Fentanyl with MI
Posted 11 November 2008 - 02:48 PM
mid 40's female
chest tightness and pressure lasting approx 40 min 7/10 radiates to left arm
bradycardic 54 bpm
pulse ox 95%
RMA b/p 98/62
+ Cardiac Family and patient specific Hx.
12 Lead is STEMI in II,III,AvF with reciprocal changes in V2,V3, and V4.
During transport: Repeated 12 leads including Right sided 12 leads which revelaed right sided involvement. Bi-lat AC 18g IV's, Pressure infused NS total admin : 600 cc's, ASA 324 mg PO, 4 lpm NC, 100 mcg of Fentanyl, and some ultra low sulfur diesel for a min 10 min trip.
The MD in the ED pulled me aside asked me what our STEMI protocols was on NTG and proceeded to chew me a new one because I gave Fentanyl to an MI patient instead of MS and NTG. He told me to explain myself and when I did, he said that I must be stupid or ignorant because Fentanyl is just as much of as a vasodilator as Morphine is. Every article I can find says the exact opposite, when given slowly it does not effect the circulatory system. I gave the Fentanyl for pain management and pt anxiety. He told me if I was giving that then I should of given the NTG bc that would of helped in the long run. But, if my right sided 12 lead showed depression in V3R and V4R, isn't the use of all pre-load reducing drug contra-indicated?? Not only that but as things progressed her perfusion was lacking with cap refil around 2-4 seconds. Sorry but I'm not giving someone with hypoperfusion NTG. Was I just balantly wrong and not see it or what?? BTW our protocol contraindicates NTG for anyone with a systolic lower then around 100, B/p upon arrival was 88/56. Pain went from a 7/10 to a 5/10.
Posted 11 November 2008 - 03:07 PM
Posted 11 November 2008 - 03:20 PM
In addition, the mechanism of action related to morphine and blood pressure is due to the fact that morphine can cause the release of histamine. This is what leads to blood pressure changes with this agent. Fentanyl; however, is not associated with histamine release and is typically hemodynamically stable. It is a great choice for hypotensive patients.
In fact, I just flew a non Q wave MI patient out of Afghanistan. He had inferior wall changes and positive cardiac markers. Developed hypotension on an isosorbide drip at the sending facility. In addition, he had hypokinesis of his inferior wall and right ventricle when looked at via echocardiogram. He was experiencing a great amount of pain. After a fair amount of fluid and a few hundred mcg's of fentanyl, he was much more comfortable and had a higher blood pressure. This was good because we had a six hour flight. So, IMHO, fentanyl is a great agent in some cardiac patients.
Posted 11 November 2008 - 03:28 PM
Posted 11 November 2008 - 05:10 PM
I would have argued (discussed?) with the doctor too. We don't use morphine in STEMI because of it's vasodilatory effects, we use it as an anxyolitic. Decreased pain and decreased anxiety are correlated with decreased cardiac work and therefore cardiac O2 demand. The doctor should have understood that.
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