PAIN MANAGEMENT PROTOCOLS

Designation of Condition: Standing orders for controlled substances are found throughout this document. Listed below is the framework of intent for EMT-Intermediates and EMT-Paramedics to administer controlled substances within their Scope of Practice.

Use of Controlled Substances

1. In general, narcotic analgesics & benzodiazepines are not appropriate for patients involved in multi-systems trauma, prior to physician evaluation.
2. Narcotic analgesics & benzodiazepines are generally only given to a patient with isolated injuries and stable/normal vital signs or an assessment consistent with kidney stones or an isolated musculo-skeletal etiology (i.e., fracture, severe sprain).
3. No narcotic analgesic or benzodiazepine should be given to any pregnant patient without first discussing the possible ramifications with on-line Medical Control.
4. Any administration outside this realm should be done with on-line Medical Control.
5. If the patient becomes nauseated after administration of narcotic analgesics or benzodiazepines, consider administration of an anti-emetic agent such as PROMETHAZINE (Phenergan®) [12.5- 25 mg] IVP or deep IM for adults, or [0.5-1mg/kg] deep IM for pediatrics.

• The use of Promethazine in children may induce dystonic reactions.
• If anti-emetic other than Promethazine is needed, may consider as a second option Zofran 4mg IV for adults.

NOTE: The use of benzodiazepines as a sole agent for pharmacological assisted intubation has been determined by the Medical Direction Committee to be not in compliance with the New Mexico Scope of Practice.

Standing Orders Summary for Adults
Drug: Pain Mgmt. Anti-Convulsant Sedation
Morphine 2-10 mg
*Meperidine* 25-50mg
Fentanyl 25-50 mcg
*Diazepam* 2-20 mg
*Lorazepam* 2-4 mg 2-4 mg
*Midazolam* 1-5 mg

NOTE: The use of Morphine and Fentanyl for pain control by EMT-Intermediates must be done with the approval of on-line Medical Control.

* Approved at Paramedic level only

MORPHINE SULFATE
CLASS OF DRUG
Narcotic analgesic.

INDICATIONS

1. Analgesia for patients with major pain such as burns, and isolated fractures.
2. Treatment of acute pulmonary edema.
3. Acute myocardial infarction.
4. Sedation for procedures.

CONTRAINDICATIONS
1. Hypersensitivity.
2. Hypotension is a relative contraindication to use. Remember that some people will be
hypotensive in response to pain itself. Be cautious.
3. Head or abdominal injuries also contraindicated, since the analgesic effect removes the clinical signs that need to be watched.
4. Do not use in persons with respiratory difficulties because their respiratory drive might be depressed, except in pulmonary edema.
5. In the presence of major blood loss, the body's compensatory mechanisms may be suppressed by the use of morphine, and the hypotensive effect will become very prominent. Do not use it in these circumstances.

DRUG INTERACTION

1. Additive effects with other CNS depressants.
2. MAO inhibitors can cause unpredictable and severe reactions, reduce dose to 25% of a usual dose.

ADMINISTRATION
Adult: [2 - 10 mg] slow IV push until desired effect achieved (Use lowest effective dose to avoid complications).
Pediatric: [0.1 mg/kg] slow IVP titrated to effect with a maximum dose of 15 mg.

SPECIAL NOTES

1. Take vital signs before and 2 minutes after administration.
2. IVP only (unless you cannot start an IV and/or are directly ordered to administer IM).
3. Often causes vomiting; administer slowly.
4. On-line medical control should be contact before administering to the non-cardiac patient.

FENTANYL (SUBLIMAZE®)
CLASS OF DRUG
Narcotic analgesic.

INDICATIONS

1. Analgesia for patients with moderate to severe pain.
2. Short term sedation.
3. Anesthesia.

CONTRAINDICATIONS

1. Hypersensitivity/known intolerance.
2. Patients particularly sensitive to respiratory depression.
3. Myasthenia gravis.
4. Pregnancy.

DRUG INTERACTION

1. Benzodiazepines Diazepam - increased risk of CV depression.
2. Sedatives/Hypnotics, other opioids, CNS depressants and alcohol - increased risk of hypotension.
3. Avoid use in patients who have received MAO inhibitors within the previous 14 days – may produce unpredictable, potentially fatal reactions.

ADMINISTRATION
Adult: [25-50 mcg] IVP.
Pediatric: Under <15 kg (transmucosal only) .
2-12 yrs of age – [1 mcg/kg].

SPECIAL NOTES

1. Use cautiously in geriatric or debilitated patient (use lower doses), diabetics, patients with pulmonary or hepatic disease, head trauma, increased ICP, undiagnosed abdominal pain and cardiac disease.