Eydawn Posted January 27, 2012 Posted January 27, 2012 Mm, if you've already got a POTENTIAL allergy issue, with histamine release and all that, wouldn't giving an opiate not necessarily be a good idea? (Am I off in the ditch with my understanding that opiates can cause histamine release?) Plus, don't you only administer opiates to help with anxiety when they also have concurrent pain (AKA chest pain) and you're treating the pain to diminish the anxiety? Unless she's got a pain source, you'd have to come up with a really good reason for having given a narc, right? I might consider a benzo... very low dose, not wanting to increase sedation too much in case this really is a zebra monster getting ready to pounce on us... hm. Never thought of that angle before. Wendy CO EMT-B
croaker260 Posted January 27, 2012 Posted January 27, 2012 Mm, if you've already got a POTENTIAL allergy issue, with histamine release and all that, wouldn't giving an opiate not necessarily be a good idea? (Am I off in the ditch with my understanding that opiates can cause histamine release?) Outside of a theorectical effect on coronary arteries (important in ACS/MIs) , and of course allergic reaction to opioids, the opioid's histamine release tends to be realtively benign. Additionbally, certain opioids have this effect more than others. Codiene and heroin tend to have it more often, whereas Fentanyl have it very little at all. Plus, don't you only administer opiates to help with anxiety when they also have concurrent pain (AKA chest pain) and you're treating the pain to diminish the anxiety? Unless she's got a pain source, you'd have to come up with a really good reason for having given a narc, right? Well, the answer is "Adult Diapers". (in otherwords...depends. Get it. Depends lol) It depends on your service protocols. It depends on your medical director as well, who may or may not have much influence on your protocols depending on your state. Here locally giving opioids strictly for sedation (outside of RSI/mai/intubation, wich is assumed to be painful anyway ) is definitly not a common occurance, but we have a process called a SWO Diviation that you would do this if you had good justification, you would just have to justify yourself later. Personally, I understand that opioids have anxiolytic effects, but given the risk vs benifit and the general pharmacological profile I would go with a benzo instead. Valium most likely, though ativan could be useful in this role. I like valium for this better though, just not impressed with Vit A.
Kiwiology Posted January 27, 2012 Posted January 27, 2012 There can be some histamine release with morphine, it's not uncommon but is not allergy. There is less with fentanyl.
DwayneEMTP Posted January 27, 2012 Posted January 27, 2012 ...You may be right. The trouble with these case presentations is that everyone gets a slightly different impression of the patient in their minds, and it becomes tempting to interpret the patient's condition in terms of your own past experiences, that may not relate to this particular case... Yeah, I'd thought about that, but then immediately discounted the possibility based on the fact that I really, really wanted to pull this out of left field and be right about it. You and your, "Let's always try and be objective" bullshit....grrrrrr There can be some histamine release with morphine, it's not uncommon but is not allergy. There is less with fentanyl... This is interesting...I've never really thought about it. So a hystamine cascade reaction (Unsure if that would be an approprate description) due to an allergic response would not be aggrevated by a secondary cause of hystamine release not allergen initiated? And no, I'm not even going to pretend that I remember the cascade involved, nor if there are a bunch of hystamines types that bind to different receptors so as not to create comorbidities if released at the same time...Etc. Just answer the God damned question... Just sayin'... :-) Dwayne
mobey Posted January 27, 2012 Posted January 27, 2012 This is a great case to present, and I'll tell you right now, I have been on both sides of the fence. One time I had a atypical anaphylaxis (to latex..... a church girl) It was one of the first scenario's I ever posted here, and if I was smart enough I would dig it up. But I cannot find it (would be laughable by now I am sure). I have also had a severe anxiety after taking an inhaled steroid for the first time, that I thought was anaphylaxis. So here is my thoughts; A) Don't trust your ears when there is a hummingbird between them. A Patient can kill themselves, and sewer you're career with fear/drama. Don't let them do it! C) Learn to love you're EtC02. If you don't have it... Get it!. If you have a high Sp02, and low EtC02, you are probably looking at anxiety. D) Never, ever, ever, ever, let anyone ever distract you when you are trying to critique you're calls to improve patient care. Stick to you're own agenda, and those with integrity and common goals in this profession will surround you with support. Casual reading: http://www.ncbi.nlm.nih.gov/pubmed/11801981 http://www.ncemi.org/cse/cse0412.htm
systemet Posted January 27, 2012 Posted January 27, 2012 (edited) Wish I could jump on these posts faster. Seems like when I spot them they've already been busted wide open and not much more can be contributed without re-iterating another post. With the vitals and pts presentation would opiates or benzos considered to reduce the pts anxiety? This is a judgment call. I mean you have to form an opinion about whether the patient's symptoms have a strong anxiety component. It doesn't have to be right, but it would help if you're fairly sure about it. And if you feel there's a strong anxiety component, you've got to take a step back, and look at the whole clinical picture (or gestalt, to get fancy), and say to yourself, "Ok, how much of this feeling of the throat tightening is due to anxiety issues? Has she just been watching Oprah with a story about someone's anaphylaxis... etc. ?". Then you've got to think about how much of the objective signs are pointing in this direction. Is there hyperventilation? Is there carpal/pedal spasm or tremor, etc.? And maybe the call has just become anxiety / hyperventilation syndrome. But, then again, maybe any anxiety component is minor, or just masking the symptoms of the original disease process, i.e. the anaphylaxis. Benzodiazepines, particularly sublingual ativan, are effective in anxiety / hyperventilation syndrome. I think we all know that. But they present their own problems. How comfortable are you in writing up a cancellation on a patient you've just given ativan to? Most systems probably aren't going to allow that. The odd person becomes strongly sedated, although this is rare. They're also just not necessary most of the time. If you're giving ativan to more than a small percentage of your anxiety / hyperventilation patients, I think you need to step back and look at how well you're communicating with them first. Because it shouldn't be necessary most of the time. I would suggest that if this patient is becoming very anxious (something that is a direct and well-reported side effect of giving them epinephrine!) then the best treatment will probably be talking to them. In this instance, I would stay well away from opiates. These relieve anxiety as the result of pain. This patient doesn't sound like she's in pain, realistically. A long time ago, we used to give MS in CHF to control anxiety as the result of pain. We don't do this any more because it was a terrible idea, because we stole the respiratory drive from a lot of very sick patients and ended up intubating them, auto-PEEPing them, giving them a nosocomial pneumonia, and messing them up on a ventilator. Most systems still give some opiate to MI patients, even if there's a little bit of question about the safety of MS in NSTEMI. But this is to reduce the sympathetic outflow associated with pain, and hopefully decrease myocardial oxygen demand as a result. Here, I don't think they're going to have any benefits, and if you get the rare patient who reacts strongly, you've now created an unnecessarily complicated mess -- and if this patient has developing laryngedema, unless you're really, really rural, or about to fly them for an hour or something, you don't want to be having to intubate them. Both groups of drugs have the potential to generate hypertension, either by releasing vasodilatory inflammatory mediators, e.g. morphine, meperidine, or decreasing sympathetic outflow (the rest). If you felt that the anxiety absolutely had to be managed pharmacologically, then you could give sublingual ativan. I would be very reluctant, and very careful that I could justify it if the patient deteriorated later. Anaphylaxis (if this is anaphylaxis here), is scarey because it can occur is so many different presentations, and the patients can deteriorate so quickly. There's a temptation in EMS sometimes to aggressively treat every complaint the patient have, as if the more drugs we give, and the higher doses and more dangerous ways we give them makes us a better provider. I would suggest that "aggressive paramedicine", unless it's very selectively applied, is probably much more dangerous than just sitting on your hands. ------------------------------------- * Just realised I should probably add, I'm assuming we're talking about the initial presentation of the patient here. If we've just potentially infarcted the patient with IV epinephrine, then we should be giving benzo's. * Also, standard caveat, I haven't been working in the field in a couple of years, so any information / opinions I give may be a little out of date. Edit: everything below the "-----" Edited January 27, 2012 by systemet
runswithneedles Posted January 27, 2012 Posted January 27, 2012 Maybe she was experiencing M.A.D. (Mexican Anxiety Disorder) It seems very difficult to make a good clear field diagnosis with the patient is as anxious as she is. IF one should give this pt a small dose of benzo to reduce the anxiety what kind of detrimental side effects would I expect to encounter if I was wrong and this pt was in anaphylaxis?
mobey Posted January 27, 2012 Posted January 27, 2012 (edited) It seems very difficult to make a good clear field diagnosis with the patient is as anxious as she is. IF one should give this pt a small dose of benzo to reduce the anxiety what kind of detrimental side effects would I expect to encounter if I was wrong and this pt was in anaphylaxis? Mike; The way this usually works, is you tell us what you think so we can lead your thinking path the right way through the forest. A Q&A session will warrent you nothing. Let me ask: What are potential side effects, both good & bad, of giving low dose benzo's to an anaphylaxis patient? Edited January 27, 2012 by mobey
Kiwiology Posted January 27, 2012 Posted January 27, 2012 I strongly disagree that we should be giving this patient any benzos, hang on, let me go scoff down my morning clonnies and we'll continue .... Many patients present with anxiety/hyperventilation/ some might even have carpopedal spasm or other symptoms; are we going to give them all midazolam? It is worth mentioning some patients receiving end-of-life care are prescribed midazolam or another benzo for administration in the event of severe distress or deterioration but that's different so you can't extrapolate one into the other.
mobey Posted January 27, 2012 Posted January 27, 2012 I strongly disagree that we should be giving this patient any benzos, hang on, let me go scoff down my morning clonnies and we'll continue .... Many patients present with anxiety/hyperventilation/ some might even have carpopedal spasm or other symptoms; are we going to give them all midazolam? No one here specified to give Midaz. Why not give a benzo? you strongly disagree, yet provide no opinion, or evidence to counter. And yes.... in the patient you mention above (anxiety, hyperventilation, carpopedal spasm) I do treat them.
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