Phenergan....good or bad?

[bassnmedic]

At my service, we have some very liberal and aggressive practice parameters to include valium up to 30mg, Morphine up to 10mg Versed and Etomdateall without orders to name a few. My question herein lies, we must do a physcian consult if we want or need to give Phenergan and then the dose is only 12.5mgIV/IM. I know that Phenergan has some dystonic effects on a few patients, I guess I'm wondering if there is something i'm missing. that would make it more controlled than our narcs. I am trying to get a meeting with our medical director this week for an answer. What do you guys think?

Take care;

Todd

[akflightmedic]

Todd, I went through the same thing when I was there and never got a straight answer. I found that quite odd as well, as liberal as we were there.

I even pitched the idea of Zofran as it has all the good effects of promethazine but none of the bad effects. I was told they were looking into it.

[EMS49393]

AK, my service has used Zofran for the past year since removing promethazine. There isn't one good thing I can say about it. As many times as I've either used it, or seen it used, it has never proven to be a good anti-nausea. It's so bad my service is now giving us compazine back. That's fine, except everything I've read on compazine says that the dystonic reactions to compazine are better then twice as often to occur then in slow administration of promethazine. Promethazine also potentiates the effect of narcotics, making it very easy to get that patient with the deformed femur, or massive MI comfortable quickly. I say bring back Promethazine!

[akflightmedic]

I say have both!!! Let us make a decision based on that particular presentation as to which one we will use. Thats what we do in the flight world.

[akflightmedic]

AK, my service has used Zofran for the past year since removing promethazine. There isn't one good thing I can say about it. As many times as I've either used it, or seen it used, it has never proven to be a good anti-nausea. It's so bad my service is now giving us compazine back. That's fine, except everything I've read on compazine says that the dystonic reactions to compazine are better then twice as often to occur then in slow administration of promethazine. Promethazine also potentiates the effect of narcotics, making it very easy to get that patient with the deformed femur, or massive MI comfortable quickly. I say bring back Promethazine!

And now, for your reading pleasure.......

Phenergan Myths

Phenergan (promethazine) has been used to prevent or treat opioid induced nausea and vomiting and as an adjunct to opioid analgesia. Despite studies showing the phenothiazines possess no analgesic activity and do not potentiate opioid analgesia, phenergan continues to be used as an adjunct to opioids. This use can lead to poor pain relief and confusion when assessing the pain patient.

Phenergan has potent sedative and anticholinergic effects. It also possesses alpha adrenergic blocking effects which can lead to peripheral vasodilatation and orthostatic hypotension. The phenothiazines also lower the seizure threshold and can cause extrapyramidal side effects ("worm like" movements of the tongue, chewing motions of the jaw) and tardive dyskenesia which may not resolve after the phenothiazine is discontinued.

When combined with opioids, phenergan potentiates the sedative effects of the opioid (which is MISINTERPRETED as increased analgesia...sedation and analgesia are not synonymous). Other problems include increased risk of orthostatic hypotension, dry mouth (especially when used in combination with meperidine which also has anticholinergic side effects), dysphoria, restlessness, and agitation. These last three may be associated with increased pain as a result of a decrease in the opioid.

A common practice of combining phenergan with meperidine can lead to significant side effects. The phenothiazines lower the seizure threshold of the CNS. Meperidine produces an active metabolite (nor-meperidine) which causes CNS "irritability". As nor-meperidine levels rise, the risk of seizure activity increases. When combined with phenergan, a lower blood level of nor-meperidine is required to cause grand mal seizures.

Other anti-emetics are recommended when faced with opioid induced nausea or vomiting. Metoclopramide (Reglan®) or odansetron (Zofran®) cause less sedation than phenergan.

Suggested Readings

Am J Hosp Pharm 1979 May;36(5):633-40

Phenothiazine analgesia--fact or fantasy?

McGee JL, Alexander MR

Double-blind clinical trials involving the use of phenothiazines as analgesics or potentiators of analgesics (aspirin, meperidine, morphine sulfate) and adverse effects of phenothiazines are reviewed and evaluated. Promethazine, promazine and propiomazine were not found to possess analgesic or potentiating properties. One chlorpromazine study contained important design and reporting deficiencies which precluded a recommendation for use of chlorpromazine in the treatment of pain. Methotrimeprazine was determined by numerous authors to have analgesic properties; however, most of the studies also were deficient in design or data presented, or both. Adverse reactions to phenothiazines, including hypotension, sedation, drowsiness, extrapyramidal symptoms, tardive dyskinesia, cardiac toxicity and agranulocytosis, are often more common and severe than those attributed to narcotic analgesics. Because of the lack of data supportive of analgesic activity and the adverse reactions associated with phenothiazines, use of these agents in the management of pain should be discouraged. The prophylactic use of phenothiazine for narcotic analgesic-induced emesis also is, in most cases, a questionable practice.

PMID: 36754, UI: 79206676

[JPINFV]

I say have both!!! Let us make a decision based on that particular presentation as to which one we will use. Thats what we do in the flight world.

Just ignore AK, he's in fantasy land again. Next thing he's going to be telling us is that we should have both nasal cannulas and non-rebreathers so that we can choose how much oxygen to give...

[akflightmedic]

Just ignore AK, he's in fantasy land again. Next thing he's going to be telling us is that we should have both nasal cannulas and non-rebreathers so that we can choose how much oxygen to give...

WARNING WARNING ---EMT CURRICULUM BASHING ABOUT TO OCCUR (NOT EMTs, BUT THE CURRICULUM

I didn't think EMTs in class these days even knew what a nasal cannula was, much less of whether or not you have a choice.

High flow O2 Non rebreather for everything, right? Cause too much O2 never hurt anyone and it doesnt matter what the problem is, everyone gets it!!

WE NOW RETURN TO OUR REGULARLY SCHEDULED DEBATE ON PROMETHAZINE

[PRPGfirerescuetech]

ten post thread, and the train has derailed a few times already....nice.

I havent heard of PreHospital Zofran use...anyone have some research on it?

[akflightmedic]

Hmmmm, I will have to find some for you. Been using it prehospitally for almost 3 years now.

Started in flight and then carried over to some ground services. Most people think it is cost prohibitive, but it has decreased significantly in recent times.

[Dustdevil]

And now, for your reading pleasure.......

Phenergan Myths...

Plus 5 to AK for beating me to the punch with that post.

Now, to answer the original question, my speculation would be that your protocols allow for rapid action for emergencies and a more measured response to non-emergencies. Phenergan is not an emergency medicine. Vomiting is not (usually) an emergency situation. And the use of phenergan in EMS is very rarely an urgent, reactive prescription, but a routine, proactive prescription to prevent MS induced nausea (as well as the aforementioned "potentiation" myth). Medicine has been trying to step away from that for quite some time now. I remember in nursing school fifteen years ago getting my hand slapped for mixing MS and promethazine routinely on a post op patient who had both ordered, but not specifically to be given together as we always had in EMS and ER practise. I have seen such use drop drastically since then.

So again, to clarify, it appears that your protocols are walking that fine line between allowing you to do what is necessary for emergent patients with a minimum of constraint, while still maintaining checks and balances for elective medications and procedures. I think that is a good thing.