Fentanyl with MI

[firedoc5]

Firedoc, the OP was correct in skipping the Nitro and Morphine given the pt's pressure. Fentanyl is a short acting drug which has minimal BP affects (great for trauma pt). Demerol has too many really bad side effects that can be avoided using other meds. Why use something so dangerous when better alternatives are available?

I don't have a problem with him using the Fentanyl, but I guess my old school shows. I'm not use to the idea of skipping the NTG or MS. Use to be if they were hypotensive, a short fluid challenge would hopefully bring up the BP to use the NTG or MS.

My bad, just showing how far behind in the times I am and I am trying to learn the new stuff here.

Thanx for the info, one and all.

[UMSTUDENT]

I see the point, MS doesn't help me either..I use the morphine mostly for kids and elderly. I also think the 2mg increment is ludicrous. Everyone is concerned about the respiratory issue, this is a bit ridiculous for most people.

4mg - 6mg to start is good in my opinion. If you go by the 0.1 mg/kg formula, 2mg doesn't even enter the picture except for kids.. 8)

I think if you stray from the MS or fentanyl, dilaudid is the next down the line....I like this stuff

Back to the program.........

You do realize that Morphine metabolizes slowly in the elderly? Repeat doses increase the risk of respiratory depression since it will remain in the system longer.

Again, use with caution.

[ccmedoc]

You do realize that Morphine metabolizes slowly in the elderly? Repeat doses increase the risk of respiratory depression since it will remain in the system longer.

Again, use with caution.

Yes, I do realize this. I still use it, and you need less of it. The elderly person and children are about the only ones responsive to low doses around here. Most need fentanyl or dilaudid. Its a safe drug IMHO

I have never seen anyone vomit or stop breathing from MS. I have pushed it pretty quick at times, and never had this problem. As with any narc, you have to be aware of the patient.

As far as MS and fentanyl. They are pretty much interchangeable around here, and up the paramedic as to which he/she uses. Kinda like ERDoc said, MS used to work wonders with low doses, now it takes a ton of morphine, or another drug...usually dilaudid or fentanyl these days.

In case I didn't say it...The OP did good. Thats my opinion

[ERDoc]

Sorry to get off topic, but the morphine sensitivity must be a regional thing. When I was in NY, I could snow some people with a few mg of morphine. I never had anyone tell me that morphine didn't work. Very rarely used dilaudid in NY.

[UMSTUDENT]

Sorry to get off topic, but the morphine sensitivity must be a regional thing. When I was in NY, I could snow some people with a few mg of morphine. I never had anyone tell me that morphine didn't work. Very rarely used dilaudid in NY.

I believe there is an entire body of research into the phenomenon of how people perceive pain. I think some of it has to do with how culture has begun to look at pain and how comfortable new generations are with describing their pain.

For instance, I encounter patients all the time who are probably in some great deal of pain, but not a 10 of 10. I always like to describe a 10 on the Verbal Analog Pain Scale as being the "worst imaginable pain." For instance, I think of having my arm sawed off or something.

I hate to pass judgement, because I constantly remind myself that it is "not my experience." I'd hate to be 80 one day, in incredible pain, and have some punk paramedic deny me medication because he thinks I'm over exaggerating. I just think a lot of people confuse general discomfort with what I think of as pain. It's hard because when you've never really experienced a big injury, or broken a bone, etc you really don't know what real pain is.

[AnthonyM83]

It is a good thing to keep in mind though... In general I don't give morphine to my ACS patients at all, but that probably has more to do with the fact that it is locked up behind two keys in the safe and takes too long to set up + administer.

Nooooooooooo...... Don't tell me you're one of THOSE. . . . You'll be hard pressed to see morphine pushed in LA County for anything less than a femur fracture. Severe Abd pain, MI, non-femue long bone fractures, NOPE

Of course, there is no doubt in my mind that much of the ineffectiveness we see with Morphine is the result of the monkey practice of dribbling it in by 2mg increments instead of just slamming it. That is cruel and ignorant. If your patient is in enough pain that you notice it, go big or go home.

I say, just mix it in a cocktail and slam it into their heart....

[AnthonyM83]

I believe there is an entire body of research into the phenomenon of how people perceive pain. I think some of it has to do with how culture has begun to look at pain --cut--

encounter patients all the time who are probably in some great deal of pain, but not a 10 of 10. I always like to describe a 10 on the Verbal Analog Pain Scale as being the "worst imaginable pain."

I hate to pass judgement, because I constantly remind myself that it is "not my experience."

UMStudent, I was going to bring up the same pain studies.

In addition, I'm always sure to emphasize "WORST PAIN IMAGINABLE" to get an accurate reading. Even someone who hasn't experienced much pain and imagine excruciating pain somewhat. It stops everyone from automatically rating it a 10/10.

But when someone honestly tells me it's a 10, even if they're handling it well, I'll take their word (unless they've been drama the entire ride).

[Niftymedi911]

I think there was an article in JEMS recently on how EMS continually does not effectively use pain management or just "play it off". Somewhat of an eye opener. But at the same time, each person responds to pain differently. Much as noted in EMStudent's post. I just try to think outside the box and do what's BEST for my patient. Not what's BEST for me.

I say 10 being the worst pain you have ever felt 1 being no pain.

[spenac]

I love when you ask them to rate the pain 10 worst ever, 1 none and they say 10. Then by the time you unlock the happy meds they have fallen sound asleep. Then you call the hospital patient rates pain 10 of 10 and is currently resting comfortably. Hospital asks how much and what type pain meds have been given. I reply none. They respond what was pain rated at again? 10 of 10. What is patient doing now? Sleeping. UMMM OK take them to triage on arrival.

Maybe I am such a boring person I just put them to sleep with my presence.

[firedoc5]

UMStudent, I was going to bring up the same pain studies.

In addition, I'm always sure to emphasize "WORST PAIN IMAGINABLE" to get an accurate reading. Even someone who hasn't experienced much pain and imagine excruciating pain somewhat. It stops everyone from automatically rating it a 10/10.

But when someone honestly tells me it's a 10, even if they're handling it well, I'll take their word (unless they've been drama the entire ride).

See, that's my problem. When asked about pain scale 1-10, with ten being the worse imaginable, I've had more than 12 kidney stones. And not too much hurts as much as a kidney stone. Same with severe migraines. So I usually have to explain to them that when I'm trying to scale my current pain, I can't go by what the usual 1-10 is. It's like pain is relevant to the event. So I tel them "on a scale not taking into consideration kidney stones, my pain may be an eight." I get some funny looks.

But what if you have a patient with a similar past with severe pain? They may say a five or six, when actually in the usual pt. it would be described as a nine or ten. So pain is relative to the pt.'s Hx.