andcold coldisiscontraindicated contraindicatedininchildren. children.Not Notrecommended recommendedfor for<<12 12yo yoor or12-18 12-18yo yowith withrespiratory respiratorycondition conditionor ornursing nursingmothers. mothers. *Codeine Opioid Cross-Sensitivities Cross-Sensitivities Opioid Phenanthrenes(related (relatedto tomorphine): morphine):morphine, morphine, Phenanthrenes codeine,oxycodone, oxycodone,hydrocodone, hydrocodone,hydromorphone hydromorphone codeine, Phenylpiperidines(related (relatedto tomeperidine): meperidine): Phenylpiperidines meperidine,fentanyl fentanyl meperidine, Riskof ofcross-sensitivity cross-sensitivityininpatients patientswith withallergies allergiesisis Risk greaterwhen whenmedications medicationsfrom fromthe thesame sameopioid opioid greater family are administered. family are administered. Generic Generic Fentanyl Fentanyl Dose Dose Intranasal Medications* Medications* Intranasal Max Dose Dose Max Comments Comments 1.5-2mcg/kg mcg/kgqq1-2 1-2hh 33mcg/kg mcg/kgor or100 100mcg mcg Divide Dividedose doseequally equallybetween betweeneach eachnostril nostril 1.5-2 10mg mgor or11mL mLper per Divide dose equally between each nostril 10 Midazolam55mg/mL mg/mL 0.3mg/kg mg/kg Midazolam 0.3 Divide dose equally between each nostril nostril (total 2 mL) nostril (total 2 mL) 0.5-1.0mg/kg mg/kgLarge Largerange range Limiteddata data Usewith withcaution cautionuntil untilfurther furtherstudied studied Ketamine+ 0.5-1.0 Limited Use Ketamine+ *Usethe theMOST MOSTconcentrated concentratedform formavailable availablewith withan anatomizer. atomizer. ++Dosing Dosingnot notwell wellestablished. established.Studies Studieshave haveused used0.5-9 0.5-9mg/kg. mg/kg. *Use Neuropathic Pain Medications nerve blocks Generic (Brand) Beginning Dose Max Dose Gabapentin* (Neurontin®) Pregabalin* (Lyrica®) SNRIs: Duloxetine (Cymbalta®) Venlafaxine ER (Effexor XR®) TCAS: Amitriptyline (Elavil®) Nortriptyline (Pamelor®) 300 mg PO QHS to TID 50 mg PO TID 30 mg PO daily† 37.5 mg PO daily 25 mg PO QHS 25 mg PO QHS 3600 mg/d 300 mg/d** 60 mg/d** 225 mg/d 200 mg/d 150 mg/d Type of Block General Distribution of Anesthesia Interscalene Plexus Block Shoulder, upper arm, elbow and forearm Supraclavicular Plexus Block Upper arm, elbow, wrist and hand Infraclavicular Plexus Block Upper arm, elbow, wrist and hand Axillary Plexus Block Forearm, wrist and hand. Elbow if including musculocutaneous nerve Median Nerve Block Hand and Forearm Radial Nerve Block Hand and Forearm Ulnar Nerve Block Hand and Forearm Femoral Nerve Block Anterior thigh, femur, knee and skin over the medial aspect below the knee Popliteal Nerve Block Foot and ankle and skin over the posterior lateral portion, distal to the knee Tibial Block Foot and ankle Deep Peroneal Block Foot (Flexeril®) Saphenous Nerve Block Foot Methocarbamol Sural Nerve Block Foot Local Anesthetics† Onset †30 mg daily for at least 7 days to decrease nausea *Requires dose adjustment based on renal function **Varies depending on indication Beginning Dose Max Dose Baclofen (Lioresal®) Cyclobenzaprine 5 mg PO TID 80 mg/d 5 mg PO TID 30 mg/d 1-1.5 g PO TID to 4x/day x 48-72 h, then 500-750 mg PO TID to 4x/day 8 g/d (Robaxin®) Duration Duration without Epi (h) with Epi (h) Max Dose without Epi, mg/kg Max Dose with Epi, mg/kg Lidocaine (1%) Rapid 0.5–2 1–6 4.5 (300 mg) 7 (500 mg) Bupivicaine (0.5%)* Slow 2-4 4-8 2.5 3 Mepivicaine (1.5%) Rapid 2-3 2-6 5 7 2-Chloroprocaine (3%) Rapid 0.5-1 1.5-2 10 15 Ropivicaine (0.5%) Medium 3 6 2-3 2-3 *Most cardiotoxic Muscle Relaxer Pain Medications Generic (Brand) Adult: 2-10mg PO TID-QID; Ped: 0.6 mg/ 5-10mg IV/IM Ped: (6-12yo): 0.12-0.8 mg/kg/day PO kg/8h IV/IM to divided q 6-8 h; 0.04-0.2 mg/kg IV/IM adult max q 2-4 h prn; Diazepam (Valium®) Ketamine (Ketalar®) Indications Indications Starting Dose IV: Adult 0.5-1.0 mg/kg, Ped 1-2mg/kg; IM: 4-5 mg/kg IV: 0.1 to 0.3 mg/kg, max initial dose ≤ 10 mg Sub-dissociative Analgesia IM: 0.5-1.0 mg/kg; IN*: 0.5-1.0 mg/kg Excited Delirium Syndrome IV: 1 mg/kg; IM: 4‐5 mg/kg Procedural Sedation †1% = 10mg/ml, 0.5% = 5mg/ml *Dosing not well established. Studies have used 0.5-9 mg/kg. Topical and Transdermal Medications* Generic (Brand) Indications Diclofenac sodium 1.5%, 2% w/w topical solution (Pennsaid) Onset (O) and Recommended STARTING Recommended STARTING Duration (D) dose for ADULTS dose for CHILDREN Osteoarthritis Variable 1% gel (Voltaren gel) 1.5% soln: 40 drops QID 2% soln: 2 pumps (40mg) BID to affected knee Maximum Dose — 1.5% soln: 40 drops QID 2% soln: 2 pumps (40mg) BID 1% gel (2g): 8 g/d to single joint of upper extremity; 1% (4g): 16 g/d to single joint of lower extremity 1% gel: 2 or 4g QID Diclofenac epolamine 1.3% patch (Flector patch) Acute pain from sprains, strains, contusion Variable 1 patch (180 mg) BID — 1 patch BID Lidocaine 5% patch (Lidoderm patch) Postherpetic neuralgia Variable 1-3 patches applied once daily, remove after 12 h — 3 patches in a 12 h period per day Fentanyl (Duragesic®) Persistent moderate to severe chronic pain O: 12-24 h D: 72 h per patch Capsaicin cream (Theragen®, Zostrix®, backache or Salonpas) Exists as several OTC formulations Strains, sprains, arthritis in combination with camphor and menthol Variable 12-25 mcg/h q 72 h Apply a thin layer to the affected area and gently massage up to QID Variable >12 yo: Apply a thin layer to the affected area and gently massage up to QID Lidocaine 4% (L.M.X.4®) Minor cuts, scrapes, burns, sunburn, insect bites, and minor skin irritations O: 20-30 min D: 60 min Apply externally LET (Lidocaine Epinephrine Tetracaine) (gel or liquid) Wound repair (non-mucosal) O: 10 min D: 30-60 min Topical 4% Lidocaine, 1:2,000 Epinephrine, 0.5% Tetracaine EMLA (2.5% Lidocaine 2.5% Prilocaine) Cover with occlusive dressing Maximum application time 4 hours Dermal analgesic (intact skin) O: 60 min D: 3-4 h 20 gm Pain-Ease® Vapocoolant/Skin Refrigerant Cooling intact skin and mucus membranes and minor open wounds O: immediate D: few sec to 1 min — Lidocaine Foley catheter and nasogastric tube insertion; intubation; nasal packing; gingivostomatitis O: 2-5 min D: 30-60 min 3-12 mo (>5 kg): 2 gm 1-6 yo (>10kg): 10 gm 7-12 yo (>20kg): 20 gm Up to QID Externally 3-4 times per day. Apply in area less than 100cm2 for children less than 10kg. Apply in area less than 600cm2 for children between 10 and 20kg 3 mL (not to exceed maximal Lidocaine dosage of 3-5 mg/kg) 3-12 mo max area 20cm2 1-6 yo max area 100cm2 7-12 yo max area 200cm2 Spray for 4-10 sec from distance of 8-18 cm. Stop when skin turns white to avoid frostbite Not recommended for < 3 yo 2% topical gel/jelly, 5% topical ointment, 2% oropharyngeal viscous topical solution 3-5 mg/kg *Dosages are guidelines to avoid systemic toxicity in patients with normal intact skin and with normal renal and hepatic function Procedural Sedation and Analgesia Medications Generic (Brand) Adult Pediatric Comments Ketamine (Ketalar®) IV 0.5-1.0 mg/kg IM 4-5 mg/kg >3 mo: IV 1-2 mg/kg; additional doses 0.5 mg/kg IV q 10-15 min prn; IM 4 - 5 mg/kg Risk of laryngospasm increases with active upper respiratory infection and procedures involving posterior pharynx; vomiting common - consider premedication with Ondansetron (Zofran). Not recommended in patients <3 mo. Midazolam (Versed®) IV 0.05-0.1 mg/kg IV slow push over 1-2 min IV 0.05-0.1 mg/kg IN 0.2-0.3 mg/kg (IN max 10 mg) Initial max dose 2 mg. Max total dose in >60 yo is 0.1 mg/kg Decrease dose by 33-50% when given with opioid Propofol (Diprivan®) Etomidate (Amidate®) Ketamine + Propofol Dexmedetomidine (Precedex®) IV 0.5-1 mg/kg slow push IV 1 mg/kg slow push (1-2 min); Risk of apnea, hypoventilation, respiratory depression, rapid changes (1-2 min); additional doses 0.5 additional doses 0.5 mg/kg in sedative depth, hypotension; provides no analgesia mg/kg IV 0.1 - 0.2mg/kg; additional doses 0.05mg/kg — IV ketamine 0.75 mg/kg + propofol 0.75 mg/kg. Additional doses: ketamine 0.5 mg/kg, propofol 0.5-1 mg/kg IV 1 mcg/kg loading dose (over IV 0.5–2 mcg/kg loading dose 10 min) followed by 0.5 to 2 mcg/ (over 10 min) followed by 0.5 to kg/h continuous infusion. Use 2 mcg/kg/h continuous infusion 0.5 mcg/kg for geriatric patients IN 2-3 mcg/kg Nitrous oxide — 50% N2O/50% O2 inhaled Morphine IV 0.05-.0.1 mg/kg or 5-10 mg IV 0.1-0.2 mg/kg, titrated to effect IV 0.5-1 mcg/kg 1-3 yo: 2 mcg/kg; 3-12 yo 1-2 mcg/kg Fentanyl Risk of myoclonus (premedication w/ benzo or opioid can decrease), pain with injection, nausea and vomiting, risk of adrenal suppression; provides no analgesia See ketamine and propofol comments respectively Risk of bradycardia, hypotension, especially with loading dose or rapid infusions, apnea, bronchospasm, respiratory depression Do not use if acute asthma exacerbation, suspected pneumothorax/other trapped air or head injury with altered level of consciousness Monitor mental status, hemodynamics, and histamine release. Requires longer recovery time than fentanyl. Difficult to titrate during procedural sedation due to slower onset and longer duration of action. Reduce dosing when combined with benzodiazepines (combination increases risk of respiratory compromise) 100 times more potent than morphine; Rapid bolus infusion may lead to chest wall rigidity. Reduce dosing when combined with benzodiazepines and in elderly. Preferred agent due to rapid onset and short duration. Stepwise Approach to Pain Management and Procedural Sedation Analgesia (PSA) http://pami.emergency.med.jax.ufl.edu/resources/ educational-materials/procedural-sedation/ 1. Situation Checkpoint What are you trying to accomplish?: analgesia, anxiety, sedation, procedure, etc. 2. Developmental/Cognitive Checkpoint What is the patient’s development stage? 3. Family Dynamic Checkpoint Who is caring for the patient? What are the family dynamics? 4. Facility Checkpoint Type of staffing and setting, team experience, facility policies, etc. 5. Patient Assessment Checkpoint Review patient’s risk factors and history. 6. Management Checkpoint Choose your “ingredients” for pharmacologic and non-pharmacologic “recipe.” 7. Monitoring & Discharge Checkpoint Joint Commission standards, reassessments, facility policies, discharge and transportation considerations.