PAMI dosing guide

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Pain Management & Dosing Guide™ *Avoid NSAIDs in renal dysfunction, PUD, CHF, < 6 mo of age, >20 wks pregnant. Use with caution in elderly and those with cardiovascular risks. Give with food. For pediatrics, do not exceed adult dosage. Opioid Prescribing and Equianalgesic Chart (*based upon 2019 ASHP recommendations) Generic (Brand) Onset (O) and Duration (D) *Approximate Equianalgesic Dose Recommended STARTING dose for ADULTS Recommended STARTING dose for CHILDREN (> 6 mo) Oral IV Oral IV Oral IV Oral IV Morphine (MSIR®) [CII] O: 30-60 min D: 3-6 h O: 5-10 min D: 3-6 h 25 mg 10 mg 5-10 mg q 4 h 2-4 mg q 2-4 h 0.3 mg/kg q 4 h 0.1 mg/kg q 2-4 h Hydromorphone (Dilaudid®) [CII] O: 30 min D: 4-6 h O: 5 min D: 3-4 h 5 mg 2 mg 2-4 mg q 4 h 0.2-1 mg q 2-3 h 0.06 mg/kg q 4-6 h 0.015 mg/kg q 2-4 h Hydrocodone/APAP 325 mg (5, 7.5, 10 mg) [CII] (7.5 mg/325 mg per 15 mL) O: 30-60 min D: 4-6 h — 25 mg — 5-10 mg q 6 h — ≥ 2 yo: 0.1-0.15 mg/kg q 4-6 h — Fentanyl [CII] (Sublimaze® Duragesic®) Patch for opioid tolerant patients ONLY Transdermal O: 12-24 h D: 72 h per patch O: <1 min D: 30-60 min — 150 mcg (0.15 mg) Do not use in opioid naive pt. 50 mcg q 1-2 h Do not use in opioid naive pt. 1-2 mcg/kg q 1-2 h (max 50 mcg/dose) Methadone (Dolophine®) [CII] Opioid tolerant patients ONLY O: 30-60 min D: >8 h (chronic use) — Variable Variable 2.5 mg q 8-12 h — 0.7 mg/kg/day PO/SC/IM/IV ÷ q 4-6 h prn severe chronic pain Oxycodone 5, 15, 30 mg (Roxicodone®), Oxycodone 5, 7.5, 10 mg/ APAP 325 mg (Percocet®) [CII] O: 10-15 min D: 3-6 h — 20 mg — 5-10 mg q 6 h — 0.05-0.15 mg/kg q 4-6 h — Tramadol (Ultram®) [CIV] Not recommended in nursing mothers. O: 1 h D: 3-6 h — 120 mg — 50-100 mg q 6 h Max: 400 mg/ day — — — Tapentadol (Nucynta®) [CII] O: 30 min D: 4-6 h — 100 mg — 50 mg q 4-6 h — — — *Use MOST concentrated form available with atomizer. Limit 1 mL/nare. Ketamine in separate table. Opioid Cross-Sensitivities Phenanthrenes (related to morphine): morphine, codeine, oxycodone, hydrocodone, hydromorphone Phenylpiperidines (related to meperidine): meperidine, fentanyl Risk of cross-sensitivity in patients with allergies is greater when medications from the same opioid family are administered. Intranasal* and Nebulized Medications Generic Dose Max Dose Comments Fentanyl IN: 1.5-2 mcg/kg q 1-2 h Neb: 1.5-4 mcg/kg 4 mcg/kg or 100 mcg Divide dose equally between each nostril Midazolam (5 mg/mL) IN: 0.3 mg/kg 10 mg or 1 mL per nostril (total 2 mL) Divide dose equally between each nostril Lidocaine Neb: 4% (40 mg/mL) 100-200 mg or 2.5-5 mL 4.5 mg/kg total or 300 mg >5 mg/kg associated with serious toxicity Pain Management Considerations • Type of pain: nociceptive, neuropathic, inflammatory • Acute vs. chronic vs. acute on chronic pain exacerbation • Pain medication history: OTC, Rx and PDMP • Patient factors: genetics, culture, age, comorbidities, past pain experiences and mental health • For pediatrics, do not exceed adult dosage • Pharmacologic Interventions: systemic, topical, transdermal, nerve block - Dose based on ideal body weight • Nonpharmacologic Interventions • Refer to pain, palliative or other specialists for advanced treatment Reassessment • Reassess pain and monitor for medication efficacy and side effects • Use scale that is age and cognitively appropriate • If no improvement, adjust regimen Discharge Planning & Patient Safety • Assess and counsel regarding falls, driving, work safety, and medication interactions • Bowel regimen for opioid induced constipation • Vital signs and oral intake before discharge • Document all pain medications administered and response at time of disposition • Consider OTC and nonpharmacologic options • Can patient implement pain management plan? - insurance coverage, transportation, etc. Procedural Sedation and Analgesia Medications Generic (Brand) Adult Pediatric Comments Ketamine (Ketalar®) IV 0.5-1.0 mg/kg IM 4-5 mg/kg >3 mo: IV 1-2 mg/kg; additional doses 0.5 mg/kg IV q 10-15 min prn; IM 4 - 5 mg/kg Small risk of laryngospasm increases with active asthma, URI and procedures involving posterior pharynx; vomiting is common, consider pretreatment with anti-emetic.Not recommended in patients <3 mo. Midazolam (Versed®) IV 0.05-0.1 mg/kg IV slow push over 1-2 min IV 0.05-0.1 mg/kg IN 0.2-0.3 mg/kg (IN max 10 mg) Initial max dose 2 mg. Max total dose in >60 yo is 0.1 mg/kg Decrease dose by 33-50% when given with opioid Propofol (Diprivan®) IV 0.5-1 mg/kg slow push (1-2 min); additional doses 0.25- 0.5 mg/kg over 1-3 min IV 1 mg/kg slow push (1-2 min); additional doses 0.5 mg/kg Risk of apnea, hypoventilation, respiratory depression, rapid changes in sedative depth, hypotension; provides no analgesia Etomidate (Amidate®) IV 0.1 - 0.2mg/kg; additional doses 0.05mg/kg Risk of myoclonus (premedication w/ benzo or opioid can decrease), pain with injection, nausea and vomiting, risk of adrenal suppression; provides no analgesia Ketamine + Propofol — IV ketamine 0.75 mg/kg + propofol 0.75 mg/kg. Additional doses: ketamine 0.5 mg/kg, propofol 0.5-1 mg/kg See ketamine and propofol comments respectively Dexmedetomidine (Precedex®) IV 1 mcg/kg loading dose (over 10 min) followed by 0.5 to 2 mcg/ kg/h continuous infusion. Use 0.5 mcg/kg for geriatric patients IV 0.5–2 mcg/kg loading dose (over 10 min) followed by 0.5 to 2 mcg/kg/h continuous infusion IN 2-3 mcg/kg Risk of bradycardia, hypotension, especially with loading dose or rapid infusions, apnea, bronchospasm, respiratory depression Nitrous oxide — 50% N2O/50% O2 inhaled Do not use if acute asthma exacerbation, suspected pneumothorax/other trapped air or head injury with altered level of consciousness Morphine IV 0.05-0.1 mg/kg or 5-10 mg IV 0.1-0.2 mg/kg, titrated to effect Monitor mental status, hemodynamics, and histamine release. Requires longer recovery time than fentanyl. Difficult to titrate during procedural sedation due to slower onset and longer duration of action. Reduce dosing when combined with benzodiazepines (combination increases risk of respiratory compromise) Fentanyl IV 0.5-1 mcg/kg 1-3 yo: 2 mcg/kg; 3-12 yo 1-2 mcg/kg 100 times more potent than morphine; Rapid bolus infusion may lead to chest wall rigidity. Reduce dosing when combined with benzodiazepines and in elderly. Preferred agent due to rapid onset and short duration. Funding provided by Florida Medical Malpractice Joint Underwriting Association (FMMJUA) and the University of Florida College of Medicine-Jacksonville, Department of Emergency Medicine. For more information on Discharge Planning, visit pami.emergency.med.jax. ufl.edu/resources/discharge-planning pami.emergency.med.jax.ufl.edu/ Stepwise Approach to Pain Management Take a video tour of the dosing guide! 1. Situation Checkpoint What are you trying to accomplish? Analgesia, anxiolysis, sedation, or procedure. 2. Developmental/Cognitive Checkpoint What is the patient’s development stage? Language barrier or nonverbal patient? 3. Family Dynamic Checkpoint Who is caring for the patient? What are the family dynamics? 4. Facility Checkpoint Type of staffing and setting, team experience, patient volume, etc. 5. Patient Assessment Checkpoint Review patient’s risk factors and history. 6. Management Checkpoint Choose your “ingredients” for pharmacologic and nonpharmacologic multimodal “recipe.” 7. Monitoring & Discharge Checkpoint Joint Commission standards, facility policies, reassessments, and discharge planning. Lidocaine for renal colic: 1.5 mg/kg IV (Max 200 mg) in 100 mL NS over 10-15 min. Cardiac monitoring preferred. Contraindications: Pregnancy, cardiac arrhythmias, CAD, age >65 yo, hepatic/renal failure, epilepsy, Amide allergy November 2020 PANEL A PANEL B PANEL C Type of Block General Distribution of Anesthesia Interscalene Plexus Block Shoulder, upper arm, lateral 2/3 clavicle Supraclavicular Plexus Block Upper arm, elbow, wrist and hand Infraclavicular Plexus Block Upper arm, elbow, wrist and hand Axillary Plexus Block Forearm, wrist and hand. Elbow if including musculocutaneous nerve Median Nerve Block Anterior forearm, lateral hand and digits 1-4 ½ Radial Nerve Block Lateral arm, posterior forearm, dorsal hand, digits 1-4 ½ Ulnar Nerve Block Medial Forearm, medial hand and digits 4 ½ to 5 Femoral Nerve Block Anterior thigh, femur, knee and medial leg distal to the knee Popliteal Nerve Block Posterior lateral leg distal to knee, ankle and foot Tibial Block Plantar surface of foot Superficial Peroneal Block Dorsal surface of foot Deep Peroneal Block Web space between 1st and 2nd toes Saphenous Nerve Block Distal medial thigh, medial knee, medial ankle and medial foot Sural Nerve Block Lateral ankle and foot Local Anesthetics† Onset Duration without Epi (h) Duration with Epi (h) Max Dose without Epi, mg/kg Max Dose with Epi, mg/kg Lidocaine (1%) Rapid 0.5–2 1–6 4.5 (300 mg) 7 (500 mg) Bupivicaine (0.5%)* Slow 2-4 4-8 2.5 3 Mepivicaine (1.5%) Rapid 2-3 2-6 5 7 2-Chloroprocaine (3%) Rapid 0.5-1 1.5-2 10 15 Ropivicaine (0.5%) Medium 3 6 2-3 2-3 *Most cardiotoxic †1% = 10mg/ml, 0.5% = 5mg/ml Neuropathic Pain Medications Generic (Brand) Starting dose Max dose Gabapentin* (Neurontin®) 300 mg PO QHS to TID 3600 mg/day Pregabalin* (Lyrica®) [CV] 50 mg PO TID 600 mg/day** SNRIs: Duloxetine (Cymbalta®) Venlafaxine ER (Effexor XR®) 30 mg PO daily† 37.5 mg PO daily 60 mg/day** 225 mg/day TCAS: Amitriptyline (Elavil®) Nortriptyline (Pamelor®) 25 mg PO QHS 25 mg PO QHS 150 mg/day 150 mg/day See labeling reccomendations for dose titration. †30 mg daily for at least 7 days to decrease nausea *Requires dose adjustment based on renal function **Varies depending on indication Muscle Relaxer Pain Medications Generic (Brand) Beginning dose Max dose Baclofen (Lioresal®) 5 mg PO TID 80 mg/day Cyclobenzaprine (Flexeril®) 5 mg PO TID 30 mg/day Tizanidine (Zanaflex®) 2 mg po q 6-8 h prn 36 mg/day Methocarbamol (Robaxin®) 1-1.5 g PO TID to 4x/day x 48-72 h, then 500-750 mg PO TID; 1 g q 8 h IV 8 g/day (PO) 3 g/day IV Diazepam (Valium®) [CIV] Adult: 2-10 mg PO q 6-8 h; 5-10 mg IV/IM Ped: (>6 mos) 1 mg to 2.5 mg PO q 8 h prn; 0.04-0.2 mg/kg IV/IM q 2-4 h Peds: 0.6 mg/ kg/8h IV/IM to adult max Ketamine (Ketalar®) Indications and Dosing Indications Starting Dose Procedural Sedation IV: Adult 0.5-1.0 mg/kg; Ped 1-2mg/kg; IM: 4 -5 mg/kg Sub-dissociative Analgesia^ IV: 0.1 to 0.3 mg/kg, Max initial bolus 45 mg IM: 0.5-1.0 mg/kg; IN: 0.5-1.0 mg/kg Excited Delirium Syndrome IV: 1 mg/kg; IM: 4 -5 mg/kg Nerve Blocks Topical and Transdermal Medications* Class Formulations (Generic & OTC) Indications Recommended Dosing Counterirritants & Rubefacients (cream, lotion, gel, ointment, spray, and patch) Numerous OTC formulations & varying combinations of cam- phor, salicylates, and/or menthol (Ex. BENGAY®, Biofreeze®) Salonpas® Patch (Methyl salicylate + menthol) Musculoskeletal pain: strains, sprains, backache Generally, > 12 yo: Apply thin layer to affected area and massage up to QID. Check labeling for age cutoff Q 8-12 h Max 2 patches/day X 3 consecutive days Capsaicin <1% (alone or in combination with other products) Available as multiple OTC formulations +/- camphor or menthol (Ex. Theragen®, Zostrix®, Tiger Balm®) Musculoskeletal pain: strains, sprains, backache. Arthritis. Post-herpetic neural- gia. Peripheral neuropathy. Up to QID NSAIDs: Diclofenac Combining topical and oral NSAIDs not recommended Pennsaid®* 1.5% solution 2% solution pump Voltaren 1% gel (OTC- 2 g=2.25 in, see package dosing card) Flector ® 1.3% patch Osteoarthritis Osteoarthritis Acute pain: sprains, strains, contusions *Pediatric dosing unavailable for Pennsaid 1.5%: 40 drops QID 2 pumps (40 mg) BID to affected knee/joint 2 g upper extremity QID (max 8 g/day); 4 g lower extremity QID (max 16 g/day); 32 g/day max all joints 1 patch (180 mg) BID (to most painful area; ≥ 6yo) Lidocaine 5% patch (Lidoderm®) 4% patch (+/- menthol) 4% cream (OTC) 4% L.M.X.4® cream (OTC) Onset 30 min; Duration 60 min 2% gel/jelly, 5% ointment, or 2% viscous solution J-Tip™ with buffered lidocaine (https://jtip.com/) Post-herpetic neuralgia Musculoskeletal pain Burns, cuts, insect bites Burns, cuts, insect bites, venipuncture, LP, abscess I &D Catheter/NG tube insertion; stomatitis IV starts: Onset 1-3 min Adults: q 12 h; max 3 patches at one time Adults and children ≥ 12 yo: q 12 h ≥ 2 years: TID -QID ≥ 2 years, up to 4 times per day. Apply in area <100 cm² if < 10 kg; < 600 cm² for 10-20 kg Lidocaine combinations (use gloves, EMLA-cover with occlusive dressing, LET-cover with cotton ball & tape) EMLA® (2.5% Lidocaine 2.5% Prilocaine); Onset 60 min; Duration 3-4 h; Max appl.=1 h if <3mo/5 kg; otherwise 4 h LET (4% Lidocaine, 1:2,000 Epinephrine, 0.5% Tetracaine) gel or liquid; Onset 10 min; Duration 30-60 min Dermal analgesic of intact skin (abscess I & D, LP, etc.) Wound repair (non-mucosal) < 3 mo (< 5 kg): up to 1 g on 10 cm² area; 3-12 mo (>5 kg): up to 2 g on 20 cm²; 1-6 yo (>10 kg): up to 10 g on 100 cm²; 7 yo - adult (>20 kg): up to 20 g on 200 cm² 3 mL (not to exceed maximal lidocaine dosage of 3-5 mg/kg) Vapocoolant Pain-Ease® Cooling intact skin, mucus membranes and minor open wounds Spray for 4-10 sec from distance of 8-18 cm. Stop when skin turns white. Use with caution in children < 4 yo *Dosages are guidelines to avoid systemic toxicity in patients with normal intact skin and with normal renal and hepatic function. Use gloves to apply and/or wash hands after application. Use with caution in children and older adults with thin skin. ^Consider in opioid tolerant patients or those with contraindications to opioids. Administer IV over 10-15 minutes to minimize side effects. SQ dose same as IV. For IV-can dilute dose in 10 ml NS and administer as IV slow push over 5-10 min. Can also be given as a continuous infusion. Disclaimer The PAMI dosing guide, website, learning modules, and resources are for educational and informational purposes only and are not intended as a substitute for professional medical management by a qualified health care professional. PAMI is not responsible for any legal action taken by a person or organization as a result of information contained in or accessed through this website or guide whether such information is provided by PAMI or by a third party. Recommended dosages and opioid conversions are estimated and cannot account for individual differences in genetics and pharmacokinetics or comorbidities. Patient care must be individualized. As new research and clinical experience becomes available, patient safety standards will change. Healthcare professionals should remain current on medical literature and national standards of care and structure their treatment accordingly. As a result of ongoing medical advances and developments, information on this site is provided on an “as is” and “as available” basis. The use of information obtained or downloaded from or through this website, module, or product is at the user’s sole discretion and risk