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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

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.
 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!