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Opioid analgesia in the hypotensive patient

Question# 763

If you have a patient who is complaining of severe pain and is initially hypotensive requiring a fluid bolus. After the fluid bolus they are now normotensive-are we then able to treat them with morphine or fentanyl as now they meet the directive? or is it expected that we patch for orders?


If your patient is initially hypotensive and responds well to your fluid bolus treatment and is still in severe pain requiring opioid analgesia, then the RPPEO believes in providing patient-centered care that includes consideration of the risk-benefit of the proposed treatment. If a patient’s vital signs fall outside the medical directive’s parameters (i.e.: hypotension) and you determine a net benefit, and the patients’ subsequent vital signs meet the indications of the medical directive, (with or without intervention, i.e.: fluid bolus), you may proceed with treatment to ensure patient centered approach to care and document accordingly.

Additionally, there are other considerations for low BP and pain relief that should also be employed. Placing the patient in a more supine position, if the patient tolerates it, could help alleviate lower blood pressures. For pain relief, consider splinting, position, heat/cold therapy and even distraction. And as always, multi-modal analgesia is best practice, therefore along with opiates, administration of acetaminophen and ibuprofen/ketorolac should be utilized if the patient meets the conditions and there are no contraindications for this treatment.

It is however prudent to consider what may be causing the hypotension in your patient. Specifically, is the patient dehydrated due to significant pain and a decrease in food and water intake? What are normal vital signs for this patient? After the administration of morphine was there a histamine release causing vasodilation? Is it an erroneous blood pressure reading due to patient or ambulance movement? A thorough event and medical history of these patients will help in conducting the risk-benefit analysis for these patients.

Please remember that morphine should be administered very slowly to help prevent nausea, vomiting, and hypotension. For the opioid naïve patient and when providing higher doses of morphine and fentaNYL intravenously, consider administering in small aliquots q3 minutes until desired effect or max single dose is reached.

Lastly, if there are any doubts about your patient and their presenting complaints and vital signs, a consult with a BHP is always available. More specifically, if the patient remains hypotensive but in severe pain and you judge the benefit of analgesia to outweigh the risks, feel free to consult a BHP to discuss an order for opioid analgesia. This may mean starting with a lower dose and titrating slowly.


23 January 2024



Please reference the MOST RECENT ALS PCS for updates and changes to these directives.