# IV acetaminophen



## 18G (Mar 11, 2014)

Somehow I just found out that IV acetaminophen was FDA approved in the US in 2010. I had an L&D transport and the patient was given IV acetaminophen. 

Are any EMS agencies carrying the IV form? I can only imagine the cost per dose.


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## Carlos Danger (Mar 11, 2014)

I'd be surprised if very many places are carrying this prehospital.

Cost is probably reasonable per dose (I want to say around $30 for the 1G vial?) but like many things, the onset time is too long to be of much benefit prehospital.


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## TransportJockey (Mar 11, 2014)

For prehospital uses Toradol would make more sense as the NSAID of choice... but I have seen it ordered here in the ED before


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## 18G (Mar 11, 2014)

Tylenol isn't an NSAID though. There is some issue with Toradol and bleeding risk in certain conditions. Some say NSAIDs should not be used in adult fractures due to complicating healing. I'm personally not a fan of Toradol in the field. 

We have PO acetaminophen in our protocols for fever only. The IV form would be useful with severe nausea and vomiting and with febrile children who refuse to take anything PO and who by chance where held long enough to start an IV. 

I'm not seeing a real good use for the IV form as analgesia. Any other thoughts?


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## 18G (Mar 11, 2014)

I don't subscribe to the "delayed onset so it's a waste of time prehospital". The sooner a med is onboard the sooner the patient gets relief. If we delay in the field, the patient could end up waiting 1-2hours before getting a med (ie busy ED, physician seeing the patient and writing orders, nurse getting around to give the med, etc).


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## Handsome Robb (Mar 11, 2014)

Renal colics

Seeing as opiates and opioids can cause ureter spasm. Seems counter productive to me...


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## jwk (Mar 12, 2014)

We use IV acetaminophen (Ofirmev) all the time in surgery.  Our PACU nurses swear by it - it decreases the need for post-op narcotics, which in our field is desirable since less narcotics = less respiratory depression.

I can't recall the exact cost - it of course is far more expensive than PO Tylenol, but far far cheaper than things like precedex which some are advocating for other uses with far fewer indications.

I suppose it would be OK pre-hospital as long as you're aware it doesn't have rapid effect like narcotics, and for that reason alone, I'm not sure how much utility it has in EMS.  There are a couple other important things to remember:

The pediatric dose is 12.5mg/kg.  It is not approved for kids younger then 2 y/o.

Make sure your receiving facility knows your patient got IV acetaminophen and WHEN the dose was administered.  Because of that relatively narrow safety margin with acetaminophen, overdosage is a distinct possibility - not great if someone comes along and gives the patient a couple Percocet shortly after arrival in the ED.

One last thing - our Ofirmev comes in a 100cc glass bottle - I'm not sure if it's available in a plastic container.  Even in the dark ages when I did EMS, glass bottles were forbidden on our units.


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## NomadicMedic (Mar 12, 2014)

Just as a point of note, Tridil and CyanoKits are in glass bottles. Both frequently used prehospital.


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## Nova1300 (Mar 12, 2014)

I don't think you will use this stuff in the field.  Its an adjunct for a patient who had other modes of analgesia (opiates, ketamine, etc.)  I don't see it doing much as monotherapy.  


If you are really dying to give Tylenol to a patient who cant tolerate PO, I have a pretty good place you can stick it :huh:


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## Carlos Danger (Mar 12, 2014)

18G said:


> I don't subscribe to the "delayed onset so it's a waste of time prehospital". The sooner a med is onboard the sooner the patient gets relief. If we delay in the field, the patient could end up waiting 1-2hours before getting a med (ie busy ED, physician seeing the patient and writing orders, nurse getting around to give the med, etc).



I somewhat agree, but why not just use a med that has a faster onset? Shouldn't prehospital patients have their pain treated now, rather than 60 minutes from now, when Ofirmev peaks?

Also, for severe pain Ofirmev is inadequate as a sole analgesic. It makes a great adjunct to opioids, but if you were hurting badly you'd want narcs anyway. 

Narcs are cheaper, they work faster, and are more suited for the management of severe pain.


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## 18G (Mar 12, 2014)

Halothane said:


> I somewhat agree, but why not just use a med that has a faster onset? Shouldn't prehospital patients have their pain treated now, rather than 60 minutes from now, when Ofirmev peaks?
> 
> Also, for severe pain Ofirmev is inadequate as a sole analgesic. It makes a great adjunct to opioids, but if you were hurting badly you'd want narcs anyway.
> 
> Narcs are cheaper, they work faster, and are more suited for the management of severe pain.



I completely agree. I was just making a general statement regarding that "delayed onset so why give it in the field" argument. Several other meds fall under this. 

That makes perfect sense about the IV acetaminophen. I was just wanting to see if there was some utility to using it pre-hospital that I may have been missing.


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## mycrofft (Mar 12, 2014)

18G said:


> I don't subscribe to the "delayed onset so it's a waste of time prehospital". The sooner a med is onboard the sooner the patient gets relief. If we delay in the field, the patient could end up waiting 1-2hours before getting a med (ie busy ED, physician seeing the patient and writing orders, nurse getting around to give the med, etc).



OFRIMEV website: 15 minutes onset for analgesia, and 30 for antipyresis.


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## mycrofft (Mar 12, 2014)

Halothane said:


> I somewhat agree, but why not just use a med that has a faster onset? Shouldn't prehospital patients have their pain treated now, rather than 60 minutes from now, when Ofirmev peaks?
> 
> Also, for severe pain Ofirmev is inadequate as a sole analgesic. It makes a great adjunct to opioids, but if you were hurting badly you'd want narcs anyway.
> 
> Narcs are cheaper, they work faster, and are more suited for the management of severe pain.



Good points.
Antipyresis is one thing narcs don't address.
Moderate to mild pain and blocks to other routes (can't swallow pills) or drugs (bad synergy)  might be reasons to use it, but I think we're talking rare and very sick people here.


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## MGretz70 (Mar 12, 2014)

Not carrying it in the St. Louis Metro east area! But might be a good thing to look into.


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## KellyBracket (Mar 12, 2014)

18G said:


> ...
> The IV form would be useful with ... febrile children who refuse to take anything PO and who by chance where held long enough to start an IV.
> ...



Yes, that would be useful, if that were an important goal. There is no need to "treat a fever" by _anyone_, let alone EMS. This is not just my wacky opinion, but also the stance of the American Academy of Pediatrics. 

I went over some of the background  and evidence in *Fever - does EMS need to treat it?*

Of course, APAP and the NSAIDs are great for treating discomfort and minor aches. And you also can't overlook the power of a popsicle. Now that pre-hospital therapeutic hypothermia is out, perhaps the fridge for the cold saline can be repurposed!


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## Carlos Danger (Mar 12, 2014)

KellyBracket said:


> And you also can't overlook the power of a popsicle. Now that pre-hospital therapeutic hypothermia is out, perhaps the fridge for the cold saline can be repurposed!



Popsicles and Kool-Aid! Sounds good to me!


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## mycrofft (Mar 13, 2014)

KellyBracket said:


> Yes, that would be useful, if that were an important goal. There is no need to "treat a fever" by _anyone_, let alone EMS. This is not just my wacky opinion, but also the stance of the American Academy of Pediatrics.
> 
> I went over some of the background  and evidence in *Fever - does EMS need to treat it?*
> 
> Of course, APAP and the NSAIDs are great for treating discomfort and minor aches. And you also can't overlook the power of a popsicle. Now that pre-hospital therapeutic hypothermia is out, perhaps the fridge for the cold saline can be repurposed!


Thanks.
HAS anyone looked at acetaminophen as tx for heat stroke? (I know, I'll go look…rustle rustle rustle).

edit (approaching footsteps running):

http://emedicine.medscape.com/article/166320-treatment

Do NOT treat non febrile hyperthermia with antipyretics. (DO give sugar and address shivering with benzos…what!?).


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## KellyBracket (Mar 13, 2014)

I'm sure _someone_, at some time, looked at it.

Doesn't play a part in modern treatment though.


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## chaz90 (Mar 13, 2014)

mycrofft said:


> Thanks.
> HAS anyone looked at acetaminophen as tx for heat stroke? (I know, I'll go look…rustle rustle rustle).



Totally different mechanisms right? I mean, Tylenol isn't some kind of internal cooling agent that will combat external extreme temperature gradients leading to hyperthermia.


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## mycrofft (Mar 13, 2014)

chaz90 said:


> Totally different mechanisms right? I mean, Tylenol isn't some kind of internal cooling agent that will combat external extreme temperature gradients leading to hyperthermia.



See my edit to my latest reply. Yes.


AND I QUOTE:
"  Antipyretics (eg, acetaminophen, aspirin, other nonsteroidal anti-inflammatory agents) have no role in the treatment of heatstroke because antipyretics interrupt the change in the hypothalamic set point caused by pyrogens. They are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heatstroke. In this situation, antipyretics actually may be harmful in patients who develop hepatic, hematologic, and renal complications because they may aggravate bleeding tendencies."


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## 18G (Mar 14, 2014)

KellyBracket said:


> Yes, that would be useful, if that were an important goal. There is no need to "treat a fever" by _anyone_, let alone EMS. This is not just my wacky opinion, but also the stance of the American Academy of Pediatrics.
> 
> I went over some of the background  and evidence in *Fever - does EMS need to treat it?*
> 
> Of course, APAP and the NSAIDs are great for treating discomfort and minor aches. And you also can't overlook the power of a popsicle. Now that pre-hospital therapeutic hypothermia is out, perhaps the fridge for the cold saline can be repurposed!



I have three kids and don't freak out over a fever. And by having three kids and treating their fever I have seen the difference it can make with how they feel. More times than not they feel a heck of a lot better AND sleep a lot better. I think rest during an illness is pretty important. Heck, I feel a lot better when I have a fever and I take Motrin or Tylenol and it reduces it. 

I don't disagree with their stance but is mortality reduction the only goal? People don't die from pain during a nasty fracture but its feels a heck of a lot better with pain medication. A fever is benign in a child but they feel a lot better when its say 99F instead of 103F.


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## mycrofft (Mar 14, 2014)

Pain can potentiate shock. Until you pass out.

They used to INDUCE fever to fight some infections long ago. Not to mention mention making the  wear sweats, hot compresses, hot baths.

ANYTHING can be pushed beyond the limits of safety, but relieving fever in a garden variety cold or flu is probably not going to be bad (Reye's Syndrome aside).


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