5. Paracetamol
Loading dose: 2g PO or 1g IV or 20mg/kgPO or 15mg/kg IV
Maintenance dose: PO 15mg/kg q4h or max 8g/day for
adults
NASIDs eg Ibuprofen 10mg/kg tds
Highly effective
Be careful in the elderly, CCF, renal impairment
Codeine – effective when used with paracetamol– easier for
6. Consider paracetamol toxicity in someone who has had difficult
to control pain in the community - typically toothache
> 20 tab in 24 hours or > 24 tab in 48 hours
-> N-acetylcysteine and ask questions later.
7. Can’t take pain relief
orally?
Paracetamol IV (usually only 1g) or PR
Parenteral NSAID eg Diclofenac IV (75mg in 100ml N Saline)
Almost never use IM analgesia in ED
Slow
Painful
8. 1µg/kg IV q3min, 3µg/kg IN prn q5min
Use half the dose in elderly or drugged (eg ethanol or
morphine)
IV dose can be repeated in a few minutes PRN
Doesn’t make people puke, itch, hypotensive or as sedated
as as morphine
Shorter acting than morphine.
Use morphine once patient analgesed if long acting
analgesia needed.
Fentanyl
9. Nitrous oxide
50:50 nitrous oxide : oxygen “Entonox”
Moderate analgesic
Very safe
Theoretical risks of diffusing into and expanding closed spaces eg
pneumothorax, bowel obstruction, hernias
Requires patient to suck to activate valve -> children under 5
usually unable to use
Use it for catheters or IV access in needlephobes
10. 70% Nitrous Oxide
70% Nitrous oxide : 30% oxygen
Strong analgesic and sedative
Can often suture with this
Need an oxygen wash-out to prevent hypoxia
11. Nerve blocks
Do a neurovascular exam first!
Use a long acting local anaesthetic eg bupivocaine,
Lignocaine if you want sensation early, eg lips
Great for hips and femurs – femoral nerve or triple block.
Maximum doses?
12. Local anaesthetic maximum doses
Bupivacaine max dose 2mg/kg
Repeated doses up to 400mg/day can be used1
Lignocaine max
4.5mg/kg without adrenaline
7mg/kg with adrenaline
Adrenaline can be put into appendages.
1: http://www.medsafe.govt.nz/profs/datasheet/m/MarcainAndadrenalineinj.pdf
14. Signs of local anaesthetic toxicity.
Perioral tingling
Visual disturbance
Seizure
Coma
VT
Antidote?
15. Antidote for LA toxicity
Fat emulsion eg Intralipid 1ml/kg prn q3minutes then infusion
16. Fascia Iliaca Block AKA triple
block
Triple block (femoral, lateral cutaneous nerve of thigh,
obtruator) by the double pop fascial puncture technique
is fantastic, super safe analgesia for # NOF and # femur
1 fascia lata, 2 fascia iliaca, 3 N. femoralis, 4 N. cutaneus femoris lateralis, 5
V. and A. femoralis, 6 M. pectinale, 7 M. psoas
17. Other blocks
There are lots other great places you can stick local anaesthetic
Femoral nerve block
Digital nerves: Go into the dorsum of the webspace ~ 2ml of local on each side of the
finger
# ribs 5 ml of local over the # site
Median, radial and ulnar nerve blocks at the wrist. 5ml per nerve
Haematoma blocks for # wrist 10ml into the #
Dental anaesthesia Inject 3ml of long acting local injected through the buccal sulcus
into soft tissue adjacent to the gum at the effected tooth
Rarely a Inferior alveolar nerve block will be needed for a lower molar.
18.
19.
20.
21.
22.
23.
24. Tramadol
Tramadol is for people who say it works well for or patients you don’t like
Old adage:
Works for 1/3
Useless for another 1/3
Makes 1/3 vomit or spin out
Crappy analagesic eg Oxford league table of analgesics in acute pain
Very good for people who you think are drug seeking. Tramadol is not “liked” by IVDU but they are often tolerant to it’s side
effects and do get an analgesic effect.
25. Benzodiazepines
No analgesic effect, no muscle relaxant effect at sub-anaesthetic doses
But may help patients tolerate pain
But usually better to use an analgesic than has sedative properties eg opioid, clonidine
Considered a harmful treatment for acute low back pain (as are opioids)
New Zealand acute low back pain guide, incorporating the guide to assessing psychosocial yellow flags in acute low back pain
http://www.acc.co.nz/
26. Smooth muscle relaxants
eg buscopan
Little evidence of effect
Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a
randomised control trial. http://www.ncbi.nlm.nih.gov/pubmed/22307926
Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute
renal colic. http://www.ncbi.nlm.nih.gov/pubmed/22487663
Is there a role for antimuscarinics in renal colic? A randomized controlled trial.
http://www.ncbi.nlm.nih.gov/pubmed/16006900
Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic.
http://www.ncbi.nlm.nih.gov/pubmed/15230794
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine
butylbromide) in abdominal colic. http://www.ncbi.nlm.nih.gov/pubmed/12748151
27. Skeletal Muscle Relaxants
eg orphendarine
Some evidence of benefit
But generally we prefer analgesics over muscle relaxants
Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American
College of Physicians clinical practice guideline. http://www.ncbi.nlm.nih.gov/pubmed/17909211
28. Ketamine - analgesia
Low dose ketamine is an excellent analgesic
But some patients spin out – unpredictable which ones
Eg 0.1mg/kg prn q 5min IV. Advise patients that it is “trippy”. Sell it to them that it
will be pleasant.
Maximum dose of ketamine for unsupervised RMO probably 30mg
If someone is nervous give eg 1mg of midazolam IV before hand
Talk them through it as it is “coming on”
30. Other agents
Seldom used outside of theatre
Clonidine
Good analgesic and sedative
Beware of hypotension especially if other hypotensing agents
on board eg spinal anaesthesia
Eg 15µg q 15min IV, 2.5mg/week patch
33. Fentanyl patch
Ketamine infusion eg 0.3mg/kg/hour
PCA eg fentanyl
SC morphine eg palliative (NZ medical system resistant to use of
SC fentanyl currently)
34. Procedural anaesthesia
Current drug limits for RMOs is say 100 mcg fentanyl + 2
mg of midazolam
RMOs currently are not allowed to use propofol or more
than 30mg ketamine unsupervised (even though probably
safer than midazolam and morphine)
Pt who had 2 respiratory arrests in Xray after a shoulder
reduction
35. Procedural Anaesthesia
Ketamine + propofol = magic
Ketamine is a excellent analgesic and patients (if you give it right) maintain their ABCs
Downside:
“Bad trips” = “emergence reactions”
Vomiting
Add propofol
Anxiolytic
Antiemetic
= near perfect combo
