Welcome to this edition of UH EMS-I’s Pharmacy Phriday.
Before beginning our review of this week's medication, let us first thank you for all you do! This coming week we celebrate EMS Week and recognize all the pre-hospital providers that make a positive difference in our patients’ lives.
The theme for this year’s EMS Week is “We Care. For Everyone.” Part of that care includes pain management. Over the past few weeks, we have reviewed some of those treatments. In this installment, we will review hydromorphone, another opioid medication choice within the UH protocol.
Pain is a common complaint shared by our patients, and the assessment and treatment of that pain is a primary role in patient care, including pre-hospital care. When assessing pain, UH protocols recommend the use of the numerical pain scale (0-10) or the Wong-Baker FACES® Pain Rating 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. Pain assessment should also be documented as a vital sign.
When considering the treatment of pain, there are many factors to consider, including:
- 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 also an option using ketorolac with hydromorphone, fentanyl, or ketamine. 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 fast-acting potent 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:
- existing respiratory depression
- head injuries
- hypotension
- OB and labor pains
- severe asthma or COPD
- shock
Some serious side effects of its use include:
- altered level of consciousness (LOC)
- bronchospasm
- circulatory depression
- nausea and vomiting
- risk of respiratory depression
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.
The dosing of hydromorphone 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 in the pre-hospital setting. IM dosing usually requires a larger dose for the desired effects.
Doses may vary based on many factors including whether a patient is opioid naive or opioid tolerant. In the case of a patient being opioid naive, 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.
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.
Monitor the patient for desired effects and adverse reactions (AMS, bradycardia, hypercarbia, hypotension, hypoventilation, hypoxia, 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.
Once again, Happy EMS Week and thank you for all you do! Until the next edition of Pharmacy Phriday, stay safe!