FIELD REFERENCE
Full criteria & treatment guidance
Indications
- Pain control, including cardiac-origin pain not relieved by nitroglycerin, only under the relevant OCEMS order and perfusion/respiratory criteria.
Contraindications & local exclusions
- The cited fentanyl citrate injection label excludes fentanyl hypersensitivity. Apply additional BP, respiratory, age and base-order limits from the particular OCEMS pathway; the label is not an IN dosing authorization.
Precautions
- Respiratory depression, hypotension and muscle rigidity are risks. Concomitant benzodiazepines/CNS depressants increase risk; have ventilation support available and reassess consciousness, breathing and BP. The cited injection label does not recommend use during or immediately before labor when other analgesic techniques are more appropriate; opioids can depress neonatal breathing. This is labeled pregnancy/labor guidance, not a transplanted county-policy contraindication.
- These are selected safety checks, not a complete prescribing monograph. Product labeling and OCEMS authorization answer different questions; confirm the actual product, patient population and applicable order.
Check before giving
- Keep micrograms (mcg) distinct from milligrams (mg).
- Adult injury and burn analgesia requires systolic BP above 90. Continue airway and ventilation assessment after dosing.
Use in OCEMS
- Opioid analgesia in applicable painful-injury/burn pathways, and IV treatment of cardiac pain not relieved by nitroglycerin or when nitroglycerin cannot be given.
- Assess pain, perfusion, respiratory status, and mental status before selecting an analgesic.
Adult / adolescent
| Indication / route | Dose & limits |
|---|---|
| Pain — IV or IM | 50 mcg; may repeat once after approximately 3 minutes for continued pain. |
| Pain — IN | 100 mcg, divided as 1 mL per nostril with 50 mcg/mL stock; may repeat once after approximately 3 minutes. |
| Cardiac pain | 50 mcg IV; may repeat once after approximately 3 minutes. Follow SO-C-015 and withhold if systolic BP is below 90. |
Pediatric
- SO-P-015 severe-injury pain: 2 mcg/kg IN/IV/IM, maximum 50 mcg per dose. May repeat once after 3 minutes; total maximum 100 mcg.
- SO-P-015 requires base contact for children age 2 or younger. I-20 uses a “younger than 2” note; retain the condition-specific age-2 contact requirement rather than dropping it.
Pediatric weight table — Severe injury pain
- SO-P-015 pediatric dose: 2 mcg/kg IN/IV/IM.
- 2 mcg/kg IN/IV/IM; maximum 50 mcg per dose. May repeat once after 3 minutes; total maximum 100 mcg.
- Base contact is required for children age 2 or younger. Monitor ventilation, mental status, and blood pressure.
- Calculated examples for the exact weights shown, using the named standing-order/procedure formula. Do not round the patient’s weight to the nearest row. For another weight, calculate from the stated formula and apply the limits. These are not the rounded I-20 weight-band volumes.
- Volumes are mathematical examples rounded to at most three decimal places. Verify the vial concentration, dose, and measurable syringe volume before administration; follow agency preparation/rounding practice.
| Exact weight | Dose — IN/IV/IM | Volume at 50 mcg/mL |
|---|---|---|
| 3 kg | 6 mcg | 0.12 mL |
| 4 kg | 8 mcg | 0.16 mL |
| 5 kg | 10 mcg | 0.2 mL |
| 6 kg | 12 mcg | 0.24 mL |
| 8 kg | 16 mcg | 0.32 mL |
| 10 kg | 20 mcg | 0.4 mL |
| 12 kg | 24 mcg | 0.48 mL |
| 15 kg | 30 mcg | 0.6 mL |
| 20 kg | 40 mcg | 0.8 mL |
| 25 kg | 50 mcg | 1 mL |
| 30 kg | 50 mcg | 1 mL |
| 35 kg | 50 mcg | 1 mL |
| 40 kg | 50 mcg | 1 mL |
| 45 kg | 50 mcg | 1 mL |
| 50 kg | 50 mcg | 1 mL |
| 60 kg | 50 mcg | 1 mL |
Preparation & reassessment
- Stock listed in I-15 is 100 mcg/2 mL. Confirm concentration and the selected route.
- Document pain before and after treatment, dose times, total dose, blood pressure, and respiratory response.
UNDERSTAND THE CARE
Why route and units need separate checks
The analgesia pathways specify route-dependent adult doses and a capped pediatric weight-based regimen. A route permitted for injury pain should not automatically be copied into cardiac-pain treatment. Confirm the condition order and blood-pressure requirements before preparation.
Applying the guidance
Keep micrograms visible in the calculation and record the actual vial concentration. Include earlier analgesic doses and the permitted repeat interval in the check. Following administration, compare pain with breathing, consciousness and pressure. A lower pain score should be reported together with whether ventilation and perfusion tolerated treatment.
Dose, concentration and volume
Diagram text & teaching checkpoints
- Indication and route
- Injury/burn versus cardiac-pain instructions.
- Units
- Micrograms and actual concentration.
- Prior treatment
- Repeat interval, maximums and pediatric contact.
- Response
- Pain, breathing, consciousness and pressure.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.
- I-15 — Adult / Adolescent Standing Order Drug Guide
- I-20 — Pediatric Medication Volume Dose by Weight
- SO-C-015 — Chest Pain of Suspected Cardiac Origin or Suspected Angina Equivalent Symptoms
- SO-T-005 — General Injury and Trauma - Adult / Adolescent
- SO-E-005 — Burn (Thermal, Electrical, Chemical) - Adult
- SO-P-015 — General Injury and Trauma - Pediatric
- Product label — FENTANYL CITRATE injection, solution
Make the analgesia report include tolerance
Analgesia assessment has two parts: how the pain changed and how the patient tolerated treatment. Report both. A patient who reports less pain but has worsening breathing or perfusion needs that change recognized, rather than a handoff that says only “pain improved.” Preserve the condition-specific respiratory, pressure and repeat-dose criteria.
Use micrograms consistently when reading the dose and concentration. The general dose-to-volume illustration elsewhere on this site uses milligrams as an example; for fentanyl, keep the numerator and denominator in matching microgram units. Do not combine a dose in mcg with a concentration expressed in mg/mL without an explicit, checked conversion.
For example, when handing off a patient treated for cardiac discomfort, state why the cardiac-pain pathway applied, which route was used, earlier nitroglycerin or analgesia, each administration time, and the subsequent pain, breathing, consciousness and blood pressure. An injury-pain route should not be silently carried into the cardiac-pain branch.
Source: Chest Pain of Suspected Cardiac Origin or Suspected Angina Equivalent Symptoms.