Pain Control Question

[mrsbull]

I was just reading up on the Fentanyl/Morphine post. Without bringing it back to light. I have a few questions.

I am an NREMT-B so please bear with me. I know fentanyl is a quicker acting pn med. Morphine is a longer acting drug.

What other than what I have just stated above is different about them?

Why would you give someone one or the other??

What would your Criteria be? ie b/p, resp rate, MOI/NOI

Is it a personal choice or is it a Med Dir thing?

Also what is the difference between the 2 mentioned above and Demerol?

I ask because these are the most commonly talked about narcs available to EMS personnel? This is not related to any study I am doing just personal knowledge. Thanks for taking the time to respond. I hope I have asked these questions in a manner that is easy to understand. It is late here and I am getting sleepy.

[Kiwiology]

Somebody can give you greater info than I can, but here is my 2c

What other than what I have just stated above is different about them?

Morphine and fentanyl are both opiods; however fentanyl is an outright synehetic opiod which is manmade; morphine may very well be able to be synthesised but it can also be made from opium.

Fentanyl requires much smaller doses in mcg (micrograms) whereas morphine is talk about in mg or milligrans so fentanyl is said to be roughly 10x as powerful ss morphine.

What would your Criteria be? ie b/p, resp rate, MOI/NOI

Pareternal analgesia (IV/IM morphhine or IV/IN fent in this case) is given here for moderate to severe pain that is not controlled by entonox.

You might start out with some nox and then move onto IV morphine or just go straight to IV morphine. As an example if I have a guy with a broken leg he might do swimmingly on sone nox but if his leg is totally shattered with an open # and he is in severe pain I would start off with morphine and go from there.

Cardiac chest pain and acute severe pulmonary edema are also candidates although for these conditions the use of IV analgesia is not really an effective treatment but it is good at reducing anxiety and pain.

Here we can use combination analgesia with morphine and midazolam or ketamine.

Is it a personal choice or is it a Med Dir thing?

We are looking at removing morphine and replacing it with fentanyl. Paramedics have morphine and Intensive Care Paramedics have morphine, midazolam and ketamine.

[chbare]

Fentanyl is not associated with histamine release unlike morphine. Therefore, fentanyl is less likely to cause hemodynamic changes and may be better tolerated by people with compromised hemodynamics such as trauma patients.

Take care,

chbare.

[mrsbull]

Somebody can give you greater info than I can, but here is my 2c

Morphine and fentanyl are both opiods; however fentanyl is an outright synehetic opiod which is manmade; morphine may very well be able to be synthesised but it can also be made from opium. Good to know. Thanks!!

Fentanyl requires much smaller doses in mcg (micrograms) whereas morphine is talk about in mg or milligrans so fentanyl is said to be roughly 10x as powerful ss morphine.

Pareternal analgesia (IV/IM morphhine or IV/IN fent in this case) is given here for moderate to severe pain that is not controlled by entonox.

Please forgive me as I have several questions about this drug at this time. Feel free not to answer all of these as I am sure they will get quite time consuming for anyone who has knowledge on this.

I did a search on Entonox because I have never heard of it: It appears that it is inhaled?? Also the short duration appears that it had a quick effect. The article I am referring to was for a Childrens hospital. Looks like it is primarily used for "procedural procedures" ie sutures, wound cleaning and the like. The article as stated here http://painsourcebook.ca/docs/pps24b.html says that is is inhaled and self administered. (going to look up adult protocol in a bit). The inhaled method of administration is a new concept to me to be quite honest. I have seen fentanyl suckers (looks like a big q-tip.) Iv, im and oral pain relievers however never heard of inhaled pain relievers. Is this given like an inhaler or like a neb? I have also seen another "route" nasally however that was the flu shot,as well as administration rectally such as phenergan and tylenol. It is uncommon if not even used in the pre hospital scene. I know there is something else given nasally in the pre hosp care scene but I don't recall what it is. (Also please bear with me I am not working active in ems at this time because of some medical problems that requite surgery next week and it has been a while since on a rig.) OK I am looking up Entonox it is becoming difficult on this search engine that I am using. I am mostly seeing peds usage and ophthalmology uses. I have found this however "" ENTONOX nitrous oxide/oxygen mixture is used for analgesia during treatment or in the prevention of short term acute pain, where rapid onset and offset is needed."" http://www.entonox.co.uk/en/entonox_in_medical_therapy/condition/pain_analgesia/index.shtml How would you determine the need for this? Would you use it to relocate a dislocated extremity? Also it appears that a contraindication is noted when the pt is unable to inhale. Is this inhalation the ONLY route this drug is taken? Is this Drug used in the United States in pre hops care? I think that is all the questions on Entinox at this point. Thanks for staying with me if you have made it this far.

You might start out with some nox and then move onto IV morphine or just go straight to IV morphine. As an example if I have a guy with a broken leg he might do swimmingly on some nox but if his leg is totally shattered with an open # and he is in severe pain I would start off with morphine and go from there.

Cardiac chest pain and acute severe pulmonary edema are also candidates although for these conditions the use of IV analgesia is not really an effective treatment but it is good at reducing anxiety and pain.

Here we can use combination analgesia with morphine and midazolam or ketamine.

We are looking at removing morphine and replacing it with fentanyl. Paramedics have morphine and Intensive Care Paramedics have morphine, midazolam and ketamine.

I was searching some drugs reactions and OD type things. I found this website that seems to be quite informative http://www.thegooddrugsguide.com/drug-guides/index.htm

Fentanyl is not associated with histamine release unlike morphine. Therefore, fentanyl is less likely to cause hemodynamic changes and may be better tolerated by people with compromised hemodynamics such as trauma patients.

Take care,

chbare.

I got the histamine part. Thanks!! This is good to know since I have seen histamine effects of morphine. Not horrible but itching and mild hives. A dose of say benadryl is appropriate for this type of reaction, I would say.

What I am reading is an allergic reaction to Morphine is more likely than an allergic reaction to Fentanyl. Am I under the correct assumption?

[WelshMedic]

I was searching some drugs reactions and OD type things. I found this website that seems to be quite informative http://www.thegooddrugsguide.com/drug-guides/index.htm

I got the histamine part. Thanks!! This is good to know since I have seen histamine effects of morphine. Not horrible but itching and mild hives. A dose of say benadryl is appropriate for this type of reaction, I would say.

What I am reading is an allergic reaction to Morphine is more likely than an allergic reaction to Fentanyl. Am I under the correct assumption?

I think you'll find that a reaction to either of the drugs is fairly rare, I have never seen it in 20 years of ALS, both in and out of the hospital setting. Having said that, if you follow CH's logic then I think you made a pretty fair assumption. Fentanyl also has the distinct advantage that it's serum plasma concentration time is shorter than that of Morphine. In layman's terms that means that it is faster-acting but has a shorter half-life. This can also been seen as an advantage too, of course. Particularly in EMS. I gave a presentation last year to EMT-P students at the Montgomery County Public Service Academy in Conshohocken, PA. Although the first half is not relevant to this discussion, the slides of the second half are about pain-management strategies in EMS. Here's the link to that presentation. I hope it helps.

WM

[Kiwiology]

Entonox is not used in any EMS system in the US to my knowledge, representing much lost opportunity.

[BAYAMedic]

Entonox is not used in any EMS system in the US to my knowledge, representing much lost opportunity.

A Public fire based ambulance in Washington state was going to be a pilot program when we got a new medical program director who was all excited about changing the face of EMS. It was going to be a ILS drug for long bone fracture and it made sence as it was an ILS agency with long (45 min plus) transport times. But alas nothing ever came of it.

[HellsBells]

I don't know why Entonox isn't used in the USA, as far as I know just about every service in ALberta Canada has it on board.

[Kiwiology]

A Public fire based ambulance in Washington state was going to be a pilot program when we got a new medical program director who was all excited about changing the face of EMS. It was going to be a ILS drug for long bone fracture and it made sence as it was an ILS agency with long (45 min plus) transport times. But alas nothing ever came of it.

ILS? Wow it's existed here at even the lowest level since at least before 1985.

Boggles the mind how you guys get away with no analgesia below ALS level.

[chbare]

I got the histamine part. Thanks!! This is good to know since I have seen histamine effects of morphine. Not horrible but itching and mild hives. A dose of say benadryl is appropriate for this type of reaction, I would say.

What I am reading is an allergic reaction to Morphine is more likely than an allergic reaction to Fentanyl. Am I under the correct assumption?

I am not sure. What do you consider an "allergic reaction?" I go by the literal definition relating to an immune response involving immunoglobulin E (IgE) mediation of mast cell and basophil activation among other mechanisms as the proper way to define an allergy (when considering anaphylaxis). Most everything else will fall under the umbrella of an adverse reaction.

From evidence I have seen, postoperative complications including puritis, nausea/vomiting, and urinary retention in patients on PCA were significantly higher in morphine groups compared to fentanyl groups. Therefore, I could say with some confidence that the incidence of adverse reactions may be lower overall in patients who receive fentanyl.

Take care,

chbare.