Paediatric Acute care Guidelines PMH Emergency Department

Medication

This protocol allows intravenous morphine to be administered by trained registered nurses in the Emergency Department when prescribed by ED medical staff

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Staff Eligibility:

Eligible Staff:

  • Registered Nurses who are permanent staff or regularly employed in ED and who have completed a 3 month orientation to the PMH ED
  • All staff must complete the education package and be deemed competent by the CNM, CNS or CDN prior to commencement of administering Morphine under the protocol

Ineligible Staff:

  • Agency, new staff and relieving staff are not to administer IV Morphine in the ED

 

Indications

Patient Inclusion and Exclusion Criteria

Inclusion Criteria

  • Age > 6 months
  • Painful condition necessitating IV narcotic

Exclusion Criteria

  • Age < 6 months (mandates administration by a doctor using lower doses, carefully titrated)
  • Any concerns regarding airway anatomy or cardiovascular, neurological or other instability
  • Note:  Maximum respiratory depression occurs within 7-10 post IV administration and 20-30 minutes post IM administration.  Respiratory depression may occur late, after the painful stimulus is removed.

 

Dosage

Age

Dose

6  months and older  

  • 0.05mg/kg to a maximum dose of 2 mg
  • Maximum of 2 boluses at a 10 minutely interval can be given by the nurse
  • If additional doses are required, they should be administered by medical staff
  • Larger doses must be administered by medical staff

 

Preparation

  • Doctor assesses the patient’s analgesia requirement, drug allergies, recent medication and suitability for IV Morphine
  • An IV cannula is inserted into the patient
  • Morphine is prescribed on the front of the YELLOW Medication Chart as IV Morphine Bolus ____mg/kg, Total Dose = ____mg 
  • Only one dose to be prescribed at a time on medication chart
  • Additional doses should be prescribed if/when required
  • Maximum number of boluses that can be administered by the nurse is 2 with a minimum of 10 minute  interval

Administration

  • Morphine is available as 10mg/ml.  Dilute 10mg of Morphine with 9 ml of 0.9% Normal Saline to make a solution of Morphine 1mg/ml
  • The calculated dose is administered over 2-3 minutes via a 3-way tap or injection port and is followed by a 0.9% Normal Saline flush
  • The Emergency Department Schedule 8 Register is completed by the staff member who administers the medication.  The staff member who checked the drug must countersign the register.

Special

Considerations and Monitoring

  • Have knowledge of the medication including the side effects (most important are hypotension, respiratory depression), dosage and rate of administration
  • Ensure suction and oxygen are available, and emergency equipment of appropriate size 
  • Observations
    • Baseline observations: HR, BP, RR, oxygen requirement, conscious state and pain scores are recorded
    • Record HR, RR, oxygen saturation level and sedation score every 5 minutes for 15 minutes after each administration of Morphine
    • BP should be recorded if clinically indicated 
  • If pain relief is inadequate after 2 doses
    • < 2 hours since last dose administered – a doctor is required to administer subsequent IV analgesia
    • > 2 hours has passed, the doctor may prescribe a second ED IV Morphine protocol
  • Reversal Agent:
    • Naloxone is available in the Resus Room
    • Should be administered for excess sedation or respiratory depression
    • For excess sedation/respiratory depression:  Dose – 1-5 micrograms/kg  IV, maximum dose of 100 micrograms, may be repeated every 2-3 minutes if required
    • For resuscitation (minimal respiration, cardio respiratory arrest):  Dose 10 micrograms /kg (up to 400 micrograms), may be repeated every 2-3 minutes if required
    • Has short duration of action – approximately 30 minutes, may necessitate repeat doses or infusion

References

PMH ED Guideline: Morphine IV – Nurse Administration – Last Updated: October 2014
AMH Children’s Dosing Companion (online).  Adelaide:  Australian Medicines Handbook Pty Ltd; 2014 July.  Available from:  https://childrens.amh.net.au

 

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