Fentanyl vs Morphine

[GhostMedic29]

The service I am employed with uses Morphine as do most other services in my area. Our protocols allow our medics to administer Morphine for suspected or confirmed fractures and suspected cardiac related chest pain with no relief from the initial NTG.

Our initial dose of Morphine is 2-4 mg, up to a total of 10 mg before we have to call for OLMD. I have been in EMS for 13 years, I personally don't like using Fentanyl but that is my opinion.

Morphine is great because of it's analgesic and vasodilation properties. I will choose Morphine over Fentanyl any day and twice on Sunday. Also since Morphine does routinely cause nausea, I usually give Zofran 4 mg after the Morphine.

[Paramagic]

The service I am employed with uses Morphine as do most other services in my area. Our protocols allow our medics to administer Morphine for suspected or confirmed fractures and suspected cardiac related chest pain with no relief from the initial NTG.

Our initial dose of Morphine is 2-4 mg, up to a total of 10 mg before we have to call for OLMD. I have been in EMS for 13 years, I personally don't like using Fentanyl but that is my opinion.

Morphine is great because of it's analgesic and vasodilation properties. I will choose Morphine over Fentanyl any day and twice on Sunday. Also since Morphine does routinely cause nausea, I usually give Zofran 4 mg after the Morphine.

You do realise that the typical (studied) dose of morphine is 0.1mg/kg? 2-4mg to a max of 10mg is almost placebo, unless you are talking about 20-40kg pediatric patients.

If you don't use fentanyl, on what grounds do you feel qualified to "prefer" morphine over fentanyl? Even if you prefer morphine, what about your patients who are suffering from oligoanalgesia? Do they get a say?

And as for "routinely" causing nausea, no study I have ever read places the incidence of nausea/vomiting secondary to morphine adminstration over 28%, with most ranging from 5-25%. Why give another drug that is not going to be indicated in 3/4s of the patients recieving morphine? Finally, vasodilation is often something we want to avoid, whilst still be able to give pain relief, so the histamine release associated with morphine administration in some people can be detrimental, not beneficial.

[usalsfyre]

Anyone here stating they're using morphine as a vasodilator needs to look at CRUSADE. If I'm trying reduce preload/afterload I've got other meds that do it much more reliably rather than relying on the side effect of stimulating an inflammatory mediator.

Fentanyl has always done ok for pain relief in my experience. I've never had it, but from surveying patients it doesn't seem to give the "high" that morphine does when given in typical EMS doses. There's a lot if people who equate "pain relief" with "gorked to the point I can't remember the pain" (which is why I there's some of the narcotic dependence issues we see. I'm big on pain management, but some people I just want to tell "harden the fuck up"). Even those who rate pain reduction from an "11" to an "8" are usually sitting still without notable tachypnea, ect. While I'm not someone who believes we can quantify pain based on physiologic signs, you also have to realize appropriate dosing may be getting someone to a level where the pains "tolerable" not "absent".

I do agree that 2mgs of morphine might as well be homeopathic.

[Bieber]

Something I noticed about fentanyl last week. It works great, but damn if it doesn't have a short half-life. My partner used it for a peds patient with a possible broken tib-fib, and while it worked great for the kid for about fifteen minutes, after that the pain was coming right back.

I knew morphine lasted longer than fent, but I was surprised at just how quickly the fentanyl's reaction diminished.

[usalsfyre]

Something I noticed about fentanyl last week. It works great, but damn if it doesn't have a short half-life. My partner used it for a peds patient with a possible broken tib-fib, and while it worked great for the kid for about fifteen minutes, after that the pain was coming right back.

I knew morphine lasted longer than fent, but I was surprised at just how quickly the fentanyl's reaction diminished.

Probably the best reason to use it for things like abdominal pain and head injuries. Gives the patient relief, but allows for "skilled surgeons hands" to do an assessment (ok, probably applicable for neuro but who goes in an abdomen without a CT anymore?)

[Bieber]

Probably the best reason to use it for things like abdominal pain and head injuries. Gives the patient relief, but allows for "skilled surgeons hands" to do an assessment (ok, probably applicable for neuro but who goes in an abdomen without a CT anymore?)

I've never been much of a fan of the idea that pain relief is bad for abdominal pain patients. Honestly, the physical exam can only tell you so much, and like you said, who's gonna start opening up someone's abdomen without a CT and labs? We can't give pain relief for head injuries or polytrauma, unfortunately. Maybe someday...!

[Paramagic]

I've never been much of a fan of the idea that pain relief is bad for abdominal pain patients. Honestly, the physical exam can only tell you so much, and like you said, who's gonna start opening up someone's abdomen without a CT and labs? We can't give pain relief for head injuries or polytrauma, unfortunately. Maybe someday...!

Head injuries I can understand (although I don't necessarily agree with it), but no pain relief for polytrauma? Huh?

[usalsfyre]

Head injuries I can understand (although I don't necessarily agree with it), but no pain relief for polytrauma? Huh? <img src='http://www.emtcity.com/public/style_emoticons/<#EMO_DIR#>/confused.gif' class='bbc_emoticon' alt=''

This is a pretty common one as well and the reasons I've always seen cited are the assessment crap (this one's been around since the late 1800s, will it die already) and vasodilation from morphine, which if your using Fentanyl shouldn't be a concern.

One are where you DO want to be careful with pain management is the profoundly shocky young patient who has a significant loss of blood volume and is compensating through severe vasoconstriction. Anything that affects the sympathetic stimulation and resultant catecholamine release will cause vasodilation, which can rapidly lead to death. Even when the patients are placed under general anesthesia for surgery usually very little anesthetic and a large dose of paralytic is administered.

[Paramagic]

This is a pretty common one as well and the reasons I've always seen cited are the assessment crap (this one's been around since the late 1800s, will it die already) and vasodilation from morphine, which if your using Fentanyl shouldn't be a concern.

One are where you DO want to be careful with pain management is the profoundly shocky young patient who has a significant loss of blood volume and is compensating through severe vasoconstriction. Anything that affects the sympathetic stimulation and resultant catecholamine release will cause vasodilation, which can rapidly lead to death. Even when the patients are placed under general anesthesia for surgery usually very little anesthetic and a large dose of paralytic is administered.

Sad that these absurdities continue to hang around. Personally for the shocked patient I prefer using ketamine, both for analgesia, and (if it's necessary) induction for RSI (with the larger dose of roc or sux). It's a pity that there is not more use of ketamine, it is a wonderful drug.

[BushyFromOz]

Oh god what i wouldn't give to have ketamine in my kit bag!