Fentanyl and Ativan In-Service

1. Fentanyl and Ativan In-Service Eastern PA EMS Council

2. Fentanyl Oh What a Relief It Is! Pain Management • “We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.” -Albert Schweitzer

3. Fentanyl Continued • Indications Fentanyl is used in the treatment of acute pain and to depress breathing in patients being ventilated. It may also be given as an infusion under the skin in palliative care patients who have intolerable side effects from Morphine

4. Fentanyl Cont. • Generic Name: Fentanyl Citrate • Product Name: Fentanyl

5. Fentanyl Cont. • Drug Class • Short acting narcotic • Opioid medication Opioids act on the opioid receptors in the nervous system to reduce pain.

6. Fentanyl Dosing For Our Regional Protocols • 50-100mcg IVP or 1mcg/kg • May repeat ½ dose every q5 minutes until max of 3mcg/kg (with Medical Command approval) • Pay special attention to your dosing this is the only medication we have that is given in Micro-grams (mcg).

7. Eastern PA Regional Pain Control Choices • ANALGESIC MEDICATION OPTIONS (Choose one) • Fentanyl 50-100 mcg IV/IO (1 mcg/kg) • may repeat ½ dose every 5 minutes until maximum of 3 mcg/kg (with Medical Command approval) OR • Morphine sulfate 2-5 mg IV • (0.05 mg/kg) • may repeat dose every 5 minutes • until maximum of 0.2 mg/kg

8. Fantanyl Dosing Continued • Fentanyl supplied in ampules of 100mcg/2ml or 250mcg/5ml

9. Fentanyl Dosing Continued • So what's the concentration for 100mcg/2ml??? • 50mcg/ml Right! • For 250mcg/5ml??? • 50mcg/ml You got it!

10. Fentanyl Dosing Continued: Milligram VS Microgram • Easy conversion formula • To convert micrograms to milligrams divide by 1000 e.g. 50mcg = 0.05 mg • To convert milligrams to micrograms multiply by 1000 e.g. 0.05mg = 50mcg • 1000mcg in 1mg • 1 million mcg in 1 gram • 1000 grams in 1 kilogram • Very potent medication, always ensure proper dosing!!!!

11. Other forms of Fentanyl • Transdermal Patch • Lollipop?

12. Fentanyl Pharmacokinetics • Intramuscular Onset 7-15 minutes Peak 15 minutes Duration 1-2 hours • Intravenous Onset minutes Peak minutes Duration 30-60 minutes

13. Fentanyl Precautions • Over Sedation Opioid antagonist Narcan

14. Fentanyl Precautions/Warnings Continued • Hypoventilation-respiratory depression from opioids is manifested by a reduced drive to breath and reduced rate, often associated with “sighing” pattern. • COPD-in such patients normal analgesic doses of opioids may further decrease respiratory drive to the point of failure!

15. Fentanyl Precautions/Warnings Cont. • Alcohol and Drugs of Abuse - May be expected to have additive CNS depressant effects when used in conjunction with alcohol • Cardiac Disease – may produce bradycardia should be used with caution in patients with known bradyarrhytmias. • Hepatic or Renal Disease – Caution because of the hepatic metabolism and renal excretion of Fentanyl.

16. Fentanyl Contraindications • Not opioid tolerant • Intermittent pain • In situations of significant respiratory depression especially in unmonitored settings • In patients who have acute or severe asthma • Patients who have or are suspected of having a paralytic ileus - paralysis of the intestine • Known hypersensitivity

17. Fentanyl Side Effects Common & Uncommon • Common Rash, Nausea, Vomiting (Zofran!!) Drowsiness, Dry Mouth, Dizziness, Difficulty Urinating, Constipation (prolonged use), Constricted pupils • Uncommon Rigid chest wall, Decreased Breathing, Confusion, Hives, Itching, Slowing or Elevated HR, ABD pain, Flushing

18. Fentanyl Summary Pros: Fast acting, Short duration, More potent than Morphine, ED’s increasing in use for all types of pain control even non-specific abdominal pain due to its short duration ( pt will unmask shortly after administration). Also coming into favor in the presence of AMI due to less of a histamine release than Morphine which causes tachycardia! Cons: New dosing mcg versus mg (double check your concentrations) Drug most likely to be abused by providers! Treat as you would any controlled substances we carry, i.e. double lock box, accountability forms checked for accuracy routinely

19. Ativan • Generic Name: Lorazepam • Brand Name: Ativan or Temesta

20. Ativan How Supplied • Tablet • Injectable (2mg/ml vial for us)

21. Ativan Usage and Class • Class: • Benzodiazepine with short to medium duration. • It has all five intrinsic Benzodiazepine effects: anxiolytic, sedative/hypnotic, amnesic, anticonvulsant, and muscle relaxant to different extents.

22. Ativan Usages and Class Continued • Usages: Relatively potent anxiolytic effects and its best known indication is the short-term management of severe anxiety. Sedative/Hypnotic effects and the duration of from a single dose make it useful for short term treatment of insomnia.

23. Ativan Usages and Class Continued As an anticonvulsant intravenous Ativan is a reliable agent for terminating acute seizures. In the violent agitated pt including acute delirium Ativan can be used. Watch for paradoxical effects, should be given with Haldoperidol. Given to CA patients as it has some antiemetic properties.

24. Ativan Pharmacokinetics • Ativan’s poor lipid solubility and its high degree of protein binding means that Ativan’s volume of distribution is mainly in the vascular compartment, versus Valium which gets absorbed by body fat. • The higher volume in the vascular compartment makes Ativan unsuitable for oral or rectal administration as compared to Valium.

25. Ativan Pharmacokinetics • Potency 1mg Ativan = 10mg Valium • Ativan compared to other Benzodiazepines has a high affinity for GABA receptors (Gamma-aminobutyric acid) increasing the inhibitory process of the cerebral cortex. • Anticonvulsant properties may be in part or entirely due to binding to voltage dependent sodium channels rather than Benzodiazepine receptors slowing the recovery of sodium channels from inactivation

26. Ativan Contraindications • Hypersensitivity • Severe respiratory failure • Acute intoxication may interact synergistically with ETOH effects • Acute narrow-angle glaucoma • Pregnancy • Liver and Kidney failure Ativan is the safest for pt’s with impaired liver function.

27. Ativan Special Considerations • Must keep refrigerated 35-45F • Protect from light (keep in carton until ready to use)

28. Ativan Eastern PA Regional Dosing • Seizures: Adult 1-2mg IVP/IO repeat q5 minutes until max dose of 8mg is reached (0.1mg/kg max 4mg dose) Pediatric 0.1mg/kg IVP/IO max 4mg dose repeat q5 until max dose of 8mg is reached.

29. Eastern PA Regional Sedation Choices • Sedation Options: (Choose one) (Titrate to minimum amount necessary) • Midazolam 1-5 mg IV/ IO (0.05 mg/kg) • titrated slowly • may repeat every 5 minutes • until maximum of 0.1 mg/kg OR • Diazepam 5-10 mg IV/ IO (0.1 mg/kg) • titrated slowly • may repeat every 5 minutes • until maximum 0.3 mg/kg OR • Lorazepam 1-2 mg IV/ IO (0.1 mg/kg, max 4 mg/dose) • titrated • may repeat every 5 minutes • until maximum of 8 mg

30. Ativan Eastern PA Regional Dosing Agitated/Violent Behavioral Patient 1-2mg IVP/IO/IM or 0.1mg/kg max 4mg dose may repeat q5 until max dose of 8mg

31. Questions??