BASIC MEDICATION OPTIONS
| Drug (Class) | Dose Range | Comment |
|---|---|---|
| Local Anesthesia and Additives | ||
| Lidocaine (Xylocaine) (0.5% – 1%) |
Most common 100- 200 mg (20 mL 1% or 40 mL 0.5%), maximum dose 300 mg | Most common in U.S. Lower concentration as effective but more expensive |
| Bacteriostatic Saline | 20 mL | Less effective than lidocaine |
| Bicarbonate Buffer | 1mL / each 10mL of lidocaine | Less injection pain and faster absorption; only for use with lidocaine |
| Vasopressin (Vasostrict) | 3-5 units mixed with anesthetic | Decreases bleeding & slows systemic absorption; do not recommend more than 5 units total |
| Oral and IV Pain Medications | ||
| Ibuprofen (Motrin; Advil) | 600 – 800 mg PO | More effective at least 30 minutes before procedure |
| Naproxen (Naprosyn; Aleve) | 250 – 500 mg PO | More effective at least 30 minutes before procedure |
| Acetaminophen | 500 – 1000 mg PO | Can be added to PO regimen (limited evidence based data) |
| Hydrocodone or Codeine | 1-2 tablets of 5mg hydrocodone or or 30 mg codeine PO |
Equivalent medications can also be used or those combined with acetaminophen |
| Fentanyl (Sublimaze) | 50 – 100 μg IV | Give over 30-60 seconds. Antidote is naloxone |
| Anxiolytics | ||
| Lorazepam (Ativan) | 0.5–2mg mg SL or 1-2 mg PO | Shorter acting benzodiazepine. Antidote is flumazenil |
| Diazepam (Valium) | 5 –10 mg PO | Longer acting benzodiazepine. Antidote is flumazenil |
| Midazolam (Versed) | 1 – 2 mg IV | Give over 30-60 seconds. Antidote is flumazenil |
| Uterotonics for Post-Aspiration Hemorrhage | ||
| Methylergonovine (Methergine) | 0.2 mg PO/IM or intracervical | Use with caution in hypertensive patients |
| Misoprostol (Cytotec) | 800mcg SL or 800-1000mcg PR |
Given a rapid time to peak concentration, SL or buccal may be preferable to PR if possible (Kerns 2013) |
| Carboprost (Hemabate)* | 0.25 mg IM, may repeat at 15-90 minute intervals to max of 2mg | Use with caution in asthmatic patients * Not available for use outside inpatient medical facilities |
| Oxytocin (Pitocin) | 10 u IM, or 10-40 u IV in crystalloid, or 10 u IVP | More uterine oxytocin receptors > 20 weeks |
| Emergency Medications | ||
| Atropine Sulfate (Atropen) | 0.2 mg (0.5 mL) IV push or 0.4 mg (1 mL) IM, each 3-5 min to max dose of 2 mg | For prolonged symptomatic bradycardia with vasovagal Some use in paracervical block to prevent vasovagal |
| Diphenhydramine (Benadryl) | 25 – 50 mg IM/IV/PO | For allergic reaction Use PO for mild symptoms and IM/IV for anaphylaxis |
| Epinephrine 1:1000 (Adrenalin) | 0.3 – 0.5 mg (1 mg/mL) SQ/IM Repeat doses at 5-15 min intervals as necessary |
For anaphylaxis. Preferable to inject in mid-anterolateral thigh |
| Naloxone (Narcan) | 0.1 mg – 0.2 mg (0.25-0.50 mL) IV / IM each 2-3 min Max dose 0.4 mg |
Opiate antidote |
| Flumazenil (Romazicon) | 0.2 mg (2 mL) IV each min Max dose of 1 mg |
Benzodiazepine antidote |
Alternative or supplemental options for pain management can include ketamine IV, dexmedetomidine IV, gabapentin (Gray 2019), and nitrous oxide (Singh 2017). However limited data on pain improvement with use.