Fentanyl with MI

[firedoc5]

The doc maybe somewhat old school and going by what has been done for years. Chest pain= NTG (if hypotensive try a moderate fluid challenge to bring up BP), ASA, MS. If BP allows, repeat NTG and MS. Titrate either to BP. I would only consider the Fentanyl if pain was 9/10. I know I might get jumped on this but...if having a lot of anxiety call med.control for 2-4 mg. Valium. I'd never done it, but have seen it done.

Maybe the doc thought that going with Fentanyl was "jumping ahead" a little too much.

Ask another doc in the ED and see what he/she says.

[medic_texas]

I know some of the newer studies are showing that morphine increases the death rate. Where I currently work, both in EMS or Surgical ICU, we are using morphine for the vasodilation properties along with nitro. Nitro being the primary drug obviously. Maybe his protocols are different but my protocols for EMS is morphine. If they have an allergy to morphine you omit the narcatic. They just added fentanyl to the protocols but it is replacing demerol and is used for long bone fractures.

I am sarcastic sometimes, sorry if it causes confusion. So, I'm not saying every patient needs MONA but obviously THIS patient did.

I should stop posting when I first wake up :?

[firedoc5]

I know some of the newer studies are showing that morphine increases the death rate. Where I currently work, both in EMS or Surgical ICU, we are using morphine for the vasodilation properties along with nitro. Nitro being the primary drug obviously. Maybe his protocols are different but my protocols for EMS is morphine. If they have an allergy to morphine you omit the narcatic. They just added fentanyl to the protocols but it is replacing demerol and is used for long bone fractures.

I am sarcastic sometimes, sorry if it causes confusion. So, I'm not saying every patient needs MONA but obviously THIS patient did.

I should stop posting when I first wake up :?

I agree, if available to with Dermerol before Fentanyl. IMHO

[chbare]

Again, pain management should be the primary goal. If we are concerned about blood pressure, I see no problem with fentanyl. I am not sure that the said patient "needed" MONA. I think the OP took a conservative approach. Blood pressure was borderline and the OP made a judgment call. I will take a step back on the V4R. It looks like one was performed showing changes. However, it does not sound like RVI was definitively confirmed. This is good practice and gives you additional information to base your decision making. I agree that fluids are helpful if no other problems exist. Holding off on NTG while giving a fluid bolus is not a bad call IMHO. However, saying somebody "screwed up" for holding off on NTG with the said pressure? Your heart loves hypotension and crap coronary perfusion pressures, especially when it is infarcting.

Why would demerol be a better agent for pain control in the said patient? Why would demerol be a better choice over fentanyl?

Take care,

chbare.

[Dustdevil]

I'm glad y'all cleared that up. I didn't see a problem with the treatment rendered until I saw MT's original reply. He seemed so sure about it that, for just a moment, I thought maybe I was the one who was behind the times. I've treated three MIs in the last five years, so I'm not exactly Mr. Cardiology these days. Glad to know I wasn't losing my mind. Yet.

[ccmedoc]

Demerol is a terrible drug..and it is being removed from a LOT of formularys, as far as I am aware..

-Just sayin'

[fiznat]

...but the pain management is the primary goal of the morphine. Not as an anxiolytic, but as a narcotic analgesic..big difference.

Okay, yeah. I admit that morphine is not considered a primary anxiolytic. ...Although in my experience a decrease in pain pretty soon after relates to a decrease in anxiety, as well. Maybe call it a secondary anxiolytic? In either case, a comfortable, relaxed and pain-free MI patient is better than an anxious one in lots of pain. Fenanyl probably does a good job of that as well, and if it is in-protocol I don't see what the problem is.

[firedoc5]

Demerol is a terrible drug..and it is being removed from a LOT of formularys, as far as I am aware..

-Just sayin'

Why do you think Demerol is such a terrible thing? It lasts longer then MS. It releives pain and from my experience is more effective. Anxiety tends to be less, unless the patient is for some reason fightng the effects for some reason. Sure, It might not be the first or second drug of choice, but at least it is an option.

Also if someone is given NTG. especially a drip, the headace that can/ will be brought on by it may need the Demerol to releive it.

[ccmedoc]

Why do you think Demerol is such a terrible thing? It lasts longer then MS. It releives pain and from my experience is more effective. Anxiety tends to be less, unless the patient is for some reason fightng the effects for some reason. Sure, It might not be the first or second drug of choice, but at least it is an option.

Also if someone is given NTG. especially a drip, the headache that can/ will be brought on by it may need the Demerol to releive it.

For the dose necessary, onset may be a bit slower than morpine and the duration of action is shorter. The duration of morphine is 4-6 hrs, where the duration for demerol is 2-4 hrs.

Interactions with SSRI can be devestating, and a lot of people take SSRI. Some retrovirals cause levels to become toxic very quickly. :?

CNS side effects are significant, including seizures. Normeperidine, it active metabolite is accumulated in the system. If the patient has a seizure disorder, this drug is not well suited for them.

The drug should be used very cautiously in the elderly due to decreased renal function (normeperidine accumulation increased) and can increase the chance of anticholinergic effects in this population.

Finally, meperidine is not reversed by narcan and may, in fact, precipitate seizures .

There is not a positive point for demerol vs. morphine, fentanyl, or ketorolac that I have seen lately. Given the plethora of probable untoward effects, meperidine is not used in any hospitals around here, and is certainly not well suited for prehospital administration. IMHO..

...The old 'morphine cannot be used for biliary colic because it causes spasms at the sphincter of oddi' argument is bunk..No study I have read has linked this with any clinical evidence..

One more word.. studies have shown that the pain relief in severe biliary colic is the same with ketorolac as it is with demerol..(Journal of emergency medicine 2001; 20(2); 121-4)

This is a short answer to why I think demerol is a terrible drug, especially with so many alternatives available for emergency services

edit:

firedoc..why do you think fentanyl was jumping ahead? This is a very good, fast acting opiod with very few side effects or contraindications. This is, in my opinion, a very good drug for pain...any pain.

Is it lack of familiarity with the drug, or do you have a specific reason??

[UMSTUDENT]

Seeing a couple of misconceptions here.

Coronary Vasodilation is really a secondary perk to both Morphine and Nitro. We give both in order to cause a systemic, peripheral drop in SVR and thusly preload. Lower preload essentially results in a decrease in the need for cardiac oxygen consumption because of less work. Please review Frank Starling's Law...

ALSO, and for some reason not many remember this, but Duke performed a pretty big landmark study years ago that showed that Morphine administration for MI resulted in a 50% increased mortality among patient's who had received it. Remember that histamine release? Well histamine happens to be a big mediator in the inflammatory process. This is especially crucial given the finding, released just the other day at the AHA's annual meeting, that shows just how much of a role inflammation plays in MI.

Duke Morphine Study

TIME Article: "Statins May Halve Heart-Attack Risk"

Your "Doctor" may not read up on the literature, but you might as well. Granted, one study from one institution does not categorically make Morphine a bad drug (I think the study specifically referred to Non-STEMIs), but it is something to think about.

Pain causes anxiety and Fentanyl is definitely an excellent sedative and pain reliever. The cardiac and physiologic issues associated with anxiety can be detrimental. Treating a patient with right-side involvement (ST elevation in V4R in the presence of inferior wall elevation) is a tricky endeavor. By no means would I always rule-out nitrates, but I would heavily consider a fluid bolus so long as my patient wasn't also in eminent cardiac failure (possible APE).

I like Fentanyl and I think it is an excellent EMS drug for all kinds of uses. The problem is that it gets pushed in micrograms and has a much larger potency in comparison to Morphine. I think some medical directors shy away from allowing its use for fear of abuse and incompetent administration.