Fentanyl and Fentanyl and Ativan In-Service Ativan In-Service Eastern PA EMS CouncilEastern PA EMS Council

Fentanyl Oh What a Fentanyl Oh What a Relief It Is! Pain Relief It Is! Pain Management Management

““We must all die. But that I can save a We must all die. But that I can save a person from days of torture, that is what I person from days of torture, that is what I feel is my great and ever-new privilege. feel is my great and ever-new privilege. Pain is a more terrible lord of mankind Pain is a more terrible lord of mankind than even death itself.”than even death itself.”

-Albert Schweitzer-Albert Schweitzer

Fentanyl ContinuedFentanyl Continued

IndicationsIndications

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

Fentanyl Cont.Fentanyl Cont.

Generic Name: Fentanyl CitrateGeneric Name: Fentanyl Citrate Product Name: FentanylProduct Name: Fentanyl

Fentanyl Cont.Fentanyl Cont.

Drug ClassDrug Class Short acting narcoticShort acting narcotic Opioid medicationOpioid medication

Opioids act on the opioid receptors in the Opioids act on the opioid receptors in the nervous system to reduce pain.nervous system to reduce pain.

Fentanyl Dosing For Our Fentanyl Dosing For Our Regional ProtocolsRegional Protocols 50-100mcg IVP or 1mcg/kg50-100mcg IVP or 1mcg/kg May repeat ½ dose every q5 minutes until May repeat ½ dose every q5 minutes until

max of 3mcg/kg max of 3mcg/kg (with Medical Command approval)(with Medical Command approval)

Pay special attention to your dosing this is Pay special attention to your dosing this is the only medication we have that is given the only medication we have that is given in Micro-grams (mcg). in Micro-grams (mcg).

Eastern PA Regional Pain Eastern PA Regional Pain Control ChoicesControl Choices ANALGESIC MEDICATION OPTIONSANALGESIC MEDICATION OPTIONS (Choose one)(Choose one) Fentanyl 50-100 mcg IV/IO (1 mcg/kg)Fentanyl 50-100 mcg IV/IO (1 mcg/kg) may repeat ½ dose every 5 minutes until may repeat ½ dose every 5 minutes until

maximum of 3 mcg/kg maximum of 3 mcg/kg (with Medical Command approval)(with Medical Command approval)

OROR Morphine sulfate 2-5 mg IVMorphine sulfate 2-5 mg IV (0.05 mg/kg)(0.05 mg/kg) may repeat dose every 5 minutesmay repeat dose every 5 minutes until maximum of 0.2 mg/kguntil maximum of 0.2 mg/kg

Fantanyl Dosing Fantanyl Dosing ContinuedContinued

Fentanyl supplied in ampules of Fentanyl supplied in ampules of 100mcg/2ml or 250mcg/5ml100mcg/2ml or 250mcg/5ml

Fentanyl Dosing Fentanyl Dosing ContinuedContinued

So what's the concentration for So what's the concentration for 100mcg/2ml???100mcg/2ml???

50mcg/ml Right!50mcg/ml Right! For 250mcg/5ml???For 250mcg/5ml??? 50mcg/ml You got it!50mcg/ml You got it!

Fentanyl Dosing Fentanyl Dosing Continued:Continued: Milligram VS Microgram Milligram VS Microgram

Easy conversion formulaEasy conversion formula To convert micrograms to milligrams divide by To convert micrograms to milligrams divide by

1000 e.g. 50mcg = 0.05 mg1000 e.g. 50mcg = 0.05 mg To convert milligrams to micrograms multiply by To convert milligrams to micrograms multiply by

1000 e.g. 0.05mg = 50mcg 1000 e.g. 0.05mg = 50mcg 1000mcg in 1mg1000mcg in 1mg 1 million mcg in 1 gram1 million mcg in 1 gram 1000 grams in 1 kilogram1000 grams in 1 kilogram Very potent medication, always ensure proper Very potent medication, always ensure proper

dosing!!!!dosing!!!!

Other forms of FentanylOther forms of Fentanyl

Transdermal PatchTransdermal Patch

Lollipop?Lollipop?

Fentanyl Fentanyl PharmacokineticsPharmacokinetics

IntramuscularIntramuscular

Onset 7-15 minutesOnset 7-15 minutes

Peak 15 minutesPeak 15 minutes

Duration 1-2 hoursDuration 1-2 hours IntravenousIntravenous

Onset minutesOnset minutes

Peak minutesPeak minutes

Duration 30-60 minutesDuration 30-60 minutes

Fentanyl PrecautionsFentanyl Precautions

Over SedationOver Sedation

Opioid antagonist NarcanOpioid antagonist Narcan

Fentanyl Fentanyl Precautions/Warnings Precautions/Warnings ContinuedContinued

Hypoventilation-respiratory depression Hypoventilation-respiratory depression from opioids is manifested by a reduced from opioids is manifested by a reduced drive to breath and reduced rate, often drive to breath and reduced rate, often associated with “sighing” pattern.associated with “sighing” pattern.

COPD-in such patients normal analgesic COPD-in such patients normal analgesic doses of opioids may further decrease doses of opioids may further decrease respiratory drive to the point of failure!respiratory drive to the point of failure!

Fentanyl Fentanyl Precautions/Warnings Cont.Precautions/Warnings Cont.

Alcohol and Drugs of Abuse - May be expected Alcohol and Drugs of Abuse - May be expected to have additive CNS depressant effects when to have additive CNS depressant effects when used in conjunction with alcohol used in conjunction with alcohol

Cardiac Disease – may produce bradycardia Cardiac Disease – may produce bradycardia should be used with caution in patients with should be used with caution in patients with known bradyarrhytmias.known bradyarrhytmias.

Hepatic or Renal Disease – Caution because Hepatic or Renal Disease – Caution because of the hepatic metabolism and renal excretion of the hepatic metabolism and renal excretion of Fentanyl.of Fentanyl.

Fentanyl Fentanyl ContraindicationsContraindications

Not opioid tolerantNot opioid tolerant Intermittent painIntermittent pain In situations of significant respiratory In situations of significant respiratory

depression especially in unmonitored settings depression especially in unmonitored settings In patients who have acute or severe asthmaIn patients who have acute or severe asthma Patients who have or are suspected of having Patients who have or are suspected of having

a paralytic ileus - paralysis of the intestinea paralytic ileus - paralysis of the intestine Known hypersensitivityKnown hypersensitivity

Fentanyl Side Effects Fentanyl Side Effects Common & UncommonCommon & Uncommon

CommonCommonRash, Nausea, Vomiting (Zofran!!) Drowsiness, Rash, Nausea, Vomiting (Zofran!!) Drowsiness,

Dry Mouth, Dizziness, Difficulty Urinating, Dry Mouth, Dizziness, Difficulty Urinating, Constipation (prolonged use), Constricted Constipation (prolonged use), Constricted pupilspupils

UncommonUncommonRigid chest wall, Decreased Breathing, Rigid chest wall, Decreased Breathing,

Confusion, Hives, Itching, Slowing or Elevated Confusion, Hives, Itching, Slowing or Elevated HR, ABD pain, FlushingHR, ABD pain, Flushing

Fentanyl SummaryFentanyl Summary

Pros:Pros:Fast acting, Short duration, More potent than Morphine, ED’s Fast acting, Short duration, More potent than Morphine, ED’s

increasing in use for all types of pain control even non-specific increasing in use for all types of pain control even non-specific abdominal pain due to its short duration ( pt will unmask shortly abdominal pain due to its short duration ( pt will unmask shortly after administration).after administration).

Also coming into favor in the presence of AMI due to less of a Also coming into favor in the presence of AMI due to less of a histamine release than Morphine which causes tachycardia!histamine release than Morphine which causes tachycardia!

Cons:Cons: New dosing New dosing mcgmcg versus versus mg (double check your concentrations)mg (double check your concentrations)Drug most likely to be abused by providers!Drug most likely to be abused by providers!Treat as you would any controlled substances we carry, i.e. double Treat as you would any controlled substances we carry, i.e. double

lock box, accountability forms checked for accuracy routinelylock box, accountability forms checked for accuracy routinely

Ativan Ativan

Generic Name: LorazepamGeneric Name: Lorazepam Brand Name: Ativan or TemestaBrand Name: Ativan or Temesta

Ativan How Supplied Ativan How Supplied

TabletTablet Injectable (2mg/ml vial for us)Injectable (2mg/ml vial for us)

Ativan Usage and ClassAtivan Usage and Class

Class:Class: Benzodiazepine with short to medium Benzodiazepine with short to medium

duration. duration. It has all five intrinsic Benzodiazepine It has all five intrinsic Benzodiazepine

effects: anxiolytic, sedative/hypnotic, effects: anxiolytic, sedative/hypnotic, amnesic, anticonvulsant, and muscle amnesic, anticonvulsant, and muscle relaxant to different extents.relaxant to different extents.

Ativan Usages and Class Ativan Usages and Class ContinuedContinued

Usages: Usages:

Relatively potent anxiolytic effects and its Relatively potent anxiolytic effects and its best known indication is the short-term best known indication is the short-term management of severe anxiety.management of severe anxiety.

Sedative/Hypnotic effects and the duration Sedative/Hypnotic effects and the duration of from a single dose make it useful for of from a single dose make it useful for short term treatment of insomnia.short term treatment of insomnia.

Ativan Usages and Class Ativan Usages and Class ContinuedContinued

As an anticonvulsant intravenous Ativan is a As an anticonvulsant intravenous Ativan is a reliable agent for terminating acute seizures. reliable agent for terminating acute seizures.

In the violent agitated pt including acute In the violent agitated pt including acute delirium Ativan can be used. Watch for delirium Ativan can be used. Watch for paradoxical effects, should be given with paradoxical effects, should be given with Haldoperidol.Haldoperidol.

Given to CA patients as it has some antiemetic Given to CA patients as it has some antiemetic properties.properties.

Ativan PharmacokineticsAtivan Pharmacokinetics

Ativan’s poor lipid solubility and its high Ativan’s poor lipid solubility and its high degree of protein binding means that degree of protein binding means that Ativan’s volume of distribution is mainly Ativan’s volume of distribution is mainly in the vascular compartment, versus in the vascular compartment, versus Valium which gets absorbed by body fat.Valium which gets absorbed by body fat.

The higher volume in the vascular The higher volume in the vascular compartment makes Ativan unsuitable for compartment makes Ativan unsuitable for oral or rectal administration as compared oral or rectal administration as compared to Valium.to Valium.

Ativan PharmacokineticsAtivan Pharmacokinetics

Potency 1mg Ativan = 10mg ValiumPotency 1mg Ativan = 10mg Valium Ativan compared to other Benzodiazepines has Ativan compared to other Benzodiazepines has

a high affinity for GABA receptors (Gamma-a high affinity for GABA receptors (Gamma-aminobutyric acid) increasing the inhibitory aminobutyric acid) increasing the inhibitory process of the cerebral cortex. process of the cerebral cortex.

Anticonvulsant properties may be in part or Anticonvulsant properties may be in part or entirely due to binding to voltage dependent entirely due to binding to voltage dependent sodium channels rather than Benzodiazepine sodium channels rather than Benzodiazepine receptors slowing the recovery of sodium receptors slowing the recovery of sodium channels from inactivationchannels from inactivation

Ativan ContraindicationsAtivan Contraindications

HypersensitivityHypersensitivity Severe respiratory failureSevere respiratory failure Acute intoxication may interact Acute intoxication may interact

synergistically with ETOH effectssynergistically with ETOH effects Acute narrow-angle glaucomaAcute narrow-angle glaucoma PregnancyPregnancy Liver and Kidney failure Ativan is the Liver and Kidney failure Ativan is the

safest for pt’s with impaired liver function.safest for pt’s with impaired liver function.

Ativan Special Ativan Special ConsiderationsConsiderations

Must keep refrigerated 35-45FMust keep refrigerated 35-45F Protect from light (keep in carton until Protect from light (keep in carton until

ready to use)ready to use)

Ativan Eastern PA Ativan Eastern PA Regional DosingRegional Dosing

Seizures:Seizures:

Adult 1-2mg IVP/IO repeat q5 minutes until Adult 1-2mg IVP/IO repeat q5 minutes until max dose of 8mg is reached (0.1mg/kg max dose of 8mg is reached (0.1mg/kg max 4mg dose)max 4mg dose)

Pediatric 0.1mg/kg IVP/IO max 4mg dose Pediatric 0.1mg/kg IVP/IO max 4mg dose repeat q5 until max dose of 8mg is repeat q5 until max dose of 8mg is reached.reached.

Eastern PA Regional Eastern PA Regional Sedation ChoicesSedation Choices

Sedation Options:Sedation Options:(Choose one)(Choose one)(Titrate to minimum amount necessary)(Titrate to minimum amount necessary)

Midazolam 1-5 mg IV/ IO (0.05 mg/kg)Midazolam 1-5 mg IV/ IO (0.05 mg/kg) titrated slowlytitrated slowly may repeat every 5 minutesmay repeat every 5 minutes until maximum of 0.1 mg/kguntil maximum of 0.1 mg/kg OROR Diazepam 5-10 mg IV/ IO (0.1 mg/kg)Diazepam 5-10 mg IV/ IO (0.1 mg/kg) titrated slowlytitrated slowly may repeat every 5 minutesmay repeat every 5 minutes until maximum 0.3 mg/kguntil maximum 0.3 mg/kg OROR Lorazepam 1-2 mg IV/ IO (0.1 mg/kg, max 4 mg/dose)Lorazepam 1-2 mg IV/ IO (0.1 mg/kg, max 4 mg/dose) titratedtitrated may repeat every 5 minutesmay repeat every 5 minutes until maximum of 8 mguntil maximum of 8 mg

Ativan Eastern PA Ativan Eastern PA Regional DosingRegional Dosing

Agitated/Violent Behavioral PatientAgitated/Violent Behavioral Patient

1-2mg IVP/IO/IM or 0.1mg/kg max 4mg 1-2mg IVP/IO/IM or 0.1mg/kg max 4mg dose may repeat q5 until max dose of dose may repeat q5 until max dose of 8mg8mg

Questions??Questions??