Welcome to UH EMS-I’s Pharmacy Phriday. In this week’s installment, we focus on the medication fentanyl, one of the most widely used pain medications allowed within the UH “Pain Management” algorithm. Fentanyl remained one of the top 10 medications administered during 2024 and was given nearly five times more often than the next most frequent pain medication, hydromorphone.
Fentanyl, a synthetic opioid, is one of the most often used pain medications for many reasons. The medication is 50-100 times more potent than morphine and other opiates. Of all the pain medications carried in our drug boxes, it is the quickest acting, has the shortest duration, and has the least side effects. It can also be administered via the IN route, making dosing quicker for most patients and much easier in the pediatric patient than starting a difficult IV. Additionally, the medication’s side effects can be reversed easily with the use of naloxone.
One of the most widely discussed side effects of fentanyl is related to respiratory depression. When administering the medication, the medic must monitor the patient for untoward effects. At a minimum, monitoring should include continuous ECG monitoring, pulse oximetry, and frequent vital signs. Capnography is strongly recommended in most circumstances and required in many circumstances.
Per UH protocol, dosing of fentanyl is 25-100 mcg, IV/IO/IM/IN, repeated every 10 minutes as needed, up to a max dose of 200 mcg for the adult patient. In pediatric patients, the dosing is 1 mcg/kg IV/IO/IM/IN, repeated every 10 minutes, up to a max of 50 mcg, unless given IN, which then increases the max to 100 mcg. (IN administration in the pediatric patient is still highly recommended.) Fentanyl can also be found as a pharmacological intervention in cases of CPR-Induced Consciousness (dosing is 100 mcg IV/IO/IM/IN, repeated as needed) and as an analgesic to be administered by the paramedic provider for drug assisted airway or RSI procedures (a 25 mcg bolus given as needed up to a maximum of 200 mcg).
Caution is advised when administering fentanyl to the elderly patient or patient with known renal failure or disease. In these cases, a lower starting dose is recommended. Reduced dosing should also be considered for patients with known recent use of another CNS depressant. When administering a dose via the IV route, it should be administered slowly over 1-3 minutes, as the likelihood of side effects increases with rapid administration.
One last consideration to bring attention to is the use of fentanyl for the Acute Coronary Syndrome (ACS) patient. Fentanyl is known to interfere with Brilinta, therefore, the ACS protocol suggests aspirin and Brilinta before the administration of fentanyl.
Abuse and overdose with fentanyl continue to be of concern in our society, but the role of pain management for our patients should remain a priority, while protocols are followed appropriately.
As always, stay safe!
