Clinical Tips

Ask what medications EMS has given in field

"Many times in the pre-hospital arena, we see medications given as if the person were young and with good kidneys and liver," says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. "One of the issues I have dealt with frequently of late, is fentanyl given for pain."

Medics may know that fentanyl clears more quickly in younger patients — "typically, we see the effects of this medication about twice as long in the older adult," she says — but they often don't realize it takes longer to "kick in." Therefore, they repeat the dose before the patient has a response to the first dose. "This leads to respiration depression that lasts two hours, instead of the 45 minutes they are expecting," says Somes.

In addition, many times emergency medical services still are giving 100 mcg of this medication, instead of starting with a lower dose of 25 mcg. "Many older patients are hypoxic due to decreased drive," she explains. "This will adversely affect the patient."

Doses of nonsteroidal anti-inflammatory drugs, such as ketorolac, ibuprofen, naproxen, and tramadol, need to start lower, or not only will the patient have problems with bleeding, but they also might develop liver and renal problems. "Mix this with a dose of aspirin, and you have a real bleeding problem," warns Somes.