Pain Management
Pain
- Pathological conditions: preexisting diseases, surgical procedure, trauma, monitoring and therapeutic devices
- Agitation
- Stress responses: tachycardia, elevated myocardial oxygen consumption, pulmonary dysfunction, hypercoagulability (thrombophilia)
Non-Pharmacologic Pain Relief
Elimination of irritating physical stimulation (pain), without the use of medication.
- Re-positioning in bed
- Stabilization of fracture
Analgesia
Provides absence of sensibility to pain without the loss of consciousness.
Analgesia and anesthesia are different. While both assist in pain relief, anesthesia results in a complete loss of physical sensation.
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
Most common prescribed and cost effective.
Examples: Ibuprofen, Naproxen, Salicylates/Aspirin, Celebrex
Indication: treat moderate pain
Administration: delivered through multiple routes (oral, IV)
Tylenol (Acetaminophen)
- Commonly used for moderate pain
- Does not address inflammation
Opioids/Narcotics
Action: rapid onset, provides analgesia and sedation
Adverse action: respiratory depression, hypotension, CNS depression
Examples: Morphine, Hydromorphone, Fentanyl, Meperidine, Codeine — lower respiratory depression
Administration: transdermal, IM, IV, orally
Sedation
Produces restful state of mind, calming effect.
Indication: treat anxiety and tension; must be used if delivering paralytic!
Hypnotic Agents (aid in inducing sleep)
- Sodium Thiopental (Pentothal)
- Etomidate (Amidate) — rapid sequence induction, conscious sedation, TBI patients
- Haloperidol (Haldol)
Benzodiazepines
Tranquilizer agents.
Indication: anxiety, panic attacks, insomnia and seizures
Tranquilizer agents — short acting:
- Midazolam (Versed) — most commonly used!
- Lorazepam (Ativan)
- Alprazolam (Xanax)
- Diazepam (Valium)
- Propofol (Diprivan) — decreased LOC and lack of memory for events (Milk of amnesia)
Vasopressors, Inotropes, and Antiarrhythmic Agents
Adenosine
Indication: treat SVT that does not improve with vagal maneuvers (carotid massage, Valsalva)
Action: decrease AV node conduction; slows impulse transmission
Amiodarone
Indications: A Fib, VFib, and ventricular tachyarrhythmias
Action: slows conduction, and delays repolarization
Atropine Sulfate
Indication: sinus bradycardia; asystole; PEA; organophosphate poisoning
Action: increase HR, and increase force of atrial contractions
Dopamine (Inotrope)
Indication: hypotension with signs and symptoms of shock; second-line drug for symptomatic bradycardia
Action: increases myocardial contractility, increases cardiac output, cerebral vasodilation, and peripheral arterial and venous vasoconstriction
Epinephrine (Inotrope)
Vasopressor: optimizes cardiac output and blood pressure.
Indications:
- Cardiac arrest — VF, pulseless tachycardia, asystole, PEA; symptomatic bradycardia, severe hypotension
- Anaphylaxis
Action: stimulates adrenergic receptors; produces vasoconstriction, increases blood pressure, heart rate, and improves perfusion to the brain and heart
Anaphylaxis
An allergic reaction which involves shock and airway obstruction.
Treatment regimen:
- Epinephrine (1st line drug therapy!)
- Antihistamines injection
- Corticosteroids injection
- Fluids
- Trendelenburg
Lidocaine
Indication: treat ventricular arrhythmias. Alternative antiarrhythmic to Amiodarone in cardiac arrest from VF/VT.
Action: increases electrical stimulation threshold; depresses ventricular electrical activity
Magnesium Sulfate
Indication: management of Torsades de Pointe or hypomagnesemia
Action: prolongs conduction time caused by hypomagnesemia
Norepinephrine (Inotrope) — Levophed
Indication: vasogenic shock (very low blood pressure), septic shock, neurogenic shock
Action: alpha-adrenergic stimulation; vasoconstriction — increases blood pressure; increases blood flow
Oxygen
Indication: decreased PaO2; provides all cellular energy and support for myocardial contraction
Action: prevents cellular and tissue hypoxia