ACEP policy: Out-of-Hospital Use of Analgesia and Sedation

ACEP states that ” The relief of suffering is among the most common reasons for requesting EMS assistance. Pain and agitation are common causes of this suffering and are commonly encountered by EMS. There is a gap between the need for patient analgesia and the willingness of EMS personnel to provide it. There is a variety of medications available for the relief of pain and agitation.”

So let’s make the point on prehospital analgesia and sedation according with this policy.

Out of hospital analgesia

1. Fentanyl for his short duration and rapid onset, multiple administration route (IV, IM, IN, and IO),   haemodynamic stability is the ideal narcotic agent for out of hospital use.
2. Do not withhold narcotics in patients with abdominal pain for the myth of confounding the surgical assessment and so clouding the final diagnosis.
3. Ketamine (at low doses) for analgesia (alone or in combination with narcotics) is safe, effective and haemodynamically stable without provoking respiratory drive and gag reflex suppression
4. Concern about Ketamine effect on (increasing) intracranial pressure is misplaced

Out of hospital sedation and chemical restraint 

1. Midazolam due to his rapid onset, short duration and multiple administration route (IV, IM, IN, and IO) is the ideal benzodiazepine for out of hospital sedation.
2. Benzodiazepines, especially when administered in multiple doses can cause respiratory drive depression: use full monitoring of the patient when using benzodiazepines (MEDEST suggest waveform capnography). Consider other agents as butyrophenones (MEDEST suggest Aloperidol, Droperidol)
3. Ketamine (in dissociative dose) is the ideal agent for patients with excited delirium (still not recognised as medical disorder in Italy!!!!!) cause of his rapid onset, safe haemodynamic profile and leave intact respiratory drive and gag reflex.

For full free open access text of this policy go to:

• ACEP clinical policy Out-of-Hospital Use of Analgesia and Sedation