Download Fentanyl and Ativan In-Service

Fentanyl and Ativan
In-Service
Eastern PA EMS Council
Fentanyl Oh What a Relief
It Is! Pain Management
 “We must all die. But that I can save a
person from days of torture, that is what I
feel is my great and ever-new privilege.
Pain is a more terrible lord of mankind
than even death itself.”
-Albert Schweitzer
Fentanyl Continued
 Indications
Fentanyl is used in the treatment of acute
pain and to depress breathing in patients
being ventilated. It may also be given as
an infusion under the skin in palliative
care patients who have intolerable side
effects from Morphine
Fentanyl Cont.
 Generic Name: Fentanyl Citrate
 Product Name: Fentanyl
Fentanyl Cont.
 Drug Class
 Short acting narcotic
 Opioid medication
Opioids act on the opioid receptors in the
nervous system to reduce pain.
Fentanyl Dosing For Our
Regional Protocols
 50-100mcg IVP or 1mcg/kg
 May repeat ½ dose every q5 minutes until
max of 3mcg/kg (with Medical Command approval)
 Pay special attention to your dosing this is
the only medication we have that is given
in Micro-grams (mcg).
Eastern PA Regional Pain
Control Choices
 ANALGESIC MEDICATION OPTIONS
(Choose one)
 Fentanyl 50-100 mcg IV/IO (1 mcg/kg)
 may repeat ½ dose every 5 minutes until
maximum of 3 mcg/kg (with Medical Command approval)
OR
 Morphine sulfate 2-5 mg IV
 (0.05 mg/kg)
 may repeat dose every 5 minutes
 until maximum of 0.2 mg/kg
Fantanyl Dosing Continued
 Fentanyl supplied in ampules of
100mcg/2ml or 250mcg/5ml
Fentanyl Dosing Continued
 So what's the concentration for
100mcg/2ml???
 50mcg/ml Right!
 For 250mcg/5ml???
 50mcg/ml You got it!
Fentanyl Dosing
Continued:
Milligram VS Microgram
 Easy conversion formula
 To convert micrograms to milligrams divide by
1000 e.g. 50mcg = 0.05 mg
 To convert milligrams to micrograms multiply
by 1000 e.g. 0.05mg = 50mcg
 1000mcg in 1mg
 1 million mcg in 1 gram
 1000 grams in 1 kilogram
 Very potent medication, always ensure proper
dosing!!!!
Other forms of Fentanyl
 Transdermal Patch
 Lollipop?
Fentanyl
Pharmacokinetics
 Intramuscular
Onset 7-15 minutes
Peak 15 minutes
Duration 1-2 hours
 Intravenous
Onset minutes
Peak minutes
Duration 30-60 minutes
Fentanyl Precautions
 Over Sedation
Opioid antagonist Narcan
Fentanyl
Precautions/Warnings
Continued
 Hypoventilation-respiratory depression
from opioids is manifested by a reduced
drive to breath and reduced rate, often
associated with “sighing” pattern.
 COPD-in such patients normal analgesic
doses of opioids may further decrease
respiratory drive to the point of failure!
Fentanyl
Precautions/Warnings Cont.
 Alcohol and Drugs of Abuse - May be expected
to have additive CNS depressant effects when
used in conjunction with alcohol
 Cardiac Disease – may produce bradycardia
should be used with caution in patients with
known bradyarrhytmias.
 Hepatic or Renal Disease – Caution because
of the hepatic metabolism and renal excretion
of Fentanyl.
Fentanyl
Contraindications
 Not opioid tolerant
 Intermittent pain
 In situations of significant respiratory
depression especially in unmonitored settings
 In patients who have acute or severe asthma
 Patients who have or are suspected of having
a paralytic ileus - paralysis of the intestine
 Known hypersensitivity
Fentanyl Side Effects
Common & Uncommon
 Common
Rash, Nausea, Vomiting (Zofran!!) Drowsiness,
Dry Mouth, Dizziness, Difficulty Urinating,
Constipation (prolonged use), Constricted
pupils
 Uncommon
Rigid chest wall, Decreased Breathing,
Confusion, Hives, Itching, Slowing or Elevated
HR, ABD pain, Flushing
Fentanyl Summary
Pros:
Fast acting, Short duration, More potent than Morphine, ED’s
increasing in use for all types of pain control even non-specific
abdominal pain due to its short duration ( pt will unmask shortly
after administration).
Also coming into favor in the presence of AMI due to less of a
histamine release than Morphine which causes tachycardia!
Cons:
New dosing mcg versus mg (double check your concentrations)
Drug most likely to be abused by providers!
Treat as you would any controlled substances we carry, i.e. double
lock box, accountability forms checked for accuracy routinely
Ativan
 Generic Name: Lorazepam
 Brand Name: Ativan or Temesta
Ativan How Supplied
 Tablet
 Injectable (2mg/ml vial for us)
Ativan Usage and Class
 Class:
 Benzodiazepine with short to medium
duration.
 It has all five intrinsic Benzodiazepine
effects: anxiolytic, sedative/hypnotic,
amnesic, anticonvulsant, and muscle
relaxant to different extents.
Ativan Usages and Class
Continued
 Usages:
Relatively potent anxiolytic effects and its
best known indication is the short-term
management of severe anxiety.
Sedative/Hypnotic effects and the duration
of from a single dose make it useful for
short term treatment of insomnia.
Ativan Usages and Class
Continued
As an anticonvulsant intravenous Ativan is
a reliable agent for terminating acute
seizures.
In the violent agitated pt including acute
delirium Ativan can be used. Watch for
paradoxical effects, should be given with
Haldoperidol.
Given to CA patients as it has some
antiemetic properties.
Ativan Pharmacokinetics
 Ativan’s poor lipid solubility and its high
degree of protein binding means that
Ativan’s volume of distribution is mainly
in the vascular compartment, versus
Valium which gets absorbed by body fat.
 The higher volume in the vascular
compartment makes Ativan unsuitable for
oral or rectal administration as compared
to Valium.
Ativan Pharmacokinetics
 Potency 1mg Ativan = 10mg Valium
 Ativan compared to other Benzodiazepines has
a high affinity for GABA receptors (Gammaaminobutyric acid) increasing the inhibitory
process of the cerebral cortex.
 Anticonvulsant properties may be in part or
entirely due to binding to voltage dependent
sodium channels rather than Benzodiazepine
receptors slowing the recovery of sodium
channels from inactivation
Ativan Contraindications
 Hypersensitivity
 Severe respiratory failure
 Acute intoxication may interact
synergistically with ETOH effects
 Acute narrow-angle glaucoma
 Pregnancy
 Liver and Kidney failure Ativan is the
safest for pt’s with impaired liver function.
Ativan Special
Considerations
 Must keep refrigerated 35-45F
 Protect from light (keep in carton until
ready to use)
Ativan Eastern PA
Regional Dosing
 Seizures:
Adult 1-2mg IVP/IO repeat q5 minutes until
max dose of 8mg is reached (0.1mg/kg
max 4mg dose)
Pediatric 0.1mg/kg IVP/IO max 4mg dose
repeat q5 until max dose of 8mg is
reached.
Eastern PA Regional
Sedation Choices
 Sedation Options:
(Choose one)
(Titrate to minimum amount necessary)

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

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Midazolam 1-5 mg IV/ IO (0.05 mg/kg)
titrated slowly
may repeat every 5 minutes
until maximum of 0.1 mg/kg
OR
Diazepam 5-10 mg IV/ IO (0.1 mg/kg)
titrated slowly
may repeat every 5 minutes
until maximum 0.3 mg/kg
OR
Lorazepam 1-2 mg IV/ IO (0.1 mg/kg, max 4 mg/dose)
titrated
may repeat every 5 minutes
until maximum of 8 mg
Ativan Eastern PA
Regional Dosing
Agitated/Violent Behavioral Patient
1-2mg IVP/IO/IM or 0.1mg/kg max 4mg
dose may repeat q5 until max dose of
8mg
Questions??