Prehospital Analgesia

and Sedation
WITOLD ARYSKI
Medical Univerisity of Lodz

Agitation
Psychomotor agitation observed in the injured may be
caused by :

hypoxia (due to many reasons; most frequently respiratory or

hypovolaemia)
pain
broadly meant STRESS

The injured may not be able to estimate his condition;

if his condition deteriorates or may potentially
deteriorate it is NECESSARY to insert a cannula
starting to treat the disorders;
if psychomotor agitation prevents from performing
life-saving activities the patient should be immobilized
by force until the cannula is inserted and drugs
administered.

Patient requierments
Manager of the rescue party (physician) should
consider whether the patient requires:

monitored anaesthesiological care

analgesia (analgesics)
sedation (sedatives)
analgesia and sedation
general anaesthesia:

intravenous
intratracheal
combined.

All of it is made besides simultaneous rescue

activities, that is: aided respiration, circulatory
system stimulation, lost blood supplementation etc.

Emergency Anaesthesia
Dangers connected with anaesthesia in emergency
conditions:
weakness of reaction from respiratory tract (risk of
vomiting or regurgitation and then gastric content
aspiration to respiratory tract)
hypoventilation decrease of respiratory drive (in those
breathing spontaneously)
hypotonia (concerns patients with heavy loss of blood
and the aged)
laryngospasm
limitations in the evaluation of the patients general
condition (concern particularly patients with
accompanying central nervous system injury and
poisoned with chemicals).

Analgesia and sedation

Conducting anaelgesia and sedation IS NOT SMEARING
the injured patients condition
The patients transport when the injury consequences are
not diagnosed or treated and lead to the development of
traumatic shock (pain component) connected with
catecholaminemia and its consequences (tachycardia,
myocardial oxygen deficit, ischaemia, hypoxia, myocardial
infarction, etc.) brings about more harm.
Modern diagnostics enables precise evaluation of injuries
without the necessity of consciousness maintenance (a
patient with accompanying pain is not a fully reliable
patient).

Examination
Diagnostic methods used in a patient the victim of the
accident:
precise clinical and neurological examination (related to
the mechanism of the accident; example: the use of
safety bests, etc.)
head computed tomography (on the way to hospital if
necessary, in every injured patient who lost
consciousness or had a head injury)
X-ray of: cervical thoracic and pelvic spine and then USG
of abdominal cavity in emergency ward
additional examinations are decided by a specialist in the
given field.

Analgesia and sedation

Analgesic and sedative drugs are administered in the following
situations:

on the accident site

during transport
during diagnostics
during analgesia in the operating suite
in early postoperative period.

Such a procedure MUST be accompanied by the treatment of the shock

and proper monitoring of life functions:

state of consciousness
arterial blood saturation (pulsoxymetry) SpO2
arterial blood pressure determined by noninvasive method NiBP
heart rate HR
body temperature
electrocardiogram ECG
respiratory parameters (respiration frequency, tidal volume, oxygen concentration
in respiratory mixture, respiratory technique).

Analgesia and sedation

Characteristics of sedative and analgesic
administered in the accident site:

effective withdrawal of anxiety

safety (sedation and analgesic effect dependently on the
dose; with a slight effect on circulation and respiration)
evoking patients hypokinesis
lack of interaction with other pharmacotherapeutics and
ethanol
possibility of action inversion (antagonists)
quick action occurrance
quick return of consciousness (short action time)
lack of side effects (eg. pain at administration).

NSAID
Nonsteroid analgesics have a LIMITED application due to:
level of analgesia is limited by the so called ceiling effect
(increase if the dose above a certain value does not
increase analgesic action)
except paracetamol, they exert an effect on the level of
peripheral nervous system (inhibit prostaglandins
production by blocking cyclooxygenase)
cause decreased blood platelets adhesion increasing the
risk of bleeding
ADVANTAGES:
lack of psychic tolerance
lack of physical tolerance

Opioids
OPIOIDS are the base of analgesic therapy, preferred
administration is INTRAVENOUS.
Analgesic action is obtained by administration:
loading dose (withdrawing pain)
maintenance doses:
in boluses (at precisely determined time,
independently on pain complaints)
in continuous infusion.

Opioids

Initial dose is determined by titration that is by

administering not big doses of opioid until pain
withdrawal; then therapeutic concentration of drug
is maintained by intravenous infusion. The infusion
velocity is determined by two ways:

A dose which should be administered after the time

equal to opioid half-life period in order to maintain
analgesic effect obtained after administration of
loading dose, will be of the loading dose.
half-life period of majority of the applied opioid is
about 3 hours.

Opioids
Opioids administered on emergency are mainly piperidine derivatives
(short time of action); it is related to easy control, quick regression
of action and thus possible side effects; slight histamine release is an
adventage of these drugs.
Drugs:
Fentanil; Fenanyl; amp. 1 ml = 0.05 mg; 2 and 10 ml; initial
dose 1 5 g/kg; continuous intravenous infusion 1 9
g/kg/h; there is a risk of drug cumulation.
Alfentanil; Rapifen; 1 ml = 0.5 mg; initial dose 15 20 g/kg;
continuous infusion 1 3 g/kg/min; 4 x weaker than fenantyl.
Sufentanil; Sufenta; 1 ml = 0.005 mg and 1 ml = 0.05 mg; initial
dose 0.005 mg/kg; continuous infusion 0.003 0.005 mg/kg/h;
10 x stronger than fentanyl
Remifentanil; Ultiva; amp. 1, 2 and 5 mg; bolus 0.5 1 g/kg b.m.
administered in the time of 30 sec or continuous infusion at
0.025 2 g/kg b.m./min; half-life time 10 min.

Opioids

Morphine; Morphinum HCI; amp. 1 ml = 10 mg; 1 ml = 20

mg; initial dose 0.01 0.02 mg/kg; continuous infusion 0.03
0.05 mg/kg/h; an advantage is sedative effect; disadvantage
histamine release
Petydine (not recommended due to release of 6-norpetydine)
a single dose 0.1 0.2 mg/kg/b.m.; strongly decreases
arterial blood pressure

Ketamine

The drug commonly used in emergency medicine is k e t a m i n e.

Drugs:
Calypsol Gedeon Richter; vial 1 ml = 0.05
Ketanest Parke and Davies; vial 1 ml = 0.01
Dosage:
analgetic dose (action devoid of anaesthetic action); 0.2 0.5
mg/kg b.m.; the drug can be administered even if the injured
is inside the vehicle
anaesthetic dose (evokes the state of dissociation
anaesthesia); 1 2 mg/kg b.m. and b.w. 2 4 mg/kg/h
(0.003 mg/kg/min)

Benzodiazepines

Sedation benzodiazepines:

Diazepam; Relanium; amp. 2 ml; dosage 0.2 1 mg/kg b.m.

Midazolam; Dormicum; amp. 1 ml = 5 mg and 1 ml = 1 mg; amp. 3
ml each (15 mg), 1 ml each (5mg) and 5 ml (5 mg); dosage 0,1
0.3 mg/kg b.m.; b.w.0.05 0.3 mg/kg/min
Lorazepam; Ativan; amp. 4 m/1 ml 0.03 0.05 mg/kg b.m. can be
repeated after 20 25 minutes; minor risk of cumulation as
compared to diazepam; less interaction with alcohol
Flumitrazepam; Rohypnol; amp. 1 ml = 1 mg; amp. In 2 ml = 2
mg; dosage 0.015 0.03 mg/kg b.m.

Specific antagonist:

Flumazenil (Anexate); amp. in 5 ml; 0.5 mg to maximum dose 0.15

mg/kg b.m.

TIVA
Sedation intravascular general anaesthetics
Barbiturates
metohexital (Brietal); vial 0.5 each ; preparation: 50 ml
distilled water is added (solution 1% that is 1 ml = mg);
dosage 1 2 mg/kg b.m.; continuous infusion 0.05 0.15
mg/kg/min
tiopental (Pentothal) vial 0.5g and 1g each; preparation:
20 ml of distilled water is added, getting the solution 2.5%
(1 ml = 25 mg), or 5% (1 ml = 50 mg); continuous
infusion 4 8 mg/kg/h.
Etomidat (Hypnomidate); amp. 20 mg in 10 ml; dosage: 0.1
0.3 mg/kg b.m.
Propofol (Diprivan); amp. 1 ml = 10 mg; amp. 20 ml each;
dosage 1.5 2.5 mg/kg b.m.; continuous infusion 1 4
mg/kg/h.

Inhale anaesthesia
Sedation inhalant general anaesthetics

the base for this respiratory mixture composition is oxygen

combined with nitrous oxide (ENTONOX) or with air; so
that oxygen content in respiratory mixture (FiO2) would
be between 0.3 and 0.35
Sevoflurane is an optimal drug for anaesthesia sedation
and is administered in the concentration 0.1 0.75 Vol/%

Sevoflurane administration

requires the use of an apparatus for anaesthesia

the patient MUST be intubated.

Sedation scale acc. to Cook

Opening of eyes:

Cough:

carries out commands

coordinated movements
incoordinated movements
does not react

4
3
2
1

spontaneous, strong
spontaneous, weakened
only on aspiration
lack

4
3
2
1
5

Respiration:

4
3
2
1

Reaction to nursing care:

spontaneous
on command
on algetic stimula
does not open

spontaneous
spontaneous, intubated patient
Si MV, CMV with trigger
fights with respirator
lack

Readiness to communicate

4
3
2
1
2

Degree of sedation
conscious
sleepy
light sedation
mean sedation
heavy sedation
unconscius

Points
17 - 19
15 - 17
12 14
8 - 11
5- 7
below 4

Sedation scale acc. to Ramsey

1.

Patient restless and agitated

2.

Patient co-operating, calmed, aware

3.

Patient responds to commands only

4.

Lively response to prick

5.

Lazy response to prick

6.

Lack of response to prick

Sedation scale acc. to Addenbrooke

agitated

conscious

reacting to voice

reacting to aspiration from trachea

not reacting to stimuli

flaccidity of limbs

coma

Drugs and organ damage

Application of drugs dependently on organs damage or on system load

Circulatory system:

Liver:

Kidneys:

Nervous system:

Endocrine and immunological system:

+ opioids, etomidat, ketamine

- barbiturates, propofol
+ fentanyl, morphine, midazdam
- alfentanyl, diazepam, ketamine
reduction of the dose of all administered drugs

+ opioids, etomidat, barbiturants, BDA, propofol

- ketamine, flumazenil
+ opioids, BDA, propofol
- ketamine, barbiturates, etomidat

Sedation or anaesthesia
Sedation:
possibility of communication
patient responds to commands

Anaesthesia:
disturbed communication
possible response to strong stimulation
lack of contact

Drugs used for sedation and

anaesthesia (I)

Benzodiazepines:

Opioids:

Midazolam (Versed, Hypnovel, Dormicum)

Diazepam (Relanium)
Flunitrazepam (Rohypnol)
Lorazepam (Ativan)
Meperydyna (Petydyna)
Morphine
Fentanyl
Alfentanyl (Rapifen)
Sufentanyl (Sufenta)
Remifentanyl (Ultiva)
Nalbufina (Nubain)

NSAID:

Ketolorak (Tora Dol)

Diclofenak (Voltarol)
Paracetamol (Pro Efferalgan)

Drugs used for sedation and

anaesthesia (II)

Intravenous anaesthetics:

Inhalant anaesthetics:

Nitrous oxide
Sevofluran
Others

Arylcykloheksylamine:

Propofol (Diprivan)
Metohexital (Brietal)
Tiopenthal
Etomidate (Hypnomidat)

Ketamine

Alfa 2 agonists:

Klonidyna
Deksmetomidyna

Characteristics of applied opioids

Drug

Action Distribution Elimination Clearance Distribution

half-time
half-time
force
volume (l/
(ml/ kg/
(h)
(h)
kg)
min)

Morphine

1 3 fast
9 20 slow

2-4

10 - 23

3.4 4.7

Petidine

0.1

4 - 30

2.4 - 7

12 - 22

3.5 5.3

Fentanil

100

1 2 fast
10 15 slow

3-4

10 - 20

3.5 4.4

Alfentanil

15

1-3

1-2

3-8

0.4 1

Sufentanil

700

1 3 fast
10 15 slow

2-4

11 - 21

1.7 - 4

Sedation and anaelgesia in the conditions of

emergency (summary)
Applied drugs:
a group of analgesics with general action; side effects are
respiratory depression, nausea, constipation
tranquillizers (benzodiazepines); advantages: slight
depressive effect on circulation; anterograde amnesia;
known antagonist
inhalant anaesthetics and hypnotic drugs
relaxants (Chlorsuccilinum, Rapacuronium Raplon,
Mivacurium Mivacron, Rocuranium, Esmeron)
ketamine
antiemetics
topical anaelgesia