Ryan Ackerman, Paramedic Practice Educator gives a brief overview of oral analgesia and how Ibuprofen and Acetaminophen fit into BCEHS pain management guidelines.
Hi this is ryan ackerman i’m a paramedic practice educator in vancouver ibuprofen and acetaminophen have recently been added a paramedic practice here in bc and i wanted to give you a quick overview of how they fit into our pain management guidelines so before we get into the pain medications themselves i wanted to give a brief overview of one of the main pathways
That actually leads to the production of pain and fever and what we’re looking at here is from a generic cell so this is the cell membrane here and within it you see these little green enzymes here this is cyclooxygenase 2 and cyclooxygenase 1 these are responsible for the production of prostaglandins within the various cells now sorry cyclooxygenase one is active
In a number of cells pretty much all the time producing prostaglandins that are helpful in daily processes what we’re really focused on here is the activation of cox 2 by injury or other factors so specifically to injury phospholipase activates cyclooxygenase 2 which simulates a pathway here that creates all these various prostaglandin is in the different cells so
For example in the platelets the prostaglandin produced is called thromboxane it’s responsible for triggering platelet aggregation on my other platelets and it’s also a really potent basal constrictor in the walls of the endothelium you also have something known as prostacyclin which opposes thromboxane and causes breakdown of the platelet clots and vasodilation
And this is predominantly responsible for a lot of the redness and swelling we associate with inflammation there are other useful prostaglandins and harmful prostaglandins in the uterus for example a uterine contraction late in pregnancy is tribulus stimulated by prostaglandins and it’s big part of the reason why for early labor a preterm labor they often give
Nsaids specifically targeted nsaids to try and stop that early labor similarly we have mast cells that are triggered by police prostaglandins allergic asthma is mediated through the mast cells by prostaglandins etc which is why steroidal anti-inflammatories are so effective in treating long-term asthma but mostly what we’re gonna focus on right now is the fact that
Just about every cell has the ability to produce this pge2 a prostaglandin e2 prostaglandin e2 works directly on pain receptors peripherally and centrally triggering a pain response it also works in the hypothalamus itself and with free-floating systemically circulating in teen father’s prostaglandin e2 triggers the production of fever this raises the set point
Of the hypothalamus which creates fever when we give a non-steroidal anti-inflammatory like ibuprofen we block this path wave further talks to to produce prostaglandins and we kind of do it for just about all of them some nsaids are more targeted than others for example a si targets platelets and the production of throwing boxing quite effectively far more so
Than ibuprofen but almost all anti-inflammatories have some effect across the broad spectrum so we’re giving it we’re not just giving it and targeting one thing like pain we’re targeting a whole range of things so now that we’ve seen how the pain pathways are produced let’s just look a bit how i borrow funding to see them and if it stack up against each other as
We just discussed ibuprofen inhibits the production of prostaglandin right of the tissue level which produces the systemic effects that we’re looking for and that could be a big part of the reason why studies have shown about performing acetaminophen in pain reduction in fever reduction and certainly in its anti-inflammatory properties as acetaminophen ism tuchus
Traditionally an anti-inflammatory one of the main risks and the most comments are just pets erg is symptoms and even gi bleeding associated with ibuprofen so chronic prolonged use can be really hard on the gut it can also be hard on cardiovascular system that was not as potent or is not as noticeable as in some of the stronger and so it’s out there but it is
Something we have to be aware of over the long term acetaminophen on the other hand though it’s been around for many years it’s been demonstrated safe and in most cases we still don’t know exactly how it works there are loads of research articles out there about it and every one of them seems to contradict each other and they’re still looking for the primary effect
But it seems to be some degree of inhibition of prostaglandins directly within the cns at the hypothalamus level as well for fever there could be some degree of anti-inflammatory property that isn’t well understood but for now it’s really just classified as an analgesic it’s a very effective analgesic for mild to moderate pain we do have to watch that chronic high
Doses are linked to liver damage as its metabolized in the liver it produces a lot of toxic byproducts and using it in high doses for long periods of time can concussive liver damage the interesting thing though is when we combine these two together the synergistic effects are pretty amazing you get the anti-inflammation properties of ibuprofen and the central
Cns analgesic properties of acetaminophen and together they actually outperform most oral opioids one of the studies that actually proved the effect of the combination of acetaminophen and ibuprofen with a study published in the journal of the american medical association in 2017 and they were looking at what the best oral analgesics to give in combination with
Acetaminophen plus so they gave a number of patients either ibuprofen oxycodone hydrocodone or codeine it all of them in combination with acetaminophen and they looked at their pain scales and the interesting thing to note here is that ibuprofen performed almost as well as oxycodone even though the baseline pain score was higher that it outperformed hydrocodone
And codeine all of which were combined with acetaminophen now it’s just one study has a relatively small sample size just over 400 people however there were a number of other studies that were performed that show very similar things all of these and many more have shown incredible synergistic effect of non-steroidal anti-inflammatories such as ibuprofen and
Acetaminophen now i know most of you are hoping for a rapid onset pain relief and they are coming but in the absence of that this is a very effective option this is just a quick look at where all these medications that we have in our toolbox now fit within the pain management guidelines i think it’s really important to point out and all of you know this intuitively
But sometimes we forget it in a moment don’t go for the drugs before we try the simple things positioning splinting keeping people warm shivering and then chilling around the broken bones all those things are really important at the emr level and up we have nitrous oxide still available methoxy fluorine though it’s not something that we’re stalking on car yeah
If a pay ski patrol agency or a first responder group of some sort it is using pens rocks if you’re taking the training on it you’re more than welcome to take it along to the hospital with you and continue that treatment on route just bear in mind that nitrous oxide and ethically flaring together have been shown in our trials to produce a little bit more sedation
Than was reported other we’re at the pcp level we now have ibuprofen and acetaminophen and intranasal ketamine now the sun in every area right now but it is rolling out further and further and we expect that to hopefully continue over the course of the year and at the acp level we have fentanyl and intramuscular academy in her eye each enamine if need be i just
Don’t want to point out during the cova 19 pandemic the intranasal root is considered an aerosol generating medical procedure so it’s considered high-risk so we should only be using intranasal root if we absolutely have to the adult dosing for ibuprofen is really straightforward we’re currently stocking it in 300 milligram tabs and that’s going to be the dose for
Every adult that can be repeated every four to six hours is needed for pain the pediatric dosing although we’re not currently stocking the liquid formula when it does become available the analgesic dose is 10 milligrams per kilogram it can be repeated once a six-hour mark if need be and the the antipyretic dose offer acps is for fear up to 39 it’ll be 5 milligrams
Per kilogram any fever over 39 celsius 10 milligrams per kilogram the acetaminophen dosing is fairly straightforward as well from 30 to 50 kilos as an adult look at one tab of 500 milligrams any at all over 50 kilos will get a thousand milligrams or two tabs and that also could be repeated once every four hours for pediatrics it’s the same dose for analgesic and
Antipyretic which is 15 milligrams per kilogram of the liquid or a 500 milligram tab if they’re between 30 and 50 kilos and old enough to swallow it we’re not giving down pills to swallow to kids under 30 kilos if you have any kids that are over 50 kilos they can also get a gram or a thousand milligrams i’m not gonna get into the details on how to dispense pills or
Tabs i’m pretty sure you’re all confident in doing that i will remind you though that there is water available on the pvc and mini bottles so if you don’t already have some at your station make sure you know she gets online to pdc in order so let’s look at the universal formula for drug quantities again though our dosing just because we’re gonna be using pediatric
Liquid and it’s something that none of us have done for a while so patient in this case is a four year old male his mother reports his weight in pounds like we all do at 40 so we do a little math and discover the si 18 kilos or thereabout we multiply that by the 15 milligrams per kilogram desired dose and we get a total dose of 270 milligrams the quantity we have
On hand is conveniently listed in single units of a single milliliter so it’s 80 milligrams per milliliter so our formula is pretty straightforward we divide the total dose of 270 milligrams by the concentration of 80 milligrams per milliliter and multiply that by 1 or just use the the number we get which is rounded in our case up to 3.4 milliliters the formula
Of acetaminophen that we’re getting is actually the tylenol brand you see here looks exactly like this for those of you who don’t have small kids or whose kids have grown a little bit reminder that these come with a syringe now ideally we’d like to be using our own medical grade syringes with more units of measurement and detailed in dosing but the nature of these
Bottles whether they’re designed to dispense is with this simple measure technique there’s a little cap inside the bottle that the syringe that comes with it fits nicely into our 10 cc syringes or 3 cc syringes don’t fit well into there so it’s very difficult to draw off with anything else you can get the cap out and use our own syringes but it’s quite difficult
To get it out it’s quite easy to use this but if we use the case of the picture we were just talking about that needs a dose of 3.4 milliliters as you can see here this is only measured in increments of up to 1.5 milliliters so we’d have to draw up two separate small doses plus a little bit and would be very difficult to get precisely accurate when we’re talking
About larger patients so we’re just going to be the best we can with this managing pediatric penis i mean is relatively new for pcps and it’s something that a lot of us are really looking forward to having better options for dealing with one of the things that we need to look at though is properly evaluating pediatric pain particularly when children are small enough
That they can’t express their pain or pick a number out of 10 per say something that’s already in the siren software in our vital signs component is this thing called a flak scale which stands for face legs activity cry and consult ability if you look at the chart here on the left it just requires a couple of minutes of observation generally with the child for the
Most part exposed so we can see their legs and we can see their face etc and we look at each column know which pic which number corresponds most accurately to the state that we observe and then we come up with a score a score of zero is somebody who’s relaxed and comfortable with little pain or no pain one two three would be considered mild discomfort four to six is
Considered moderate pain and seven to ten is considered severe pain or discomfort you can see here on the left how the flack score is represented within the siren software it’s a pick list and it generates a score for you automatically once you’ve picked your way through there on the right you see the visual pain score with the faces and the simplistic definitions
Below whichever one you use it’s really important that we use something all age groups adult to pediatric need a paints were reported before analgesia is given and after analgesia is given and that’s just as simple as doing a set of vitals like you all normally would before you give them a vacation and then doing a follow-up set or more after the pain medications
Been given so that we can really track how well our pain scores and how well our pain medications are working so i just want to finish up with a really quick word on fevers antipyretics are not in the pcp scope under the ema regulations and that’s frustrating to a lot of pcps who like the idea of having antibiotics and their toolkits the number of beavers that they
See in it particularly now during the pandemic however when we look at severe discomfort a significant discomfort as a result of a fever myalgia those kind of body aches and things of that nature in some cases it would be appropriate to give analgesia to deal with the discomfort associated with fever but in that case we’re treating analgesia we’re not treating
Fever it’s also important that we’re not rushing to give these medications without a clinical indication both ibuprofen and acetaminophen have downside effect they do suppress some helpful immune response and they do produce some side effects that we don’t quite like so we really are only looking at treating a significant discomfort even at the acp level fever is
Really something that should only be treated if it’s causing distress if there’s no tachycardia there’s no altered loc there’s no seizure activity there’s nothing clinically that needs to be treated we probably don’t need to go giving an antipyretic and that brings us to the end i thank you again for listening to one of my videos i would like to remind everybody
That if you have questions going forward as always clinical practice at dce hfca– or learning at bc ehs doca will help get you in touch with your paramedic practice leaders or your paramedic practice educators respectively there’s also a nice feature within the bc hs handbook if you click on the operations tab and then the context tab you’ll see practice leader
In educator context and that will show you all the practice leaders and practice educators around the province and what areas they cover and it’ll help you get in touch with them so if you have any questions please reach out to someone and have a great day
Transcribed from video
Oral Analgesia: Ibuprofen and Acetaminophen By BCEHS Clinical \u0026 Professional Practice
