Question: Recent call of a 40 years old woman with a past history of renal colic and experiencing intense low back pain that she likens to an exacerbation. She is a small woman at about 45 kg and a candidate for narcotics under the standing order for pain relief. Two questions: Firstly, we were unable to establish an IV after 2 attempts and the standing order specifies only the IV route of administration. Can morphine and/or fentanyl be given IM in this instance as a standing order? Secondly, her initial BP was 90/60. Given the patient's size and her statement of usually having a low BP, can this reading of 90/60 be considered as normotensive? What if it was 85/60? Thanks in advance for your answer.

Thanks for the great question. To answer the first question, you are correct. The Pain Medical Directive specifies that only the IV route of administration is acceptable in this instance. As such, no, morphine and/or fentanyl cannot be administered as a standing order via the IM route.

To answer the second question, when designing the medical directives, at some point, a convention needed to be established as to the definition of "normotension". In your handbook on page 12, the definition of normotension is listed as greater or equal to 100mmHg systolic.

While you are absolutely correct that some patients (especially those with small body mass) "normally" have a "low" blood pressure, the intention was to establish a convention that would allow the majority of patients who meet the other indications in the directive to receive therapy. Most patients do not have a resting blood pressure below 100mHg systolic, especially when they are sympathetically driven from such situations as being in severe pain. As such, from your case above, no, this patient would not be able to receive narcotic analgesia from this Medical Directive with a blood pressure of 90/60mmHg or 85/60mmHg.

While the option to patch to a BHP exists for extenuating situations, many BHP would have reservations in administering IV narcotics to patients with BP in the ranges you describe.

Analgesia,Pain/Sedation/Nausea

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