January 25, 2010 Michael W Bove, CCEMT-P

Analgesia and Sedation
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Analgesia: The inability to feel pain while still conscious. From the Greek an, without + algesis, sense of pain. Sedation: The act of calming by administration of a sedative. A sedative is a medication that commonly induces the nervous system to calm.

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Analgesia and Sedation
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Analgesics NSAIDS - ASA,
Acetaminophen, Ibuprofen , naproxen, Toradol, etc.

Sedatives ‡ Barbiturates - Seconal,
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Nembutal, Phenobarbital, etc.

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Benzodiazepines Valium, Atavan, Zanax, Lorazepam, Midazolam, etc. ± Catnip, ashwagandha, Kava, etc.

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COX -2 inhibitors Rofecoxib, (Vioxx), celecoxib, (Celebrex)

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Herbal Sedatives

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Opiates and Morphinometics Morphine, codeine, oxycodone, hydrocodone, Fentanyl, etc.

Nonbenzodiazepines Lunesta, Sonata, Ambien, etc.

Antihistamines Diphenhydramine, Promethazine, Doxylamine etc.

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Other Agents - Tricyclic
antidepressants, Anticonvulsants

but it carries potentially severe adverse effects such as agitation. respiratory tone and hemodynamic changes induced by catecholamines. € . € Pain is sometimes required for diagnosis. producing poor outcomes.Analgesia and Sedation Sedatives do not relieve pain in themselves. they can be a useful adjunct to analgesics.

Pain is often difficult to measure in an emergency situation. once the ABCs (Airway. . Breathing. factors such as anxiety level and the patient¶s personality are important. and the usual assessment tools are more relevant to chronic pain. allowing greater precision in further management.Analgesia Pain should be assessed and managed as an early priority. Circulation) have been managed. However.

Pain produces sympathetic hyperactivity. Pain is clearly a component of clinical need that deserves attention sooner rather than later. stroke volume. resulting in an increase in heart rate. mild. Early analgesia will reduce the neuro-endocrine response to stress. dehydration. and promotes catabolism of proteins and lipids. starvation. pain. antidiuretic hormone (ADH). cortisol. Pain can be graded as none. Factors that drive this stress response are anxiety. infection. moderate. hypo-/hyperthermia. and looking at µincident to analgesia time¶ may reduce the time taken to provide pain management. The stress response reduces insulin uptake. and a decrease in gastrointestinal motility and urine output. relative glucose intolerance and insulin resistance. and myocardial oxygen consumption. causing hyperglycemia. which produces an increase in adrenocorticotrophic hormone (ACTH). growth hormone (GH) and glucagon.Pain is assessed rapidly using both verbal and behavioral cues. and severe. hypoxia. and prolonged immobilization. . acidosis.

nasogastric intubation. Measures that will reduce the amount of analgesia required are cooling and covering burns. Effective. thirst. Analgesic requirements can be reduced by attending to simple matters first. endotracheal intubation. feeling cold. Sedation should only be considered once adequate analgesia is achieved as pain relief should allay much of a patient¶s anxiety. elevating. intravenous cannulation. anxiety. confident communication with the patient will create an atmosphere of trust and co-operation that will facilitate management. lying on a Back board. lack of rest. urinary catheterization. splinting and immobilizing an injured limb. and poor communication.What distresses patients? Pain. . poor fitting cervical spine collars. cooling muscle injuries.

Conscious sedation.Sedation Some patients may require sedation without analgesia in an emergency. Synergism between opioids and benzodiazepines is both positive and negative in implication: Analgesia + sedation = procedural sedation If the synergistic action is not understood/anticipated. this could be seen as: Opioids + benzodiazepine = respiratory depression Bottom line is sedatives and analgesics are synergistic . monitored anesthetic care. and dissociate anesthesia are all anesthetic terms. Emergency environment terminology of sedation may be confusing and inappropriate. The benzodiazepines are the favored group of drugs for sedation after analgesia has been given.

or pharmacological interactions. facilitate care and management. Patient agitation is another common problem in the critical care environment . longer ICU stays and economic effects. and the avoidance of self extubation and inadvertent removal of catheters and other life dependency equipment is essential. The desired result of a sedation regimen is to allow the patient to tolerate the physical environment. Failure to meet goals of proper sedation and analgesia have deleterious consequence. it may result from a specific cause such as hypoxia. that are associated with an increase in adverse events. under ventilation. reduced oxygen consumption and ventilator synchrony are other important goals of sedation therapy. inadequate or excessive sedation and analgesia is still common. metabolic derangement and other correctable entities that should be addressed first.Sedatives and analgesics are the most commonly administered medications in the critical care environment. Recent studies have shown better outcomes and cost savings using protocol driven sedation and analgesia guidelines. but it may be the result of sleep deprivation. and reduce both anxiety and stress. Despite the frequency of use of these drugs. and require sedation to control . Patient safety is paramount. The blunting of autonomic responses. poor outcomes.

an increased time in the intensive care unit. and an increased cost of care. . 21: 457 . British Medical Journal. The benefits and pitfalls of pulse oximetry. when there is an increased concentration of inspired oxygen [1].458. In the extubated patient it may be associated with severe hypercarbia. but will prolong the weaning process. The common effect of an increasing dose of most sedative agents is respiratory depression. The pulse oximeter is a LATE detector of respiratory depression. Respiratory rate and end-tidal carbon dioxide measured via a nasal cannula. 1. are reliable monitors of depressed respiration . hypoxia and respiratory arrest. Hutton P & Clutton-Brock T. This may facilitate ventilator synchrony.Over Sedation The results of over sedation in the mechanically ventilated patient are an increased time being ventilated.

Under Sedation The untoward effects of under sedation include an increased production of endogenous catecholamines. Palmeri BA & Hammond JS. .635. Survivors. Coursin DR. The mental sequelae from being awake while painful. Patient recall of therapeutic paralysis in a surgical critical care unit. Wagner BK. 26: 634 . 18: 358 . beware of posttraumatic stress disorder: What shall we tell the Men in Black? Critical Care Medicine 1998. 2. Coursin DB. The patient may be at risk for self injury from the accidental removal of the endotracheal tube or vital catheters. Pharmacotherapy 1998. heart rate and myocardial oxygen consumption. The patients¶ who are unresponsive because of the administration of neuromuscular blocking drugs are most at risk [2]. Sweeney JB. Zavotsky KE. that may require prolonged therapy after discharge [1]. and terrifying procedures are performed on the patient can be the development of a post-traumatic stress disorder.363. that results in an increase in blood pressure. 1.

In fact sedation scoring systems should be in regular use where ever potent respiratory depressant drugs are being used.To prevent the adverse complications of poorly controlled sedation. used routinely and be part of the regular assessment of the critical care patient. The depth of sedation should be clearly defined and the infusion of sedative drug precisely targeted to this clinical endpoint. The scoring system selected for use must be easily understood. as all care-givers understand the required depth of sedation. the dangers of over or under sedation are minimized. It will also provide for continuity of care. . By defining the sedation level and carefully controlling the sedation infusion to meet this endpoint. To be able to reach this goal the routine use of sedation scales is essential. sedation therapy should be administered in a careful and precise manner.

The RSS scores sedation at six different levels. or both Patient is co-operative. was the first scale to be defined and was designed as a test of rousability. and tranquil Patient responds to commands only Patient exhibits brisk response to light glabellar (Forehead) tap or loud auditory stimulus Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus Patient exhibits no response . not only in the ICU. It can be added to the pain score and be considered the sixth vital sign. It is an intuitively obvious scale and therefore lends itself to universal use. according to how rousable the patient is. oriented. but wherever sedative drugs or narcotics are given. Ramsay Sedation Scale 1 2 3 4 5 6 Patient is anxious and agitated or restless. Table).The Ramsay Sedation Scale The Ramsay Sedation Scale (RSS.

Flow Chart 2 ± Anxiety Model € Flow Chart 3 ± Head injury Model € Flow Chart 4 ± Non-intubated Patient Model .Sedation Flow charts € € Flow chart 1 ± Patient assessment and determination of prognosis.

Flow Chart 1 Patient Assessment Spontaneous Respiration CPP Compromised Flow Chart 4 Mechanically Ventilated Flow Chart 3 Pain Anxiety Delirium Flow Chart 2 Fentanyl 50 ± 100mcg Or Morphine 2 ± 5mg Bolus then re-evaluate Q 15 min.5 mg . Midazolam 2.5 ± 5 mg Re-evaluate then 2.

need for blood pressure management or need for neurologic assessments Prolonged need for Sedation > 24 hrs Propofol 10 ± 25 mcg/kg/min in increments of 10 ± 25 mcg/kg/min.Flow Chart 2 Anxiety Expected to wean from vent < 24 hrs. q 5 ± 10 minutes until desired level Or Midazolam 2 mg bolus followed by 1 ± 2 mg/hr infusion or 1 ± 2 mg prn until desired level Hepatic dysfunction/renal impairment Midazolam 2 mg bolus followed by 1 ± 2 mg/hr infusion or 1 ± 2 mg prn until desired level Lorazepam bolus followed by infusion to desired level of sedation .

Flow Chart 3 Neurotrauma NO Elevated ICP Or Compromised CCP YES Sedation with Midazolam or Lorazepam YES ICP under control or Propofol infusion > 3 days *Propofol 25-50 mcg/kg/min titrate in increments of 25 mcg/kg/min to desired level * Note on next slide ICP still an issue continue Propofol .

Any fall in blood pressure associated with the use of Propofol can be avoided by reducing bolus dose and titrating cautiously in these vulnerable patients. There are many times that you don¶t want to use Propofol in increased ICP± remember that you don¶t want to drop BP precipitously in the setting of increased ICP because. you can stroke the patient out if the ICP:BP ratio changes dramatically (Perfusion pressure isn¶t sufficient to overcome the ICP) .Falls in blood and cerebral perfusion pressure are particularly risky in the elderly and emergency patient. when they will cause a significant fall in brain oxygenation.

Late head injury Rule out causes of agitation ‡Hypoxia ‡ETOH ‡Hypotension ‡CNS injury ‡Illicit drugs ‡Hypercarbia If negative ± Midazolam 1-2 mg prn .

5.5 mg reassess in 30 minutes and titrate to desired level with 1-2mg bolus .5 mg reassess in 30 minutes and titrate to desired level with 1-2mg bolus If inadequate analgesia. Hypoxia ETOH Hypotension CNS injury Illicit drugs hypercarbia Midazolam 2. but stable respirations with Morphine re-bolus after 30 min and increase prn dose 2 mg If negative Midazolam 2. 6.Flow Chart 4 Patient Assessment Pain Anxiety Delirium Rule out Fentanyl 50-100mcg bolus every 15 min to desired level then maintain at 50100mcg q 1-2 hours or Morphine 2-5mg bolus followed by 25mg q 2 hours prn 1. 3. 4. 2.

29 SEDATION 7.Protocols 2.14 Intubated and Chemically Paralyzed Patients RSI Protocol .

2010 SCT Protocols Section 7 of the MLREMS Protocols € Defines Standard of Care. Care expectations € Treatment guidelines for various conditions € Medication data sheets € .

(2) Half-life ranges from 20 to 90 minutes. muscle relaxation. alleviation of anxiety. anticonvulsant activity (2) Little cardiovascular effect b) Pharmacokinetics (1) Onset of action is extremely rapid following IV administration. hypnosis. c) Indications (1) Sustained and/or recurrent seizures (2) Pre cardioversion to reduce anxiety (3) Awake patient requiring transcutaneous pacing .Medications DIAZEPAM (VALIUM) a) Pharmacology (1) Sedation.

especially if given too rapidly. persons ingesting alcohol.Diazepam d) Contraindications (1) Known hypersensitivity. slurred speech. or acute narrow angle glaucoma e) Adverse Effects (1) Lightheadedness. amnesia (2) Additive effect with ethanol (3) Irritability and excitation may be seen paradoxically. (2) Respiratory support may be required. hypotension. or persons ingesting sedatives. ataxia. motor impairment. . f) Precautions (1) Respiratory depression may occur with IV administration. altered mental status (2) Should be used with caution in patients with altered mental status. head injury. confusion. impairment of mental and psychomotor function. (3) Use with caution in pregnant patients.

2 mg/kg slow IV/IO.Diazepam (g) Dosage (1) Adult: Administer 5 mg slow IV/IO (2) Pediatric: Administer 0. maximum dose 5 mg .

RSI ONLY a) Pharmacology Hypnotic b) Pharmacokinetics A short-acting nonbarbiturate hypnotic agent without analgesic properties c) Indications Pre-sedation of responsive patients prior to administration of neuromuscular blocking agents d) Contraindications Known hypersensitivity to Etomidate e) Adverse Effects (1) Respiratory depression or apnea (2) Hypotension (infrequent) (3) Involuntary myoclonus (4) Adrenal suppression (possible with repeated dosing) .ETOMIDATE (AMIDATE) .

(2) Myoclonic movements are common and should not be confused for fasciculation's due to a depolarizing neuromuscular blocking agent or seizure activity. such as narcotics and alcohol.3 mg/kg IV over 30 to 60 seconds. (2) Pediatric Not indicated . g) Dosage (1) Adult: Administer 0.Etomidate f) Precautions (1) The effects of Etomidate can be accentuated by CNS depressants.

5 mg slow IV.MIDAZOLAM (VERSED) a) Pharmacology (1) Sedative (2) Hypnotic b) Pharmacokinetics A short-acting benzodiazepine with strong hypnotic and amnesiac properties c) Indications (1) Sedation of responsive patients prior to cardioversion or transcutaneous pacing (2) Sedation of combative patients who threaten both their and providers¶ safety (3) Sedation of intubated patients with ventilatory difficulty secondary to bucking or combativeness d) Contraindications (1) Hypotension (2) Acute narrow-angle glaucoma (3) Known hypersensitivity to Midazolam e) Adverse Effects (1) Respiratory depression or apnea (2) Hypotension (3) Amnesia f) Precautions The effects of Midazolam can be accentuated by CNS depressants. such as narcotics and alcohol g) Dosage (1) Adult: Administer 2. while maintaining BP systolic greater than 90 mmHg (2) Pediatric: Not Indicated .

(3) Causes peripheral arterial and venous vasodilation c) Indications (1) Acute myocardial infarction (2) Acute pulmonary edema (3) Burns (4) Isolated injuries requiring pain relief (5) Sedative for transcutaneous pacing .MORPHINE SULFATE a) Pharmacology (1) Decreases pain perception and anxiety (2) Relaxes respiratory effort (3) Causes peripheral dilation which decreases preload (4) Decreases left ventricular afterload b) Pharmacokinetics (1) Binds with opiate receptors in the CNS. altering both perception and emotional response to pain (2) Onset of action is in less than 5 minutes after IV dose and effects last 4-5 hours.

MORPHINE SULFATE d) Contraindications (1) Head injury (2) Undiagnosed abdominal pain (3) Multiple trauma (4) COPD with compromised respiratory effort (5) Hypotension (6) Sensitivity to morphine. or percodan e) Adverse Effects (1) Respiratory depression/arrest (2) Altered mental status (decreased level of consciousness) (3) Increased vagal tone due to suppression of sympathetic pathways (slowed heart rate) (4) Nausea and vomiting (5) Constricted pupils (pin-point) (6) Increased cerebral blood flow . codeine.

maximum dose 5 mg.1 mg/kg slow IV/IO. repeat doses with medical control authorization (2) Pediatric: Administer 0. repeat doses with medical control authorization .MORPHINE SULFATE g) Dosage (1) Adult: Administer 5 mg slow IV.

if relaxation is inadequate after 2-3 minutes.5 mg/kg rapid IV may be given (2) Pediatric: Not indicated .29 SUCCINYLCHOLINE (ANECTINE) ± RSI ONLY a) Pharmacology Depolarizing neuromuscular blocking agent b) Pharmacokinetics Onset of action within 60 seconds. myasthenia gravis. muscular dystrophy) (d) Chronic renal failure on hemodialysis or presence of hemodialysis access (2) History of malignant hyperthermia (3) Patients with known hypersensitivity to the drug e) Adverse Effects (1) Apnea (2) Bradycardia (2) Prolonged paralysis f) Dosage/Route (1) Adult: Administer 1. amyotrophic lateral sclerosis.6.5 mg/kg rapid IV. duration 5-7 minutes c) Indications To achieve paralysis to facilitate endotracheal intubation in patients as per RSI Protocol d) Contraindications (1) Conditions that may cause hyperkalemia: (a) Burns greater than 24 hours old (b) Spinal cord injury greater than 24 hours old (c) Known neuromuscular disease (Guillain-Barré Syndrome. a repeat dose of 0.

31 VECURONIUM (NORCURON) ± RSI ONLY a) Pharmacology Non-depolarizing neuromuscular blocking agent b) Pharmacokinetics Onset 3-5 minutes with duration of 30-45 minutes c) Indications For paralysis in cases of ventilatory difficulty secondary to bucking or combativeness in intubated patients d) Contraindications (1) Non-intubated patients (2) Patients with known hypersensitivity to the drug e) Adverse Effects (1) Bradycardia (2) Prolonged paralysis f) Precautions (1) Pre-sedation must be provided when Vecuronium is administered to a patient who is either responsive to stimulus or who may become responsive to stimulus during neuromuscular blockade.6. g) Dosage (1) Adult: Administer 0.1 mg/kg IV (2) Pediatric: Not indicated .

analgesia and neuromuscular blockade in the ICU. Prehospital anesthesia and Analgesia.com ± Capnography in sedation and pain management - .References € € € € Vanderbilt Medical Center guidelines for sedation. EMS Responder. ITACCS ± Summer 2004. MLREMS Protocols 2010 and Formularies.