For you medics out there? A chest pn question

[rimdup]

We recently took morphine off of our trucks and replaced it with Fentanyl. The protocol states for ANY pn greater than 3/10 on pn scale. For Chest Pain we start with ASA, and NTG sl, 12 ekg with all other treatments/ hx in place. Alot of medics here will not give Fentanyl for chest pain for a few reasons, 1) In our city the nearest hospital is usually no longer than 10-15 minutes away, 2) some cardiologists don't like it because it masks pain (though the half life for Fentanly is only 30-60 minutes and morphine did the same thing but also releases histamine which causes a decrease in BP ontop of other things). 3) Old school medics don't like change and are stringent MSO4 fans. Just curious to see what other EMS services are doing.

[AZCEP]

1) In our city the nearest hospital is usually no longer than 10-15 minutes away

How does transport time relate to not treating pain? Unless you are doing all of your treatment enroute, you have time to relieve the pain. If you don't think you need to treat pain, then you don't need to have ALS providers either.

2) some cardiologists don't like it because it masks pain.

This is total, unadulterated CRAP. This philosophy has been widely disproven, and should not be used to limit pain relief options.

3) Old school medics don't like change and are stringent MSO4 fans.

If they don't like change they should get out of medicine altogether. Morphine has been used for so long that people don't want to have to think about whether it is effective or not. Fentanyl is a much better drug for this effect, and a good many places are already using it as an alternative rather than a replacement.

[DwayneEMTP]

We give morphine for the vasodilation properties, right?

But why else do we give it, and can we get those results from fentanyl? Sure.

Pain relief, that also causes a decrease in anxiety, which leads to a decreased heart rate, which leads to decreased O2 demand, right?

So what would your choice be? Mine would be yes.

Good question.

Dwayne

[chbare]

That is one train of thought. You can have a release of histamine associated with morphine. This may lead to vasodilation, however, this response is rather unpredictable at best. In reality, the benefit of narcotics comes from blunting the sympathetic response (decreasing pain) and preventing increased myocardial work and oxygen consumption associated with the sympathetic response.

I still use mophine, but opt to use fentanyl anytime I suspect hemodynamic compromise could be a problem. (inferior wall MI for example)

I am not sure any definitive evidence exists to prove one is better. At this point I think it is a crap shoot. I like having another option for pain control and with good clinical judgment, I think I am able to povide better care than simply giving morphine because "that is what I have Always done."

Take care,

chbare.

[air.stump]

I worked at a service that changed medical directors. The old doc had us stock five different narcs in the drug box and had protocols for use with each one. The new doc thinned out the stock and dropped it down to two drugs, MSO4 was one of them, and changed the protocols with them.

On one hand, I didn't mind learning all the meds from the first doc. On the other hand, it kind of made it easy when it came to narc use with the new doc.

If I have a choice, I like MSO4. I am comfortable with it and have used it a lot. Besides, we use it now. But, if the director chooses to use fentanyl, then I would learn to use it and eventually be comfortable with it.

One of the things that I enjoy about treating patients with a medication is that in most cases, you can see changes in their condition in less than ten minutes. This is especially true with cardiac patients. NTG and MSO4 work quickly and their effectiveness can be evaluated, seen. Not using a drug because you are ten to twenty minutes away is BS. Not using it because of the masking crap is also BS. We treat patients as do the cardiologists. Pain is only one of the symptoms.

AZCEP has a point, if the old heads don't like change then they should leave the profession. Change is one of the only constants in EMS.

[EMS49393]

I worked at a service that changed medical directors. The old doc had us stock five different narcs in the drug box and had protocols for use with each one. The new doc thinned out the stock and dropped it down to two drugs, MSO4 was one of them, and changed the protocols with them.

On one hand, I didn't mind learning all the meds from the first doc. On the other hand, it kind of made it easy when it came to narc use with the new doc.

If I have a choice, I like MSO4. I am comfortable with it and have used it a lot. Besides, we use it now. But, if the director chooses to use fentanyl, then I would learn to use it and eventually be comfortable with it.

One of the things that I enjoy about treating patients with a medication is that in most cases, you can see changes in their condition in less than ten minutes. This is especially true with cardiac patients. NTG and MSO4 work quickly and their effectiveness can be evaluated, seen. Not using a drug because you are ten to twenty minutes away is BS. Not using it because of the masking crap is also BS. We treat patients as do the cardiologists. Pain is only one of the symptoms.

AZCEP has a point, if the old heads don't like change then they should leave the profession. Change is one of the only constants in EMS.

Actually, morphine given IV does not reach peak effectiveness for 20 minutes. Fentanyl reaches peak effectiveness in seconds.

Morphine does little in the way of vasodilation in the coronary arteries. However, it does produce hypotension rather quickly, and for a patient that may already having pressure problems, may not be the ideal choice for pain control. Fentanyl does not have the same effect on blood pressure. It is now thought that the main function of the narcotic analgesic is to reduce anxiety, thereby further reducing demand on the possibly compromised myocardium. Any narcotic analgesic could service this purpose.

I really have no idea why people seem so timid about fentanyl. I had a parapup with me for a long time that was scared to death of fentanyl. Personally, I'm fond of it. It's amazingly effect for the fractured hip patient that required moving out of a tight back room. It's fast, it's potent, and has minimal side effects, especially when compared to morphine. I also like the ability to truly titrate to pain relief. My last service had standing orders for fentanyl. We could push 50-100 mcg, titrated to relief, with a max of 200 mcg without consult. I often started with 10 mcg on elderly patients. I've reached fantastic pain control with less than 50 mcg on several elderly patients. Fentanyl is so fast a provider can start with 10 mcg and slowly increase the dose until the patient is pain free. Morphine is so slow it often takes a huge dose to make a minimal dent in pain, and before you know it, your patient is hypotensive.

Fentanyl is not a big, bad, misunderstood drug. It's a welcome addition to the analgesic cache on the ambulance. Hopefully your service has a protocol roll-out for new drugs, and you are taught enough about the drug to feel more comfortable about using it. In case your service just tosses random drugs in your box and hopes you know all about them, then they suck.

[jwt]

we carry both, but only morphine falls into our chest pain protocol.

[AlamanceMD]

"While patients hospitalized for a heart attack have long been treated with morphine to relieve chest pain, a new analysis by researchers from the Duke Clinical Research Institute has shown that these patients have almost a 50 percent higher risk of dying."

The quote above is based on a large study from Duke University showed in 2004.

People who had chest pain and received Morphine did worse (as in... died more often).

I can't find a free link to the study published in the American Heart Journal, but here's a link to a digested news story on the study.

http://www.sciencedaily.com/releases/2004/...41116233621.htm

I'm glad to see many supporting the use of Fentanyl and recognizing the limitation of Morphine.

In all areas of medicine, we often base what we do on what we've been taught and on anecdotal evidence.

Instead, we should establish protocols on what well reasoned research and clinical trials proves works (or doesn't work).

Bottom line.... just because we've used morphine for decades does not make it a good drug.

My service will soon remove morphine and use fentanyl.

Please provide me with your thoughts on this. I found this thread while reviewing this issue and any input before I change protocols is appreciated.

Regards,

AlamanceMD

[akflightmedic]

Thanks for responding Doc.

Welcome to the site and please feel free to contribute. We have several other physicians on this site and adding one more to the mix is fantastic.

Please go the the meet and greet and introduce yourself.

[spenac]

Welcome to the city AlamanceMD. Thanks for the reference link. We appreciate you doctors taking time to help us move EMS forward as a profession.

A question though. You mention removing morphine, do you mean completely from the ambulance or just chest pain protocol. I ask because it would seem having options would be a good thing for your paramedics that are properly educated. Does morphine still have a place in pain management of any sort or should it be completely done away with?