Acetaminophen (Tylenol) 650-1000mg PO q4h (peds: 15mg/kg q4h)
-Mild to moderate pain, not an anti-inflammatory, few CI’s (liver disease)
-Works best combined with an NSAID, opioid-sparing agent
Ibuprofen (Motrin) 400-800mg PO q6-8h (peds: 10mg/kg q6-8h)
-Mild to moderate pain, anti-inflammatory, opioid-sparing agent
-More problems than Tylenol (GI upset, bleeding, renal damage)
-Avoid in known renal disease, PUD, elderly
Ketorolac (Toradol) 30mg IM or IV q6h (peds: 0.5mg/kg q6h)
-The only FDA approved parenteral NSAID
-More expensive and no more effective than PO NSAIDs
-Avoid in elderly, renal disease and dehydration or loop diuretics (pre-renal)
-No more than 5 days
-Acute pain: 60mg IM unless < 65 years of age 30mg IV (max dose 120mg/24hrs)
Morphine 0.1mg/kg IV or IM (may start with 4mg and titrate to effect) lasts 2-4hrs
-May cause hypotension
Fentanyl 0.5-2mcg/kg (may start with 50-100mcg and titrate to effect) lasts 30-45min
-Beware chest wall rigidity
-Avoid in children less than 4 months old
-Short acting so good for abdominal pain of unknown etiology
Hydromorphone (Dilaudid) 1-4 mg IM/SC/IV
-There may be a particular role in sickle cell disease
PO narcotic-analgesic combinations
-Norco(hydrocodone/APAP 5-10/325) 1-2 tabs q4-6h prn
-Percocet (oxycodone 5mg/APAP 325mg) 1-2 tabs q6h prn
-Very potent, in civilian practice requires triplicate prescription in some states
-Tylenol w/codeine (APAP 300mg/codeine 15mg #2, 30mg #3, 60mg #4) 1-2 tabs q4h
-Elixir for peds has 12mg codeine and 120mg APAP per tsp
-T#3 shown in studies to be no more effective than APAP alone
PO narcotics. Usually prescribed by PCP’s.
-Hydromorphone (dilaudid), methadone, morphine, oxycodone, propoxyphene (darvon)
-Some use Darvon 65mg PO q4h prn for liver disease pts (contains no APAP)
ALL narcotics may cause N/V. Some docs give prophylactic amtiemetics.
Lidocaine 1% (onset 2-5min, lasts 30-60min)
-Max dose w/o epi is 4.5mg/kg or 0.45ml/kg and w/epi 7mg/kg or 0.7ml/kg
- Avoid epi on, pinna of ear, nose, penis and digits
Bupivacaine 0.25% (onset 3-7min, lasts 90-360 minutes). Higher cardiac toxicity than lido. -Max dose w/o epi is 2mg/kg or 0.8ml/kg and w/epi is 3mg/kg or 1.2ml/kg
LET (lido/epi/tetracaine) for topical use on non-intact skin.
-Drip some into wound and place some on gauze taped to wound for 20min
Topical lidocaine is available as well. May use in wounds.
-Used in ED for intraoral lacs
-Used for outpatients with intraoral ulcers and genital ulcers
-Remember maximum dose to avoid toxicity in the outpatient setting
LMX - lidocaine
-Recommended for use only on intact skin. 30 minutes to effect
-Useful for pediatric LPs
Nerve blocks: median/ulnar/radial/digital/inferior alveolar/infraorbital/intercostal