Fentanyl with MI

[Niftymedi911]

I ran a call the other day and got a rash of mess for it by the MD. Let me bounce this off ya'all to see if I was a little off with my thinking.

mid 40's female

chest tightness and pressure lasting approx 40 min 7/10 radiates to left arm

bradycardic 54 bpm

pulse ox 95%

RMA b/p 98/62

+ Cardiac Family and patient specific Hx.

12 Lead is STEMI in II,III,AvF with reciprocal changes in V2,V3, and V4.

During transport: Repeated 12 leads including Right sided 12 leads which revelaed right sided involvement. Bi-lat AC 18g IV's, Pressure infused NS total admin : 600 cc's, ASA 324 mg PO, 4 lpm NC, 100 mcg of Fentanyl, and some ultra low sulfur diesel for a min 10 min trip.

The MD in the ED pulled me aside asked me what our STEMI protocols was on NTG and proceeded to chew me a new one because I gave Fentanyl to an MI patient instead of MS and NTG. He told me to explain myself and when I did, he said that I must be stupid or ignorant because Fentanyl is just as much of as a vasodilator as Morphine is. Every article I can find says the exact opposite, when given slowly it does not effect the circulatory system. I gave the Fentanyl for pain management and pt anxiety. He told me if I was giving that then I should of given the NTG bc that would of helped in the long run. But, if my right sided 12 lead showed depression in V3R and V4R, isn't the use of all pre-load reducing drug contra-indicated?? Not only that but as things progressed her perfusion was lacking with cap refil around 2-4 seconds. Sorry but I'm not giving someone with hypoperfusion NTG. Was I just balantly wrong and not see it or what?? BTW our protocol contraindicates NTG for anyone with a systolic lower then around 100, B/p upon arrival was 88/56. Pain went from a 7/10 to a 5/10.

[mshow00]

As a still learning paramedic student fresh out of ACLS, I don't see anything wrong with what you did. Was the Doc wanting you to bolus her up to 100 sys so you could give the Nitro? I say good call on the Fentanyl MOA, as we give MS for its pain and anxiety effects with the vasodilation being just a nice perk so Fentanyl seems a perfectly good substitute. Please correct me if I am way off base here.

[chbare]

Did you perform a V4R? This is about 90% specific and sensitive to the detection of right ventricular infarct (RVI). Inferior wall MI is not a specific contraindication to giving pre-load reducing agents; however, RVI can accompany inferior wall MI. A V4R gives you a better picture of the inferior wall MI patient and gives you ammunition when you decide not to give preload reducing agents. Because RVI patients depend highly on preload, giving agents that reduce preload can cause disastrous side effects. However, hypotension is somewhat of a no -brainer. Having all of your facts laid out and having the ability to defend your actions is a great asset.

In addition, the mechanism of action related to morphine and blood pressure is due to the fact that morphine can cause the release of histamine. This is what leads to blood pressure changes with this agent. Fentanyl; however, is not associated with histamine release and is typically hemodynamically stable. It is a great choice for hypotensive patients.

In fact, I just flew a non Q wave MI patient out of Afghanistan. He had inferior wall changes and positive cardiac markers. Developed hypotension on an isosorbide drip at the sending facility. In addition, he had hypokinesis of his inferior wall and right ventricle when looked at via echocardiogram. He was experiencing a great amount of pain. After a fair amount of fluid and a few hundred mcg's of fentanyl, he was much more comfortable and had a higher blood pressure. This was good because we had a six hour flight. So, IMHO, fentanyl is a great agent in some cardiac patients.

Take care,

chbare.

[p3medic]

Unfortunately he is the one that holds the medical licence, so wading into a pissing contest with him would be unwise. He asked you about your protocol, and according to what you said, this woman would not have qualified for NTG. As far as the MS v.s fentanyl, both relieve pain, fentanyl has less affect on hemodynamics and no histamine release (or minimal) as opposed to MS. What your pt needed was a rapid and safe transport to a cath lab, with IV fluids prn, ASA, pain management and o2. It sounds like you provided all of the above.

[fiznat]

ST depression in your right sided leads doesn't mean there is actually right sided involvement just yet. It could be indicative of ischemia over there, but it could also just be recriprical changes to the (LV) inferior injury. Still, I think you were absolutely right in your caution with the NTG, especially given the borderline blood pressure . I might have considered using NTG paste or better yet a drip if you've got it, because both can be titrated much more effectively. Didnt the pressure change at all with your 600cc bolus?

I would have argued (discussed?) with the doctor too. We don't use morphine in STEMI because of it's vasodilatory effects, we use it as an anxyolitic. Decreased pain and decreased anxiety are correlated with decreased cardiac work and therefore cardiac O2 demand. The doctor should have understood that.

[medic_texas]

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).

Also, if you are worried about a right sided AMI you should bolus your patient and rechecked a BP before giving NTG and Morphine. Those are the 2 drugs, along with aspirin and oxygen, that are given for AMI.

MONA - Morphine, Oxygen, Nitro, Aspirin. I would have given the NTG and morphine after the bolus personally.

Basically, you screwed up. If you really had this big of doubt and issue, call medical control and ask for orders. Put the monkey on their back and treat accordingly. I would have bitched you out myself, you ran outside of ACLS protocol and you practiced medicine without a license. Also, you lack understanding of the true reason why Morphine is giving for AMI.

Tough lesson to learn I hope you learned it well. Take it upon yourself to research each drug, right sided AMI, and review your ACLS/STEMI protocol. When you work outside of protocol you make yourself liable. Time is tissue and you dropped the ball on this call. Good luck next time..

[spenac]

Medic was that sarcasm or have you missed much of the lastest studys?

[chbare]

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).

Also, if you are worried about a right sided AMI you should bolus your patient and rechecked a BP before giving NTG and Morphine. Those are the 2 drugs, along with aspirin and oxygen, that are given for AMI.

MONA - Morphine, Oxygen, Nitro, Aspirin. I would have given the NTG and morphine after the bolus personally.

Basically, you screwed up. If you really had this big of doubt and issue, call medical control and ask for orders. Put the monkey on their back and treat accordingly. I would have bitched you out myself, you ran outside of ACLS protocol and you practiced medicine without a license. Also, you lack understanding of the true reason why Morphine is giving for AMI.

Tough lesson to learn I hope you learned it well. Take it upon yourself to research each drug, right sided AMI, and review your ACLS/STEMI protocol. When you work outside of protocol you make yourself liable. Time is tissue and you dropped the ball on this call. Good luck next time..

Hu? :scratch:

Take care,

chbare.

[ccmedoc]

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).

:shock:

Medic was that sarcasm or have you missed much of the lastest studys?

I hope for sarcasm as well. Morphine is not, in fact, given for its vasodilation properties..primarily. It is a nice side effect, but the pain management is the primary goal of the morphine. Not as an anxiolytic, but as a narcotic analgesic..big difference. Basically, no pain, no morphine. There is better pharmacology for vasodilation, and I hope you would understand that..

Nitro is given for its effect on the coronary circulation, in hopes of some vasodilation and getting additional blood flow to the tissue distal to the occlusion. I think that Fentanyl is a good alternative to morphine, if you are allowed to use it.

I would not think the doc would chastise you for using the fentanyl, although I think with the vitals you cited, morphine would have been acceptable. Its a comfort thing at this point IMHO. Judicious use of nitro is also not out of the question. Its largely situational and comfort based, again in my opinion.

As for going out of ACLS and practicing medicine without a license...WTF :?

ACLS guidelines are just that..guidelines. If the protocols allow fentanyl for pain, then this is perfectly acceptable.

I dont think the OP messed up, I think others are still too attached to their protocol books :evil: (again with the monkeys 8) )

again.....my opinion

[chbare]

Yeah, I had a vision of the monkeys throwing their poo at another monkey because he was doing something they thought was different. "Every MI patient needs MONA ya know. Why? Because we give every MI patient MONA."

Take care,

chbare.