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Sara's - Medical Directives > Analgesia and Nausea Vomiting > Flashcards

Analgesia and Nausea Vomiting Flashcards

1
Q

Analgesia Medical Directive

What are the INDICATIONS?

How can we interpret pain? Types of pain

A

Pain

Nociceptive Pain - Typically the result of tissue injury

Inflammatory Pain - An abnormal inflammation caused by an inappropriate response by the body’s immune system

Neuropathic Pain - Pain caused by nerve irritation

Functional Pain - Pain without obvious origin, but can cause pain

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2
Q

Analgesia Medical Directive

What is Acetaminophen? + Generic Name

What is Ibuprofen? + Generic Name

A

Drug to treat mild to moderate pain, commonly known for its analgesic and antipyretic effects - acetaminophen does not disrupt or inhibit platelet aggregation.

Tylenol

NSAID – non-steroidal anti-inflammatory drug, shown to
have properties for management of pain (analgesia), fever (antipyretic), and inflammation (anti-inflammatory)

Advil

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3
Q

Analgesia Medical Directive

What is Ketorolac? + Generic Name

A

An non-selective blocker of prostaglandin synthesis NSAID that’s used to treat moderate pain

Toradol

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4
Q

Analgesia Medical Directive

What are the CONDITIONS for Acetaminophen?

Why is liver disease important?

What are the CONTRAINDICATIONS?

A

≥ 12 years

Unaltered

it’s metabolized in the liver i.e. disease implies poor metbolization

Allergy or sensitivity to acetaminophen

Acetaminophen use within previous 4 hours

Hx of liver disease

Active vomiting

Unable to tolerate oral medication

Suspected ischemic chest pain

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5
Q

Analgesia Medical Directive

Why is 4h important as a contraindication for acetaminophen?

A

Because it’s dosing interval is 4-6 hours - all of the receptors are occupied

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6
Q

Analgesia Medical Directive

What are the CONDITIONS for Ibuprofen?

What are the CONTRAINDICATIONS?

A

≥ 12 years

Unaltered

Allergy or sensitivity to ASA or NSAIDs

NSAID use within previous 6 hours

Patient on anticoagulation therapy

Current active bleeding

Hx of peptic ulcer disease or GI bleed

Pregnant

If asthmatic, no prior use of ASA or other NSAIDs

CVA or TBI in the previous 24 hours

Known renal impairment

Active vomiting

Unable to tolerate oral medication

Suspected ischemic chest pain

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7
Q

Analgesia Medical Directive

What would happen if the patient were on anticoagulation medication/therapy and you were thinking of giving ibuprofen?

Why is 6h important as a contraindication for ibuprofen?

Why is pregnancy relevant?

A

Don’t give it because it’s known to slow down blood clotting which would cause further complications.

Because it’s dosing interval is 6-8hours

Ibuprofen can pass the placental barrier and is excreted in breast milk which can be toxic for the fetus

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8
Q

Analgesia Medical Directive

Why is renal impairment important as a contraindication for ibuprofen?

A

Ibuprofen is removed by the kidneys i.e. impairment would result in a buildup of the medication in the body

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9
Q

Analgesia Medical Directive

What are the CONDITIONS for Ketorolac?

What are the CONTRAINDICATIONS?

A

≥ 12 years

Unaltered

Normotension

Allergy or sensitivity to ASA or NSAIDs

NSAID use within previous 6 hours

Patient on anticoagulation therapy

Current active bleeding

Hx of peptic ulcer disease or GI bleed

Pregnant

If asthmatic, no prior use of ASA or other NSAIDs

CVA or TBI in the previous 24 hours

Known renal impairment

Suspected ischemic chest pain

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10
Q

Analgesia Medical Directive

Why is normotension a condition for ketorolac?

How should you administer it?

Why is hx of peptic ulcer disease or GI bleed a contraindication?

A

becasue administration can cause severe reboud bradycardia - BUT hypertension is more common

You should push slowly

because the medication can be hard on the tissue that lines the stomach (already not good if theres a hx of peptic ulcer disease or GI bleed)

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11
Q

Analgesia Medical Directive

What is the ROUTE, and TREATMENT PLAN for Acetaminophen for a pt who is ≥12 years to < 18 years?

What is the ROUTE, and TREATMENT PLAN for Acetaminophen for a pt who is ≥ 18 years?

A

ROUTE - PO

Dose - 500-650mg

Max. Single Dose - 650mg

Dosing Interval - N/A

Max # of Doses - 1

ROUTE - PO

Dose - 960 - 1,000mg

Max. Single Dose - 1,000mg

Dosing Interval - N/A

Max # of Doses - 1

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12
Q

Analgesia Medical Directive

What is the ROUTE, and TREATMENT PLAN for Ibuprofen?

A

ROUTE - PO

Dose - 400mg

Max. Single Dose - 400mg

Dosing Interval - N/A

Max # of Doses - 1

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13
Q

Analgesia Medical Directive

What is the ROUTE(s), and TREATMENT PLAN for Ketorolac?

The vial is supplied in 30mg/1mL

How much volume will you need to draw up if you’re looking to give 10mg? AND 15mg?

A

ROUTE - IM/IV

Dose - 10 – 15 mg

Max. Single Dose - 15 mg

Dosing Interval - N/A

Max # of Doses - 1

.333mL AND .5mL

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14
Q

Analgesia Medical Directive - clinical considerations

Can you administer more than one pain medication at the same time?

IV in this directive means what?

What should suspected renal colic patients be considered for?

A

Yes, try to co-administer acetaminophen and ibuprofen (but not ibuprofen and ketorolac)

only to PCPs authorized for PCP Autonomous IV can administer ketorolac

Ibuprofen and ketorolac

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15
Q

Analgesia Medical Directive

When would you go IV over IM?

Can ketorolac and ibuprofen be taken together?

A

In preperation for more the potential for more meds or fluid therapy

NO - they have similar effects and targeted receptors therefore toxic buildup and/or increased adverse effects will occur

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16
Q

Analgesia Medical Directive

Can we make clinical judgements on which pain medication to give the patient?

Compare oral administraion to parental

The 1st line analgesia for patients who can tolerate oral administration are?

A

Yes - it’s encouraged

Oral is as effective and is less invasive than parenteral analgesia

Acetaminophen and ibuprofen

17
Q

Analgesia Medical Directive

Why should suspected renal colic patients be routinely considered for NSAIDS?

i.e. ketorolac and ibuprofen

What is the only advantage of parenteral ketorolac over oral ibuprofen?

A

NSAIDS inhibit prostaglandin (cause chronic pain and inflammation when bulit up) production.

NSIADS also produce anti-inflammatory and smooth muscle relaxant effects that reduces the glomerular filtration rate which reduces renal pelvic pressure and stimulation of the stretch receptors therefore reducing the pain

the ability to administer the NSAID despite vomiting (even if they’re vomiting)

18
Q

Analgesia Medical Directive

Is an external trauma that has been dressed and controlled an active bleed?

Is occult bleeding considered active bleeding? i.e. hematuria/GI bleed

If the pt has suspected renal colic AND trace blood in the urine, is that considered active bleeding?

A

NO

YES

NO

19
Q

Nausea/Vomiting Medical Directive

What are the INDICATIONS?

A

Nausea

OR

Vomiting

20
Q

Nausea/Vomiting Medical Directive

What is Ondansetron (Zofran)?

What’s preferred meds for an elderly (65y) pt with nausea or vomiting?

What is Dimenhydrinate (gravol)?

A

An antiemetic that blocks the 5-HT3 serotonin receptors (in central AND peripheral NS) used to treat nausea/vomiting due to stimulation of the vagus nerve.

Ondansetron because dimenhydrinate causes confusion and somnolence/sleep

An antihistamine H1 receptor antagonist used to treat motion sickness, nausea, or vomiting and is known to have anticholinergic effects

21
Q

Nausea/Vomiting Medical Directive

When do you consider ondansetron?

When do you consider dimenhyDRINATE?

A

chemotherapy, alcohol, cannabis, or illicit drug interaction causing nausea or vomiting

taking diphenhydrAMINE, anticholinergics or tricyclic
antidepressants (TCAs) causing nausea or vomiting

head trauma (less risk of ICP)

elderly patients

motion sickness or vertigo

upset stomach due to food ingestion

hyperemesis for a pregnant patient

best for people on SSRIs

avoid with head injuries (increases ICP)

22
Q

Nausea/Vomiting Medical Directive

What are the CONDITIONS for Ondansetron?

What does the addition of Ondansetron allow us to use?

What are the CONTRAINDICATIONS?

A

≥ 25 kg

Unaltered LOA

our clinical judgment in terms of medication selection

Allergy to ondansetron

Prolonged QT syndrome (known to
patient)

Apomorphine use (used for parkinson’s - is a D2 dopamine agonist)

23
Q

Nausea/Vomiting Medical Directive

Why is Apomorphine Contraindicated for ondansetron?

What patient population are you most likely to see Apomorphine usage in?

Is a 12-lead needed to assess for long-QT syndrome before administration of ondansetron?

A

It may precipitate profound hypertension

used for pts with Tremor, Huntington, Parkinson

No - because it should be known to the pt however if you were to look for it, you’d need a 12-lead to confirm, as 4-leads won’t show a long-QT

24
Q

Nausea/Vomiting Medical Directive

What are the CONDITIONS for Dimenhydrinate?

What are the CONTRAINDICATIONS?

A

< 65 years old

≥ 25 kg

Unaltered LOA

Allergy or sensitivity to dimenhydrinate
OR other antihistamines

Overdose on antihistamines OR
anticholinergics OR tricyclic
antidepressants

Co-administration of diphenhydramine

25
Q

Nausea/Vomiting Medical Directive

Why would this particular
overdose (TCA or anticholinergics) be relevant to dimenhydrinate administration?
AND
What does an anticholinergic overdose look like?

Why is co-administered with diphenhydrAMINE contraindicated?

A

they have similar effects and targeted receptors therefore toxic buildup and/or increased adverse effects will occur

Increased HR
Dry, hot, flushed
Altered mental staus
Dilated Pupils

the combined effect can lead to anticholinergic side effects, and over-sedation

26
Q

Nausea/Vomiting Medical Directive

What is the WEIGHT, ROUTE, and TREATMENT PLAN for ondansetron?

A

ROUTE - PO

Dose - 4mg

Max. Single Dose - 4mg

Dosing Interval - N/A

Max # of Doses - 1

27
Q

Nausea/Vomiting Medical Directive

What are the ROUTE(s), and the TREATMENT PLAN for a pt that is ≥25 kg to < 50 kg for dimenhydrinate?

IV in this directive means what?

What are the ROUTE(s), and the TREATMENT PLAN for a pt that is ≥ 50 kg for dimenhydrinate?

A

ROUTE - IV or IM

Dose - 25mg

Max. Single Dose - 25mg

Dosing Interval - N/A

Max # of Doses - 1

only to PCPs authorized for PCP Autonomous IV can

ROUTE - IV or IM

Dose - 50mg

Max. Single Dose - 50mg

Dosing Interval - N/A

Max # of Doses - 1

28
Q

Nausea/Vomiting Medical Directive

How do you administer dimenhydrinate via the IV route?

Do you dilute IM medication before administering?

Can you co-administer Zofran and Gravol?

A

Dilute it with saline to facilitate a slower AND less painful administration.

Based on a supply of 50 mg in 1 ml, either dilution method of 5 mg/ml (diluted with 9
ml of NaCl) or 10 mg/ml (diluted with 4 ml of NaCl) is acceptable.

NO!!

In either administration of medication, if the patient has no relief of their nausea & vomiting symptoms after 30min then you can administer the other medication - still in accordance with it’s conditions and contraindications

29
Q

Nausea/Vomiting Medical Directive

Why is pregnancy risky but not a full contraindication for ondanstetron?

Can you give dimenhydrinate to pts ≥65?

A

Because it can pass the placental barrier and is excreted in breast milk

it’s still considered for pregnant pts in hyperemesis but dimenhydrinate is more likely than not the most approriate choice

only if ondansetron is not available

Sara's - Medical Directives (16 decks)

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