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Điều này có một khởi đầu chậm hơn so với chuẩn độ tĩnh mạch và chấn thương bệnh nhân nghèo lưu lượng máu ngoại vi sẽ tiếp tục làm giảm hấp thu làm cho nó khó khăn để đạt được kiểm soát ban đầu đau đầy đủ. | PAIN RELIEF AFTER TRAUMA 309 opioid tolerant patients may need high bolus doses for example 4 mg but usually the lockout interval remains constant. Many elderly patients will not or are unable to use PCA effectively even after a seemingly good explanation and other routes must be used. Other opioids for example fentanyl may be used by the PCA route according to local protocols. For PCA purposes 20 pg fentanyl is equivalent to 1 mg morphine. Intramuscular analgesia This has a slower onset of action than intravenous titration and in the trauma patient poor peripheral blood flow will further reduce absorption making it difficult to achieve initial adequate pain control. However when opioid requirements have been established it may be the preferred method of maintaining analgesia particularly in elderly patients unable to understand and use PCA. Intravenous infusion Require reliable intravenous access. Patients must be under close supervision to enable effective rate adjustment without the risk of overdosage. Usually restricted to patients in a HDU or ICU. Oral route An ideal way for continuing analgesia. Patients must be able to tolerate an oral intake. Severe pain may need high oral doses of opioids. Can be continued after discharge from hospital. May avoid the need for admission to hospital after some injuries despite severe pain. Must be balanced against the potential for misuse in some populations. Other opioids Fentanyl An alternative morphine for instance when there is allergy. An initial dose of 0.1 mg is equivalent to approximately 10 mg of morphine. Has a short duration of action. As with all opioids careful titration and observation is required. Pethidine Short duration of action. Relatively impotent against severe pain. Associated with severe nausea and vomiting. Metabolites are proconvulsant. Codeine methyl morphine 310 TRAUMA RESUSCITATION Metabolized to morphine to become active. 10 of the population are unable to metabolize codeine to morphine i.e. no .
