April 12, 2024

Welcome to this edition of UH EMS-I’s Pharmacy Phriday.  In our last note, we reviewed the use of Fentanyl for pain management. This week we will review Hydromorphone, another of the opioid medication choices within the UH protocol. 

Before looking specifically at Hydromorphone, we should consider some general principles regarding the treatment of pain in the pre-hospital setting. Pain is a very common complaint shared by patients, and the assessment and treatment of that pain is a primary role in patient care, including pre-hospital care. Unfortunately, pain is often under-assessed and under-treated in this setting.

A study of pain management from 2019 NEMSIS data showed only about 15% of those patients complaining of pain rated 6/10 or greater received an analgesic [1]. The obstacles to effective pain management in EMS are too numerous to discuss in this short article, but this phenomenon should cause all of us to consider how we approach pain management in the field.

When assessing pain, UH protocols recommend the use of numerical pain scale (0-10) or the Wong-Baker Faces Pain Scale for pediatric patients or those with communication or language barriers. Remember that pain is subjective, and the assessment relies on the patient’s self-report. Also, remember that pain assessment should be documented as a vital sign.

When considering the treatment of pain, there are many factors to consider. These can include:

• The type of pain      

• The severity of the pain      

• Medication routes available

• The age of the patient

• Patient history

• Current use or non-use of an opioid (opioid tolerant or naïve?)

• Previous addictions

• Previous reactions to pain medications ·        

• The patient’s beliefs and attitudes regarding pain medications

Remember that non-pharmacological interventions such as splinting, positioning, ice, distraction, or even empathy or touch can sometimes be effective in relieving the patient’s pain.

When the medication option is considered for pain management, the UH provider has several options. UH protocols allow the Advanced EMT or Paramedic provider to administer one of the narcotic or non-narcotic agents based on the assessment and patient presentation. As discussed in an earlier episode reviewing the use of Ketorolac, a “multi-modal” approach is now possible using Ketorolac with Hydromorphone, Fentanyl, or Ketamine.  Remember that as the provider you can call medical direction for additional online direction at any time. 

If Hydromorphone is the agent chosen, remember some of these facts. It is a narcotic agent that effectively controls pain by interrupting pain signals to the brain. Some of the indications for the use of Hydromorphone include “moderate to severe,” “extended duration,” “intractable,” and/or “unremitting” pain, to name a few. These descriptive phrases seem to lead the provider to consider Hydromorphone’s use in cases of some of the worst, long-lasting pain that does not respond to other treatments. 

Contraindications to the use of Hydromorphone include:

• Head injuries

• Hypotension

• Shock

• Existing respiratory depression     

• Severe asthma or COPD     

• OB and labor pains

Some serious side effects of its use include:

• The risk of respiratory depression

• Circulatory depression

• An altered LOC

• Bronchospasm

• Nausea and vomiting

Providers should be prepared to address emergent reactions to Hydromorphone’s use with Naloxone, BVM and airway equipment, suction, etc. The provider should also consider Ondansetron’s use to prevent nausea.

Dosing of Hydromorphone under the UH protocols for the adult patient is 0.5-1.0 mg via the IV/IO/IM routes. Doses may vary based on many factors including whether a patient is opioid naïve or opioid tolerant. In the case of a patient being opioid naïve, they have not been taking an opioid regularly and may require smaller doses for the desired effect. In the case of tolerance, a patient may already be taking an opioid routinely and have developed a tolerance to the medication requiring a larger dose for the desired effect.

Administration can be repeated in 10 minutes to a maximum dose of 2 mg.   It is not recommended for the pediatric patient. IM dosing usually requires a larger dose for the desired effects. Other considerations in dosing should include lower doses and increased time intervals between doses for those over 65 or with a history of liver or kidney failure. As with most medications, slow administration minimizes side effects.

Be sure to monitor the patient for desired effects and adverse reactions (AMS, hypotension, bradycardia, hypoventilation, hypoxia, hypercarbia, S&S of allergy or anaphylaxis). A full set of vital signs, including ECG, SpO2, ETCO2, and pain reassessment, should be completed and documented after all pain medication administration.

Till the next edition of Pharmacy Phriday, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

September 8, 2022

Welcome to this edition of UH EMS-I’s Pharmacy Phriday.  September is Pain Awareness Month, so we use this opportunity to look at the options available to our providers under the UH “Pain Management” protocol.   The UH pain management protocol allows the provider to make choices, within guidelines, regarding the treatment of pain. Throughout the year, this forum has reviewed the number one used pain medication in our system, Fentanyl, as well as a non-narcotic, Ketamine, and an anti-inflammatory, Ketorolac. In this edition, we focus on another of the narcotic alternatives, Dilaudid.

Before looking specifically at Dilaudid, we consider some general principles regarding the treatment of pain in the pre-hospital setting. Pain is a very common complaint shared by patients, and the assessment and treatment of that pain is a primary role in patient care, including pre-hospital care. Unfortunately, pain is often under-assessed and under-treated in this setting. One recent study of pain management from 2019 NEMSIS data showed only about 15% of those patients complaining of pain rated 6/10 or greater received an analgesic[1]. The obstacles to effective pain management in EMS are too numerous to discuss in this short article, but this phenomenon should cause all of us to consider how we approach pain management in the field.

When assessing pain, UH protocols recommend the numerical pain scale (0-10) or the Wong-Baker Faces Pain Scale for pediatric patients or those with communication or language barriers. Remember that pain is subjective, and the assessment relies on the patient’s self-report. Also, remember that pain assessment should be documented as a vital sign.

When considering the treatment of pain, there are many factors to consider. These can include:

• the type of pain ·        

• the severity of the pain ·        

• medication routes available

• the age of the patient

• patient history

• previous addictions

• previous reactions to pain medications ·        

• the patient’s beliefs and attitudes regarding pain medications

Remember that non-pharmacological interventions such as splinting, positioning, ice, distraction, or even empathy or touch can sometimes be effective in relieving the patient’s pain.

When the medication option is considered for pain management, the UH provider has several options. UH protocols allow the Advanced EMT or Paramedic provider to administer one of the narcotic or non-narcotic agents based on the assessment and patient presentation. The UH protocol does not currently allow a “multi-modal” approach using multiple medications. However, remember that if one medication is not successful, the provider can call medical direction for additional online direction. 

If Dilaudid is the agent chosen, remember some of these facts. It is a narcotic agent that effectively controls pain by interrupting pain signals to the brain. Some of the indications for the use of Dilaudid include “moderate to severe,” “extended duration,” “intractable,” and/or “unremitting” pain, to name a few. These descriptive phrases seem to lead the provider to consider Dilaudid’s use in cases of some of the worst, long-lasting pain that does not respond to other treatments. 

Contraindications to the use of Dilaudid include:

• head injuries

• hypotension

• shock

• existing respiratory depression ·        

• severe asthma or COPD ·       

• OB and labor pains

Some serious side effects of its use include:

• the risk of respiratory depression

• circulatory depression

• an altered LOC

• bronchospasm

• nausea and vomiting

Providers should be prepared to address emergent reactions to Dilaudid’s use with Narcan, BVM and airway equipment, suction, etc. The provider should also consider Zofran’s use to prevent nausea.

Dosing of Dilaudid under the UH protocols for the adult patient is 0.5-1.0 mg via the IV/IO/IM routes. Administration can be repeated in 10 minutes to a maximum dose of 2 mg.   It is not recommended for the pediatric patient. IM dosing usually requires a larger dose for the desired effects. Other considerations in dosing should include lower doses and increased time intervals between doses for those over 65 or with a history of liver or kidney failure. As with other opioids, slow administration, preferably over two minutes, minimizes side effects. Slow dose titration will also help to reduce the incidence of typical adverse events. 

Be sure to monitor the patient for desired effects and adverse reactions (AMS, hypotension, bradycardia, hypoventilation, hypoxia, hypercarbia, S&S of allergy or anaphylaxis). A full set of vital signs, including ECG, SpO2, ETCO2, and pain reassessment, should be completed and documented after all pain medication administration.

In the next edition of Pharmacy Phriday, we will review another of the narcotic options sometimes available to the provider as we address this important yet sometimes overlooked aspect of emergency care. Till then, stay safe!

[1] https://www.tandfonline.com/doi/full/10.1080/10903127.2021.2018073

Sincerely,



The UH EMS-I Team

University Hospitals