Table 6 Systemic analgesics, adapted from [180]. LOE denotes level of evidence in parentheses, provided if available. COX cyclooxygenase, mcg micrograms, mg milligrams, g grams, kg kilograms, mL milliliters, IV intravenous, IM intramuscular IN intranasal, NSAIDS nonsteroidal anti-inflammatory drugs, OTFC: oral transmucosal fentanyl citrate, po: by mouth, q: ‘every,’ qd: daily, bid: twice daily, tid: three times daily
From: Multiple trauma management in mountain environments - a scoping review
| AGENT/DOSE SITE | DOSAGE ADULTS/(PEDS); LOE | REMARKS |
|---|---|---|
| Ice | 1B | Simple, noninvasive; reduces inflammation/oedema; avoid freezing injury [180]. |
| NSAIDS/paracetamol | 1A | All NSAIDS: if po, potential dyspepsia lessened with food. Avoid with GI bleed/ulcer history, dehydration. Possible kidney injury or increased bleeding |
| Diclofenac topical | 2.3% topical; 2-4 g bid; unknown | |
| Ibuprofen PO | 2400 mg/d divided tid (10 mg/kg/d); 1A | |
| Naproxen PO | 660 mg/d divided tid; unknown | |
| Meloxicam PO | 15 mg qd; unknown | Cardiovascular events may increase. COX-2 selective inhibitor meloxicam minimises bleed/platelet disfunction. |
| Ketorolac IM | 60 mg q 6 h (0.5 mg/kg q6h); 2C | |
| IV | 15-30 mg (0.5 mg/kg, max 15 mg); 1B | |
| Paracetamol PO | Max 1300 mg (10 mg/kg) TID; 1B | Renal and GI sparing. Avoid in severe hepatic disease. Overdose can result in hepatic failure [179, 180, 182].. NSAIDS + paracetamol result in pain diminution better than either alone. |
| IV | > 50 kg:1 g < 50 kg:15 mg/kg IV/15 min; 1B | |
| OPIOIDS | All opioids tend to cause respiratory depression/desaturation and arterial hypotension; monitor. Avoid opioids if patient needs full cognition (i.e. self-evacuation). Naloxone reverses opioids [178,179,180]. | |
| Fentanyl IV | 25-100 mcg (1-3 mcg/kg); 1A | Slow fentanyl push mitigates risk of ‘frozen chest.’ |
| IN | 180 mcg (1.5 mcg/kg); 1B | |
| Buccal/transmucosal | OTFC: 800 mcg (10-15 mcg/kg); 1B | Oral transmucosal fentanyl citrate self-administered, ideal for austere situation. Transdermal route good for sustained dosing. |
| Transdermal | Transdermal route good for sustained dosing. | |
| Morphine IV | 5-10 mg (0.1 mg/kg-max 10 mg); 1A | Avoid morphine in renal failure. May cause histamine release. |
| IM | 10-20 mg (0.2 mg/kg, ma× 10 mg); 2B | Poor blood flow may limit absorption. |
| Oxycodone PO | 5-10 mg q8 h; 2B | PO opioids easy to carry on smaller expeditions. |
| OTHER | ||
| Ketamine | 1B | Use half dose for S-ketamine. Slower administration lessens emesis and psychosis. Can cause hypertension and tachycardia; preserves respiration; many prefer for multiple trauma. Vocal calming measures and adding midazolam minimise psychosis [178,179,180,181,182,183,184,185]. |
| IV | 10-30 mg (0.1-0.3 mg/kg); 1B | |
| IM | 1 mg/kg; 2C | |
| IN | 0.5 mg/kg (0.5 mg/kg); 2B | |
| Methoxyflurane Inhaled | 3 mL given to self; max 6 mL/day; 2A | Altitude use. No renal effects; avoided by some; anxiolysis [186,187,188]. |
| Nitrous Oxide nhaled | 60-70% N2O/40-30% O2; 2B | Less effective at altitude, complex; potentiates barotrauma! |