Pharmacology

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Pharmacology

• Medicinal and Recreational

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• Presented by..

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• Me again!!!

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What I hope to teach and/or review

• A little history
• Drug names
• Drug Sources
• Drug Schedules
• Responsibility of the Medic
• Mechanism of Action
• Medicinal Drugs
• Drips
• Recreational Drugs
• Pain Management
• Studies
• Special Considerations

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• History

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History

• Ancient health care
• Herbs minerals used to treat sick injured
• Documented use as long as 2,000 B.C.
• Ancient Egyptians, Arabs, Greeks
• The Bible, Torah and Koran all make references to
  medicinal herbs
• The renaissance period
• Pharmacology became a distinct and growing
  discipline
• Separate from medicine

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History

• Modern health care
• Last 50 years have seen explosion in growth of
  biological sciences and associated medicine and
  pharmacology
• The present period of change
• Research directed to discover new treatments,
  cures and prevention of disease

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• Drug Names

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Drug Names

• Chemical Name
• Precise description of the drugs chemical
  composition and molecular structure
• 7-chloro-1, 3-dihydro-1methyl-5-phenyl-2H-1,
  4-benzodiazepin-2-one
• Generic Name (Non-proprietary Name)
• Official name approved by the FDA
• Usually suggested by the first manufacturer
• diazepam

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Drug Names (continued)

• Official Name
• The name assigned by the USP (U.S Pharmacopeia)
• diazepam, USP
• Trade Name (Proprietary Name)
• The brand name registered to a specific
  manufacturer or owner
• Valium

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Who am I?

• Chemical Name
• 5-2-ethoxy-5-(4-methylpiperazin-1-ylsulfonyl)p
  henyl-1- methyl-3-propyl-1,6-dihydro-7H-pyrazolo
  4,3-dpyrimidin-7-one, formula C22H30N6O4S

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Who am I?

• Brand Name
• Sildenafil

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• Viagra, USP

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• Drug Sources
• (No, not THOSE kind of sources)

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Drug Sources

• Plants
• morphine sulfate, atropine
• Animals and/or Humans
• insulin,
• Minerals
• sodium bicarb, calcium
• Synthetic (Chemical Substances)
• lidocaine, diazepam

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• Drug Schedules

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Drug Schedules

• Schedule I
• Heroin, LSD
• NO accepted medical use
• Schedule II
• Opium, Cocaine
• Accepted medical use
• Severe dependence

• Schedule III
• Tylenol with Codeine
• Low dependence
• Schedule IV
• Diazepam
• Limited dependence
• Schedule V
• Opiods (cough

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• Responsibilities of the Medic

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Medic Responsibility

• You have the responsibility for the safe and
  therapeutic drug administration to your patient
• You also have the responsibility for each drug
  you administer.
• Legally
• Morally
• Ethically
• You also have the responsibility to be able to
  justify which drugs you DID NOT administer.

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Medic Responsibility (continued)

• Observe and document effects of drugs
• Keep knowledge base current
• Understand pharmacology

• Identify drug indications and contraindications
• Seek drug reference literature
• Take a drug history from patients
• Consult with medical control when necessary

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• Mechanisms of Actions

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General properties of Drugs

• Drugs do NOT stimulate new functions on a tissue
  or organ, they merely modify existing functions
• Drugs in general exert multiple effects (good and
  bad) rather than a single effect

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Drug Receptor Interaction

• Agonists
• Drugs that bind to a receptor site and CAUSE a
  physiological response
• Antagonists
• Drugs that bind to a receptor site and PREVENT a
  physiological response or prevent another drug
  from binding to a receptor site

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Types of Receptors

• Beta 1
• Beta 2
• Alpha 1
• Alpha 2

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Beta Receptors

• Beta 1 Receptors
• Located primarily in the heart
• Cause increases in inotropy chronotopy
• Beta 2 Receptors
• Located primarily in the lungs
• Dilate bronchioles blood vessels
• Relax smooth muscle

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Alpha Receptors

• Alpha 1 Receptors
• Stimulate contraction of smooth muscle
• Results in increase in BP
• Alpha 2 Receptors
• Inhibit further release of norepinephrine
• Mediate vasoconstriction

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Factors Altering Response

• Age
• Infants liver kidney not fully developed
• Elderly liver kidney function deteriorates
• Body Mass
• More body mass more fluid available to dilute
  drug
• Gender
• Differences in the relative proportions of fat
  and water

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Factors Altering Response

• Environment
• Changes in temperature
• Time of Administration
• Presence or absence of food in GI tract
• Pathological State
• Illness or injury
• Underlying disease processes

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Factors Altering Response

• Genetic
• Lack of specific enzymes
• Lowered basal metabolic rate
• Psychological
• If the patient believes it will work it will work
  (placebo effect without the placebo)

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Desired and Predictable Effects

• Desired Action
• Action or effect is seen that is consistent with
  why the drug was given
• Side Effects
• Undesirable and often unavoidable effects of a
  drug
• Action or effect other than those for which the
  drug was given

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Unpredictable and Undesirable Effects

• Allergic Reaction
• Activates the Immune System
• Anaphylactic Reaction
• Severe allergic reaction
• Idiosyncracy
• Drug effect unique to individual
• Different than expected

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Unpredictable and Undesirable Effects

• Tolerance
• Physiologic response that requires a drug dosage
  to be increased to produce the same effect
• Cross Tolerance
• Tolerance after administration of a different
  drug

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Unpredictable and Undesirable Effects

• Tachyphylaxis
• Rapidly occurring tolerance to a drug
• Common in decongestant and bronchodilation agents
• Cumulative Effect
• Tendency for repeated doses of a drug to
  accumulate in the blood stream often causing
  toxic effects

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Unpredictable and Undesirable Effects

• Drug Dependence
• State in which withdrawal of a drug produces
  intense physical or emotional disturbance
• Drug Interaction
• Beneficial or detrimental effects of one drug by
  the prior or concurrent administration of another
  drug

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Ready for a Break?
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Medicinal Drugs

• Lets review our least used drugs

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Amidate

• Actions and Effects
• Nonbarbituate hypnotic with minimal
  analgesic activity has minimal effects on
  myocardial activity, BP and respirations onset
  is 30-60 seconds duration is 3- 10 minutes and
  is dose dependent. (Intubated patients should be
  sedated with versed or Fentanyl, 5-10 minutes
  after the administration of Etomidate)
• Indications
• To facilitate anesthia for RSI or to provide
  the stun effect for procedures such as
  extrication
• Precautions/Contraindications
• Pregnancy
• Known Hypersensitivity
• Patients under the age of 10 due to lack of
  adequate dosage data
• Administration/Dosage
• Adult 0.2 0.6 mg / kg IVP (0.3 mg / kg
  STUN DOSE / 0.5 - 0.6 mg / kg INTUBATION)
• Pedi 0.02 0.06 mg / kg IVP (Not recommended
  under the age of 10y/o)

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Amidate

• Side effects
• Laryngospasm
• Transient pain at IV site
• Nausea/vomiting
• Hiccoughs
• Transient adrenal suppression (seen mostly in
  repeat dosing)
• Allergic reactions (rare)
• If Etomidate is used for RSI consider Versed or
  Fentanyl for synergistic effects to obtain
  amnestic/analgesic effects secondary to Etomidate
  not having either of these properties

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Calcium Gluconate

• Actions and Effects
• May relieve the tetany and spasm from certain
  insect bites
• Indications
• Black Widow Spider bites _ resulting in sever
  muscle cramping
• May be used in renal patients
• Respiratory Depression with Mag Sulfate
  administration
• Precautions/Contraindications
• Avoid in patients taking digitalis preparations
• Rapid IV administration my result in
  vasodilatation, hypotension, bradycardia,
  arrhythmias, syncope or cardiac arrest
• Infiltration at IV site may cause venous
  irritation, necrosis and sloughing of tissue
• Administration
• Administer 10ml of a 10 solution (4.65 mEq)
  slow IVP

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Dobutamine

• Actions and Effects
• A direct acting inotropic agent possessing beta
  stimulating activity. Increases cardiac output
  by increasing stroke volume with minimal increase
  in rate and BP, and minimal disturbance to
  rhythm.
• Indications
• Cardiogenic Shock
• CHF
• Precautions/Contraindications
• Hypersensitivity to sulfates
• Hypovolemic shock (uncorrected)
• Use caution with AMI (may increase ischemia or
  infarct size)
• incompatible with Sodium Bicarbonate, Calcium
  Chloride, TPA, Valium, Digoxin, Lasix, and
  Magnesium Sulfate
• Administration/Dosage
• 2 20 mcg / kg / min (may take up to 10 min to
  achieve effect)
• Precautions/Contraindications
• Tachydysrhythmias, V-tach-V-Fib,
  Nausea/Vomiting, HTN, AMI/chest pain, Headache,
  SOB, palpations

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Dopamine

• Actions and Effects
• Naturally occurs in a person and has 3
  adrenergic effects
• Dopamanergic (dilates renal and mesenteric
  vessels)
• Beta (increases cardiac output)
• Alpha (peripheral vasoconstriction, may cause
  renal vasoconstriction, high doses may lead to
  shutdown of renal and mesenteric circulation
• Indications
• Cardiogenci Shock
• Hypotensive situations not realted to
  hypovolemia
• Precautions/Contraindications
• Do not mix with Sodium Bicarb
• Do not use with hypotension due to hypovolemia
• Do not use in the presence of uncorrected
  tachyarrhythmias
• Titrate down graually if terminating or
  reducing
• Contraindicated in known Pheochromocytomia

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Dopamine

• Administration/Dosage
• Administer 5 -10 mcg / kg / min IV drip
• Start drip at 5 mcg / kg / min (Titrate to BP
  of 90- 100 mmHG SYSTOLIC)
• Side Effects
• Palpatations, tachycardia, nausea/vomiting,
  dyspnea, headache, HTN, ventricular arrythmias

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Magnesium Sulfate

• Actions and Effects
• A CNS depressant, it is often used in managing
  seizure activity in eclampsia. May also have
  vasodilation effects
• Indications
• Refractory V-fib
• Seizure activity as a result of eclampsia
• Severe respiratory distress
• Precautions/Contraindications
• Contraindicated in heart block or recent MI
• Monitor respirations for depression, prepare to
  assist ventialtion
• In the event of respiratory depression, Calcium
  preparations may be adminsitered
• Administration/Dosage
• Refractory V-fib 1 2 g IVP
• Eclampsia 1 4 g IVP
• Respiratory Distress 2g OVER 20 min
• Side Effects
• Hypotension
• Circulatory collapse
• Respiratory depression

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Procainamide

• Actions and Effects
• Increased ventricular fibrillation threshold.
  Is no more effective than Lidocaine.
• Indications
• Ventricular dysrhythmias
• PVCs and PSVT with WPW
• Precautions/Contraindications
• Hypersensitivity
• Complete heart block
• High degree heart blocks unless pacemaker is
  operative
• Hypotension
• Administration
• Adult 20 30 mg / MIN IVP UP TO 17 mg / kg
  total
• IV PIGGY BACK 1 4 mg / MIN
• Pedi 2 6 mg / kg IV, lt20 mg /min IO (DRIP
  20 80 mcg / kg / min)
• Side Effects
• PR, QRS and QT widening_ Stop administration,
  AV block, cardiac arrest, hypotesnion, seizures,
  nausea/vomiting

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Solu-Medrol

• Actions and Effects
• A synthetic steroid that suppresses acute and
  chronic inflammation. It also penetrates
  vascular smooth muscle causing relaxation by
  beta- adrenergic agonists and may alter airway
  hyperactivity. It may also be used for reduction
  of post-traumatic spinal cord edema.
• Indications
• Anaphylaxis
• Bronchodilator for respiratory difficulty
• Acute spinal cord injury
• Precautions/Contraindications
• Use caution with GI bleeds, use caution with
  Diabetes, crosses the placenta and may cause
  fetal harm.
• Administration/Dosage
• Adult 125 mg IVP
• 30 mg / kg IVP (Spinal cord injury)
• Pedi 1 2 mg / kg IV
• Side Effects
• Headache, HTN, Hypokalemia, Alkalosis,
  Sodium/water retention

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• Drips

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Nitroglycerin Drip

• Packaged 50mg/250cc
• Dosage 5mcg/min escalating by 5mcg/min, titrate
  to maintain BPgt 100 systolic
• Directions Draw Nitroglycerin straight from
  bottle to fill 60cc Terumo syringe. Pump setting
  for 5mcg/min is 1.5ml/hr, each increase of
  1.5ml/hr will increase Nitroglycerin
  administration by 5mcg/min.

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Magnesium Sulfate

• Packaged 5gms/10ml
• Dosage 2gms over 20min
• Directions Draw 4cc from vial into 60cc Terumo,
• Fill syringe to 60cc with NS, set syringe pump to
  180ml/hr

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DOPamine

• DOPamine
• Packaged (400mg/10ml)
• Dosage 5mcg-10mcg/kg/min titrate to systolic of
  90-100mmHG
• Directions Draw entire contents of vial and add
  to 1000cc NS. Draw 60cc into Terumo syringe
• DOPamine starts at 5mcg/kg/min

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DOBUTamine

• Packaged (250mg/20ml)
• Dosage 2mcg-20mcg/kg.min titrate to effect
• Directions Draw entire contents of vial and add
  to 1000cc NS. Draw 60cc into Terumo syringe
  DOBUtamine starts at 2mcg/kg.min

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Epinephrine

• Packaged (250mg/20ml)
• Dosage 2mcg-20mcg/kg.min titrate to effect
• Directions Draw entire contents of vial and add
  to 1000cc NS. Draw 60cc into Terumo syringe
  DOButamine starts at 2mcg/kg.min
• 2mcg/min 8ml/hr
• 4mcg/min 15ml/hr
• 6mcg/min 23ml/hr
• 8mcg/min 30ml/hr
• 10mcg/min 38ml/hr

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Solu-Medrol

• Packaged 125mg or 1gm
• Dosage 30mg/kg over 30 minutes
• Directions Draw appropriate amount into 60cc
  Terumo syringe. Fill syringe to 60cc with NS. Set
  pump rate to 120cc per hr.

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Lidocaine Drip

• Packaged Pre-mixed
• Dosage 2-4mg/min
• Directions Separate IV line, or piggyback.
• If bolus is Drip rate would be
• 1.5mg/kg 2mg/min
• 1.5-2mg/kg 3mg/min
• 2-3mg/kg 4mg/min
• Using a 60gtt set,
• 15 drops per minute 1mg/min,
• 30 drops per minute 2mg/min,
• 45 drops per minute 3mg/min
• 60 drops per minute 4mg/min.

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Amiodarone

• Packaged 150mg/3ml
• Dosage 150mg over 10 minutes
• Directions Draw entire contents of vial into
  Terumo syringe, fill syringe to 60cc with NS, set
  pump rate at 360cc/hr

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• Recreational Drugs
• (and abused prescription drugs)

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Recreational Drugs (Abused
Prescription Drugs)

• Some of the most commonly abused recreational
  drugs are
• Methamphetamines
• Heroin
• Cocaine
• Marijuana
• GHB
• Benzodiazapines

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Overdose

• Meth overdose
• No antagonist approved for humans
• Life support measures
• Watch for dehydration, HTN and signs of impending
  organ failure

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Overdose

• Heroin
• Semi synthetic opioid
• Watch for respiratory depression/arrest
• Reversed with Narcan
• Slow push, too fast, or too much can lead to
  withdrawls
• Half life of Heroin is longer than that of
  Narcan, dose may need to be repeated

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Overdose

• Cocaine
• While listed as a narcotic Narcan will have
  little effect on Cocaine
• Cocaine is often mixed with other drugs, so
  Narcan may be effective on THOSE drugs (i.e.
  Speedball)
• Stimulant properties
• Watch for tachyarrythmias

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Overdose

• Marijuana
• As my goal in life is to one day smoke pot with
  Jimmy Buffett on a beach in Key West, I will
  comfortably day that it is nearly impossible to
  overdose on Marijuana.

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Overdose

• GHB
• Second most popular date rape drug, most
  popular is Rohyphnol
• No antagonist approved for humans
• Life support measures

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Overdose

• Benzodiazapines
• CNS depressant
• Watch for respiratory depression/arrest
• Antagonist is Romazicon
• Life support measures in prehospital environment

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Prescription Medications

• A recent article shows that 12 of the top 20
  abused drugs of all types are prescription drugs.

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Top Ten

• 10) Chlordiazepoxide (Librium)
• 9) Temazepam (Restoril)
• 8) Propoxyphene HCL and N, Propacet,
  Darvocet
• 7) Lorazepam (Ativan)

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Top Ten

• 6) Methadone
• 5) Diazepam (Valium)
• 4) Alprazolam (Xanax)

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Top Ten

• 3) Codeine Combinations Tylenol 3 4, Apap
  with Codeine, etc.
• 2) Oxycodone Derivatives Percodan, Percocet,
  Tylox, Roxicet, etc.

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Top Ten

• And the number 1 most abused prescription drug
  is..
• Hydrocodone Combinations Vicodin, Lorcet,
  Lortab, Norco, Hydro-Apap, etc.

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• Pain Management

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• In 1989, two physicians coined the phrase,
  oligoanalgesia, which means the undertreatment
  of pain. Since then, studies have shown it at
  epidemic proportions.

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Myths of Pain Management

• Myth 1
• If I give my patient narcotics, they wont be
  competent enough to consent to surgery later.

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Myths of Pain Management

• Fact
• A person who has received narcotic analgesia may
  be able to more clearly consider treatment
  decisions than a patient who is experiencing
  severe pain. In some ways, withholding
  appropriate analgesia until after consent can be
  looked upon as coercion, whereas the analgesia is
  a reward for consenting to a procedure

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Myths of Pain Management

• Myth 2
• If I gove my patient narcotics for abdominal
  pain, it will change the physical findings,
  making diagnosis difficult

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Myths of Pain Management

• Fact
• The dogma of withholding analgesia for fear that
  it will alter abdominal examination stems from a
  book written in 1921. Research done recently
  randomly assigned patients suffering from
  abdominal pain either Morphine or Normal Saline,
  and were assessed for surgery after
  administration. The presence of peritoneal signs
  did not change from group to group, and the
  accuracy between the two groups did not differ.

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Myths of Pain Management

• Myth 3
• If I give my patients narcotics, they will
  develop respiratory arrest.

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Myths of Pain Management

• Fact
• While it is true that narcotic analgsics can
  lead to respiratory depression or arrest, the
  respiratory depressant effects are offset by
  respiratory rate increase that the nociceptive
  receptors produce. As long as the nociceptive
  stimulus is present and the narcotic analgesia is
  used properly, the patients respirations wont
  be depressed.

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Myths of Pain Management

• Myth 4
• If I give my patient narcotics, theyll abuse
  narcotics.

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Myths of Pain Management

• Fact
• In the prehospital setting, as well as in the
  ED, it can be difficult to distinguish
  drug-seeking individuals from those requiring
  legitimate analgesia. Remember that if they have
  previously abused narcotics, they may require
  larger doses due to tolerance. It is unethical to
  withhold appropriate analgesia based solely upon
  addiction concerns. Although some patients may be
  malingering and/or drug-seeking, that doesnt
  warrant withholding analgesia from all patients

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Pain Management

• The single most frequent reason people summon
  EMS or present to an emergency department (ED) is
  pain. However, studies have shown that, in
  general, we do a poor job of treating
  itespecially in the prehospital setting.

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Pain Management

• Historically, EMS providers have been less
  than accurate with rating pain, and studies have
  shown that a scale of 1-10 is not always the most
  reliable means of evaluating pain. One complaint
  of the 1 to 10 scale is that it never allows
  the patient to be pain free. The Visual Analog
  Scale (VAS) is considered to be more reliable for
  accuracy, and easier to use in younger patients
  and non native language speaking patients.

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Pain Management

• Pain is the number one reason people summon EMS.
  Unfortunately, pain management in EMS is poor at
  best. Numerous studies have identified the
  problems with prehospital pain managementbut
  have primarily looked at adults. A study by Bob
  Swor, DO, and his colleagues at a Royal Oak,
  Michigan hospital, looked at the prehospital
  management of pain in injured children.

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Pain Management

• They performed a retrospective records review of
  children with a final diagnosis of extremity
  fracture or burn that were transported by
  ambulance. These two diagnoses were chosen
  because there are few contraindications to
  prehospital analgesia in these cases. They found
  76 patients who met their criteria (three were
  excluded because EMS records were unavailable).
  The mean age was 12.4 years and only 4 patients
  were less than 5 years of age. The majority of
  patients were male and sustained femur (27.4
  percent) or tibia/fibula (35.6 percent)
  fractures. Only 22 percent (16 of 73) patients
  received prehospital analgesia, while 79 percent
  received analgesia in the ED.

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Pain Management

• This study supports others that illustrate that
  EMS does a poor job of treating pain. Pain should
  be assessed using a quantitative scale. There are
  pain scoring systems for all ages (including
  neonates) and these should be used. Compassionate
  prehospital care is more about making people feel
  better than about saving lives. One of the most
  compassionate things a paramedic can do is treat
  painespecially in children.

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Pain ManagementVisual Analog Scale

• No Pain Worst Pain Ever

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Fentanyl

• Short acting narcotic
• For use in pain management
• Can also be used as sedative agent at higher
  doses
• Rapid administration can cause Wooden Chest or
  rigidity of chest wall muscles
• Watch for hypotension and respiratory depression
• Can be reversed with Naloxone

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• Studies

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Studies

• To determine the safety and effectiveness of
  fentanyl administration for prehospital pain
  management. METHODS This was a retrospective
  chart review of patients transported by ambulance
  during 2002-2003 who were administered fentanyl
  citrate in an out-of-hospital setting. Pre- and
  post-pain-management data were abstracted,
  including vital signs, verbal numeric pain scale
  scores, medications administered, and recovery
  interventions. In addition, the emergency
  department (ED) charts of a subgroup of these
  patients were reviewed for similar data elements.
  RESULTS Of 2,129 patients who received fentanyl
  for prehospital analgesia, only 12 (0.6) had a
  vital sign abnormality that could have been
  caused by the administration of fentanyl. Only
  one (0.2) of the 611 patients who had both field
  and ED charts reviewed had a vital sign
  abnormality that necessitated a recovery
  intervention. There were no admissions to the
  hospital, nor patient deaths, attributed to
  fentanyl use. There was a statistically
  significant improvement in subjective pain scale
  scores (8.4 to 3.7). Clinically, this correlates
  with improvement from severe to mild pain.
  CONCLUSION This study showed that fentanyl was
  effective in decreasing pain scores without
  causing significant hypotension, respiratory
  depression, hypoxemia, or sedation. Thus,
  fentanyl citrate can be used safely and
  effectively for pain management in the
  out-of-hospital arena.

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Studies

• To assess the knowledge of emergency medical
  technicians-paramedics (EMT-Ps) and compare their
  practice perceptions with actual pain management
  interventions in adults and pediatric patients
  (adolescents and children) with chest pain (CP),
  extremity injuries, or burns. METHODS This study
  included a cross-sectional survey of EMT-Ps and
  review of the emergency medical services (EMS)
  system patient care database. EMT-Ps were
  surveyed for
• 1) knowledge of pain treatment protocol
• 2) estimated number of CP, extremity injury, or
  burn encounters and the frequency of morphine
  administration and
• 3) barriers to providing morphine.

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Studies

• RESULTS Of 202 EMT-Ps, 155 (77) completed the
  survey. Eighty-two percent reported knowledge of
  pain treatment protocol for both adults and
  pediatric patients. For adults, EMT-Ps estimated
  they administered morphine to 37 with CP, 24
  with extremity injuries, and 89 with burns. In
  children and adolescents, inability to assess
  pain (93) was the most common reason for
  withholding morphine. According to the EMS
  database, 5 of adults with CP, 12 extremity
  injuries, and 14 burns received morphine. In
  children and adolescents, 3 with extremity
  injuries and 9 with burns received morphine.
  Pain score was documented in 67.0 of adult
  patients, compared with only 4.0 in pediatric
  patients

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Studies

• CONCLUSIONS Significant disparity exists
  between EMT-Ps' perceptions of acute pain
  assessment and the frequency of providing
  analgesia and their actual practice. Children and
  adolescents had less documentation of pain
  assessment and received less analgesic
  interventions compared with adults. Inability to
  assess pain may be an important barrier to the
  provision of analgesia.

90
Studies

• Prehospital analgesia can be safely provided
  with only three agents fentanyl, morphine and
  the mixed-gas nitrous oxide/oxygen. Of these
  three, fentanyl is by far the best agent for
  general EMS analgesic therapy by paramedics.
  However, to initiate prehospital analgesia
  earlier in the EMS response time frame, EMT's
  should administer nitrous oxide/oxygen. This
  protocol can easily be added to the EMT education
  program or through a continuing education
  session. All of the other agents discussed have
  absolutely no role in modern prehospital care.

91
Studies

• Pain measurement and relief is complex and
  should be a priority for prehospital providers
  and supervisors. The literature continues to
  prove that we are poor pain relievers, despite
  the high prevalence of pain in the
  out-of-hospital patient population. Lack of
  education and research, along with agent
  availability, controlled substance regulation,
  and many myths given credence by health care
  providers, hinder our ability to achieve adequate
  pain assessment and treatment in the prehospital
  setting. Protocols must be established to help
  guide providers through proper acknowledgment,
  measurement, and treatment for prehospital pain.
  Finally, formation of quality improvement pain
  programs that evaluate patient outcomes and
  provider practice patterns will help EMS systems
  understand the pain management process and
  outline areas for improvement. Only through
  emphasis on pain education, research, protocol
  and program monitoring development will the
  quality of pain assessment and management in the
  prehospital setting improve.

92
Studies

• STUDY OBJECTIVE The aim of this study was
  to compare morphine (M) and fentanyl (F) in a
  prehospital setting. METHODS Consecutive
  patients with severe, acute pain defined as a
  visual analog scale score (VASS) of 60/100 or
  higher were included. The M group received an
  initial intravenous M injection of 0.1 mg/kg then
  of 3 mg every 5 minutes. The F group received an
  initial intravenous F injection of 1 microg/kg
  then of 30 microg every 5 minutes. The goal of
  analgesia was a VASS of 30/100 or lower. The end
  point was the VASS measured 30 minutes after
  initial administration RESULTS There were 26
  patients included in the M group and 28 in the F
  group. Sixty-two percent of patients in the M
  group described analgesia as excellent or good vs
  76 of those in the F group who did. There were
  no differences in the incidence of side effects
  in the 2 groups.

93
Studies

• CONCLUSION This study demonstrates that M and
  F were comparable in treating severe, acute pain
  in a prehospital setting during the first 30
  minutes in spontaneous breathing patients.

94

• Special Considerations

95
Special Considerations

• Pain management in the patient who admits to,
  or exhibits signs of addiction presents us with
  special considerations. These considerations
  include the patients right to refuse medications
  and/or treatment regimens. It is our duty and
  obligation to offer alternatives to what would be
  considered the norm.

96
Special Considerations

• We as medical professionals, cannot impart our
  own morals, values or ethics to our patients with
  regards to the level of care they receive. We
  have a duty and an obligation to offer a quality
  level of care to our patients regardless of our
  own personal views, and to offer compassionate
  care to all who request it.

97
Addicts and recovering addicts

• When dealing with the patients who have built
  a tolerance level through heavy use or abuse of
  narcotics, consider alternative dosing. While a
  starting dose of 2mg of Morphine my be
  appropriate, titrating to effect will come into
  play, and the amount of Morphine administered may
  require Medical Control consultation.

98
Addicts and recovering addicts

• Often times pain will be reduced with
  reduction of anxiety. Other regimens to consider
  may be Versed for sedative effects if the patient
  refuses narcotics. Amidate may also be considered
  but has a much shorter half life, and fails to
  cause the amnesic effects that Versed does. If
  Amidate is used, considering following that with
  Versed for the synergistic effect.

99
Basics

• The 6 Rights to Medication Administration
• Right Medication
• Right Dose
• Right Time
• Right Route
• Right Patient
• Right Documentation

100
Things not to say after giving a medication

• Sir? Sir? Can you still hear me? Stop playing
  around and start breathing
• Holy shit what did you give him?. Where did his
  eyes go? Throw that vial away quick. Did he
  already sign the refusal? Lets bail.
• Atropine is in the RED box right?
• Some for you and some for me..
• Stupid decimal system, just give him all of it..
• No, Dr. Kevorkian really IS my name
• Of course you can give it rectally, dont they
  teach you guys anything in paramedic class
  anymore?
• Whoa..I bet nobody expected THAT to happen huh?
  Wanna do it again?

101

• Questions?
• Comments?
• Concerns?
• Additions?
• Deletions?