Entonox
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- 50:50 mixture of nitrous oxide and oxygen
- Provides effective inhalational analgesia
- Patient able to self-administer and control the mouthpiece
- Useful in the ED, pre-hospital care, labour analgesia and for procedural analgesia.
- In some settings it may be used without a medical prescription, by appropriately trained staff. E.g. Labour suite.
Contraindications:
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- Pneumothorax
- Bowel obstructions
- Visceral perforations
- Decompression sickness
- Head injury
- Middle/inner ear injury
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Ketamine
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- Potent NDMA receptor antagonist and some modulation at opioid receptors.
- Given by IV infusion by specialists
- Prescribed on the “continuous infusion” section of TPAR.
- Prepared as 5 mg/mL
- Rate of infusion between 1-3ml/hour (5-15mg/hour)
- Useful in both nociceptive and neuropathic pain
- Should be supervised by specialists – pain team and anaesthetists.
- May also be given orally.
Contraindications:
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- Raised intracranial pressure
- Ischaemic heart disease
- Mental illness, delirium and/or hallucinations
- Pregnancy and breast feeding
- Glaucoma
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Consider adjunctive therapies if appropriate.
Gastrointestinal or Biliary Spasm:
Hyoscine butylbromide (Buscopan®) 20mg IM or Slow IV, repeated after 30 minutes if necessary (Oral dose 20mg QDS)
Skeletal muscle spasm, short course of either:
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- Benzodiazepines e.g. diazepam.
- Baclofen
Pain from skeletal metastasis (specialist therapies):
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- Bisphosphonates (IV Pamidronate up to 90mg once, every 4 weeks) – caution in impaired renal function and consider dose reduction
- Radiotherapy
- Strontium
