Analgesia: Butylscopolamin and Metamizole

Butylscopolamin

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Age < 12 years
  • Myasthenia gravis
  • Pregnancy/Breastfeeding
  • Known prostatic adenoma with residual urine formation
  • Stenosis in the gastrointestinal tract
  • Renal colic
  • Symptomatic tachyarrhythmia
  • Glaucoma
• Side effects:
  • Tachycardia
  • Hypotension
  • Anaphylaxis
  • Dry mouth
  • Dizziness
  • Flush
  • Anticholinergic effect
  • Sedation
  • Headache
  • Visual disturbances
  • Urinary retention
• Measures for side effects: Symptomatic therapy
• Onset of action: 4 minutes (duration 30 minutes)

Metamizole

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity/allergy to the active substance
  • Pregnancy/Breastfeeding
  • Children < 3 months, or < 5 kg body weight
  • Known impaired blood formation
  • Glucose-6-phosphate dehydrogenase deficiency
  • Pre-existing hypotension [RRsys < 100 mmHg/circulatory instability]
  • Pre-existing medication with methotrexate
• Side effects:
  • Hypotension
  • Sweating
  • Nausea
  • Restlessness
  • Tachycardia
  • Anaphylaxis
  • Agranulocytosis
• Measures for side effects:
  • Flat positioning
  • Infusion therapy with crystalloid infusion solution
• Onset of action: 4-5 minutes (duration 4-5 hours)
• Risk information:
  • Metamizole is usually well-tolerated but in rare cases can lead to blood and immune system disorders.
  • Signs of these complications can be fever, chills, fatigue, sore throat, inflammation of the oral mucosa.
  • Medical advice should be sought immediately if these signs occur.

Initial Assessment for Strong Pain Management

• Initial NRS (Numerical Rating Scale) ≥ 5 and patient criteria:
  • Age ≥ 12 years, GCS (Glasgow Coma Scale) ≥ 14, Respiratory Rate ≥ 10, SpO2 ≥ 92%, SBP ≥ 100 mmHg, HR ≥ 50/min

Pain Management Algorithm

• Initial NRS ≥ 5 leads to a treatment decision depending on presence of:
  • Abdominal (flank) pain
  • Cardiac pain
  • Traumatic pain
  • Other pain
• Initial NRS < 5 leads to therapy according to findings.

Pain Management Options and Considerations

• Metamizole (for abdominal/flank pain):
  • Requires risk explanation and documentation
  • Administer 1g as short infusion
• Morphine (for abdominal/flank pain):
  • Administer 2.5 mg IV
  • Repeat every 3 minutes up to maximum 10 mg
  • Further application only in consultation with TNA (telephone consultation with anesthesia specialist)
• Esketamine (for traumatic pain, if no contraindications):
  • According to dosage table
  • Repeat after 3 minutes
• Midazolam is according to dosage table
  • Further application only with TNA
• Fentanyl (for other pain, or traumatic pain with contraindications for Esketamine):
  • Administer 0.05 mg IV
  • Repeat at 3-minute intervals if needed, 0.05 mg IV
  • Further application only in consultation with TNA
• Butylscopolamine (for colicky pain):
  • Administer 20 mg slowly IV
• Insufficient analgesic effect with Metamizole: 0.05 mg Fentanyl i.v., repeat after 3 min if necessary, or consult TNA
• Treat respiratory depression with BTM (opioids):
  • Request emergency physician
  • Increase oxygen supply
  • Instruct to breathe (command breathing)
  • Perform assisted ventilation if necessary
  • Titrate 0.4 mg naloxone + 9 ml NaCl IV
• Nausea: SAA Nausea (93)

Documentation and Transport

• Basic measures should be considered before medication application
• Complete monitoring, including capnometry when applying Esketamine, Morphine or Fentanyl
• Target: NRS < 4 or halving of initial NRS
• CAVE: With missing pain stimulus: Decrease of respiratory drive
• With non-traumatic headache: TNA consultation required
• Note: 0.05 mg fentanyl corresponds to 5 mg morphine

Morphine

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Age < 12 years
  • Pregnancy/Breastfeeding
  • ABCD instability (airway, breathing, circulation, disability)
• Side effects:
  • Respiratory depression
  • Sedation to somnolence
  • Nausea and vomiting
  • Miosis
  • Bronchoconstriction
  • Itching
  • Exanthema
  • Bradycardia
  • Hypotension
• Measures for side effects:
  • For respiratory depression: Increase O2, command breathing, assisted ventilation, if necessary naloxone administration
• Onset of action: Few minutes (duration 4-5 hours)

Fentanyl

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Age < 12 years
  • Pregnancy/Breastfeeding
  • ABCD instability
• Side effects:
  • Respiratory depression
  • Sedation to somnolence
  • Nausea
  • Vomiting
  • Miosis
  • Bronchoconstriction
  • Itching
  • Exanthema
  • Bradycardia
  • Hypotension
  • Thoracic rigidity
• Measures for side effects:
  • Respiratory depression: Increase O₂, command breathing, assisted ventilation, if necessary naloxone administration
• Onset of action: Few minutes (duration 0.5 hours)
• Note: 0.05 mg fentanyl corresponds to 5 mg morphine; 0.1 mg fentanyl corresponds to 10 mg morphine

Paracetamol

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Pregnancy/Breastfeeding
  • ABCD Instability
  • Liver dysfunction
• Side effects:
  • Anaphylaxis (analgesic asthma)
  • Hypotension
  • Agranulocytosis
• Measures for side effects:
  • Flat positioning
  • Infusion therapy with crystalloid infusion solution
• Onset of action: 5-10 minutes (duration 4-6 hours)
• Cave: Note interval > 6 hours to last dose.
• Note: Consider maximal dose of 4g

Midazolam

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Myasthenia gravis pseudoparalytica
• Side effects:
  • Respiratory depression to respiratory arrest
  • Amnesia
  • Sedative to hypnotic
  • Anxiolytic
  • Centrally muscle relaxant
  • Paradoxical effect possible, especially in older patients
• Measures for side effects:
  • Give breathing instructions, encourage breathing; assisted, if necessary controlled ventilation
• Onset of action: 1-2 minutes (duration > 2 hours)

Esketamine

• Indication: Analgesia
• Contraindications:
  • Hypersensitivity to the active substance
  • Pregnancy/Breastfeeding
  • Intracranial pressure without prior sedation
  • Disturbance of consciousness or influence of drugs, alcohol, etc.
  • Poorly controlled SBP, angina pectoris or myocardial infarction within the last 6 months
  • Heart failure
  • Severe mental disorder
• Side effects:
  • Hypersalivation
  • Nausea and vomiting
  • Nightmares
  • Increase in blood pressure and heart rate/rhythm
  • Respiratory depression with rapid injection
• Measures for side effects:
  • ABC control (airway, breathing, circulation)
  • If necessary, clear the airways
• Onset of action: Approx. 1 minute (duration 30-40 minutes)

Esketamine Dosage Table

• 5 ml Esketamine (25 mg) plus 5 ml NaCl IV and 1 ml Midazolam (5mg) plus 4ml NaCl.
• 40-90kg KG 1mg Midazolam | > 90kg KG ggf. 1-2mg Midazolam
• Dosage table provides the dose of Esketamine and the volume to administer, relative to body weight:
  • <40 kg: no medication
  • 40-50 kg: 5 mg - 2 ml
  • 51-75 kg: 7.5 mg - 3 ml
  • 76-90 kg: 10 mg - 4 ml

  • 90 kg: 12.5 mg - 5 ml

• Re-evaluate NAS and ABCDE vital signs after 3-5 minutes.
• Repeat Esketamine once if needed, using the same dose.