# Acetaminophen pain protocol in MD



## sinus (Jan 18, 2014)

I'm a EMT-B student in Maryland, and we were going over BLS medications. Tylenol syrup is available for mild to moderate pain, but the max dose is 625 mg (2 *regular* strength Tylenols). Also, I asked the teacher about the long onset time for an oral painkiller. He said it would take a long time, and that he didn't personally like that protocol.

Does 625 mg treat anything more than a headache effectively?


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## unleashedfury (Jan 18, 2014)

We have it for a antipyretic.. 

So yes Tylenol is great for fever control


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## sinus (Jan 18, 2014)

In MD it is for pain only. Protocols do not allow it to be used for fever for some reason. Of course, a child sick with a bad fever probably has at least mild pain.


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## unleashedfury (Jan 18, 2014)

sinus said:


> In MD it is for pain only. Protocols do not allow it to be used for fever for some reason. Of course, a child sick with a bad fever probably has at least mild pain.



What level of course are you in? 

I am curious as can EMT-Basics perform medication administration in MD. Or you working on a advanced provider like AEMT/EMT-I standard? 

For PA ALS practitioners can carry Acetaminophen for a Antipyretic, in a suppository or suspension. Generally pain medication includes some sort of Narcotic analgesic.


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## frdude1000 (Jan 18, 2014)

No, it is actually a regular BLS skill in MD.  Not used really in the more urban and suburban areas.  Would be curious of its use in more rural areas with extended transport times.

See protocol below, page 205.
https://www.miemss.org/home/LinkClick.aspx?fileticket=Tz5wGQYZrKI=&tabid=106&mid=875


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## Brevi (Jan 19, 2014)

I wouldn't think Tylenol is generally called for in relieving pain so intense that an ambulance needed to be called.

If a patient was in pain so excruciating that it was going to be pharmaceutically managed pre hospital, I would have them treated ALS and given a more potent analgesic.


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## Tigger (Jan 19, 2014)

Somehow people still call an ambulance for pain that doesn't fit that definition however...


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## sinus (Jan 19, 2014)

Brevi said:


> I wouldn't think Tylenol is generally called for in relieving pain so intense that an ambulance needed to be called.
> 
> If a patient was in pain so excruciating that it was going to be pharmaceutically managed pre hospital, I would have them treated ALS and given a more potent analgesic.



IIRC, it's allowed to be used for 2/5 on FACES scale or 4/10 regular pain scale.


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## WoodyPN (Jan 20, 2014)

Well, actually the max dose is 640mg, following the protocol, using the 160mg/5ml cups. 

As far as giving it, in Western MD, I've given it a few times. Mostly to ward off QA nazis/keep in line with protocol, not because I thought it would help the patient. Take that as you will, but it's the reality.

And I wouldn't attach the numbers from the FACES scale to it, although the protocol states 2-5.


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## Brevi (Jan 20, 2014)

sinus said:


> IIRC, it's allowed to be used for 2/5 on FACES scale or 4/10 regular pain scale.



That sounds about right. On the out of 10 scale, 1-3 you might see providers use Tylenol, Ibuprofen or even non pharmacological measures. 4-7 maybe Tylenol with codeine, being one of the less aggressive options.


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## Tigger (Jan 20, 2014)

I think there is certainly a place for non-narcotic pain control medication on an ambulance and acetaminophen is not a bad start. It is widely used in New Zealand (known as Paracetamol) for moderate pain. 

As EMS seeks a place in the healthcare continuum we need to remember that our treatments need to do more than keep the patient alive till we arrive at the hospital. Many times your patient with moderate (but still real to them) might not be seen by the ED physician for quite some time after hand off. Why not help them in the interim?


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## Handsome Robb (Jan 20, 2014)

We can give 1000 mg of Tylenol and/or 600 mg of ibuprofen PO for "mild to moderate" pain.

I use it all the time even when I'm giving narcs. Narcotic pain relief plus anti-inflammatory effects, cryotherapy and positioning is money. 

That's assuming inflammation is present.

I also have suppositories and oral solution for kiddos. Apparently it tastes really good because they love it.


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## mycrofft (Jan 20, 2014)

Heads up to the dawning _re_discovery that tylenol can kill, especially when coupled with certain other drugs or chemicals. Tylenol was discovered in the 1800's but wasn't being used by the public much until it started being prescribed then advertised in the later 1960's because people were dying due to chronic use and overdose, or concomitant exposures to things like carbon tetrachloride.

Concern is being voiced about combination meds which also contain acetaminophen. We once had a pt on  two tabs Parafon Forte (original formula has 625 mg tylenol in each tablet along with the Chloroxazone muscle relaxant) BID, two tabs extra strength Tylenol (1 gm tylenol) BID, and a combination cold medication which was tab two po bid 325 mg per tab). 2,250 mg's twice a day.


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## Akulahawk (Jan 20, 2014)

Robb said:


> We can give 1000 mg of Tylenol and/or 600 mg of ibuprofen PO for "mild to moderate" pain.
> 
> I use it all the time even when I'm giving narcs. Narcotic pain relief plus anti-inflammatory effects, cryotherapy and positioning is money.
> 
> ...


Way back in my sports medicine days, I normally gave 600 mg of ibuprofen to athletes when they were injured and we had a desire to control inflammation, and there was no concern about ongoing hemorrhage. Our normal protocol for pain control for the first 48 hours post injury was 1000 mg acetaminophen, cryotherapy, compression, and elevation. After that, we normally went to 600 mg ibuprofen, heat pre-rehab and cold post-rehab. We had very good results, actually.


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## Av8or007 (Jan 20, 2014)

mycrofft said:


> Heads up to the dawning _re_discovery that tylenol can kill, especially when coupled with certain other drugs or chemicals.




“All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.”

But in all seriousness, thats all a drug is - a poison given in a therapeutic dose (atropine anyone?)

Tylenol can have toxic effects if taken in large doses or for too long


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## mycrofft (Jan 21, 2014)

Av8or007 said:


> “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.”
> 
> But in all seriousness, thats all a drug is - a poison given in a therapeutic dose (atropine anyone?)
> 
> Tylenol can have toxic effects if taken in large doses or for too long



Yes. Lately larger doses are being touted (my wife has chronic orthopedic issues so we have run into this) but as she has a good liver and doesn't drink and is not exposed to industrial chemicals, she does ok.
However, once that was started around 2006 or so, they start having trouble with some patients due to the other fact we have to learn over and over…not everyone reacts the same way to treatment. Plus so many combination drugs are being sold with tylenol or aspirin or other "harmless" drugs added that you can have a pt taking much more than they realize. Add that to the many "silent"cases of Hep C...

Related Sidebar: our pharmacodynamics prof told of what he called "Dry Cleaners' Syndrome" from the late 1800's/early 1900's when carbon tetrachloride was used for dry cleaning, and no one used respirators or machines or ventilators or even gloves. After a while, one day, one of these fellows would sit up on a bar stool, order a shot, down it, and collapse.


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## sinus (Jan 30, 2014)

Av8or007 said:


> “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.”
> 
> But in all seriousness, thats all a drug is - a poison given in a therapeutic dose (atropine anyone?)
> 
> Tylenol can have toxic effects if taken in large doses or for too long



Acetaminophen is one of those drugs where that saying doesn't apply really. The toxic mechanism has nothing to do with the therapeutic mechanism (unlike atropine). Acetaminophen isn't even the toxic agent, it's the failure of the liver to futher metabolize a hepatotoxic minor metabolite of acetaminophen due to glutathione depletion that can result in fulminant hepatic failure.

Tylenol is low in side effects and drug interactions compared to NSAID's and is pretty safe as long as there is enough gluathione stores to handle the NAPQI metabolite. Predicting what dose over what time is enough to deplete the gluathione is difficult to predict though.


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