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Fentanyl with MI

68 posts in this topic

Posted · Report post

I ran a call the other day and got a rash of mess for it by the MD. Let me bounce this off ya'all to see if I was a little off with my thinking.

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.

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Posted · Report post

As a still learning paramedic student fresh out of ACLS, I don't see anything wrong with what you did. Was the Doc wanting you to bolus her up to 100 sys so you could give the Nitro? I say good call on the Fentanyl MOA, as we give MS for its pain and anxiety effects with the vasodilation being just a nice perk so Fentanyl seems a perfectly good substitute. Please correct me if I am way off base here.

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Posted · Report post

Did you perform a V4R? This is about 90% specific and sensitive to the detection of right ventricular infarct (RVI). Inferior wall MI is not a specific contraindication to giving pre-load reducing agents; however, RVI can accompany inferior wall MI. A V4R gives you a better picture of the inferior wall MI patient and gives you ammunition when you decide not to give preload reducing agents. Because RVI patients depend highly on preload, giving agents that reduce preload can cause disastrous side effects. However, hypotension is somewhat of a no -brainer. Having all of your facts laid out and having the ability to defend your actions is a great asset.

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.

Take care,

chbare.

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Posted · Report post

Unfortunately he is the one that holds the medical licence, so wading into a pissing contest with him would be unwise. He asked you about your protocol, and according to what you said, this woman would not have qualified for NTG. As far as the MS v.s fentanyl, both relieve pain, fentanyl has less affect on hemodynamics and no histamine release (or minimal) as opposed to MS. What your pt needed was a rapid and safe transport to a cath lab, with IV fluids prn, ASA, pain management and o2. It sounds like you provided all of the above.

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Posted · Report post

ST depression in your right sided leads doesn't mean there is actually right sided involvement just yet. It could be indicative of ischemia over there, but it could also just be recriprical changes to the (LV) inferior injury. Still, I think you were absolutely right in your caution with the NTG, especially given the borderline blood pressure . I might have considered using NTG paste or better yet a drip if you've got it, because both can be titrated much more effectively. Didnt the pressure change at all with your 600cc bolus?

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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Posted · Report post

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).

Also, if you are worried about a right sided AMI you should bolus your patient and rechecked a BP before giving NTG and Morphine. Those are the 2 drugs, along with aspirin and oxygen, that are given for AMI.

MONA - Morphine, Oxygen, Nitro, Aspirin. I would have given the NTG and morphine after the bolus personally.

Basically, you screwed up. If you really had this big of doubt and issue, call medical control and ask for orders. Put the monkey on their back and treat accordingly. I would have bitched you out myself, you ran outside of ACLS protocol and you practiced medicine without a license. Also, you lack understanding of the true reason why Morphine is giving for AMI.

Tough lesson to learn I hope you learned it well. Take it upon yourself to research each drug, right sided AMI, and review your ACLS/STEMI protocol. When you work outside of protocol you make yourself liable. Time is tissue and you dropped the ball on this call. Good luck next time..

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Posted · Report post

Medic was that sarcasm or have you missed much of the lastest studys?

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Posted · Report post

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).

Also, if you are worried about a right sided AMI you should bolus your patient and rechecked a BP before giving NTG and Morphine. Those are the 2 drugs, along with aspirin and oxygen, that are given for AMI.

MONA - Morphine, Oxygen, Nitro, Aspirin. I would have given the NTG and morphine after the bolus personally.

Basically, you screwed up. If you really had this big of doubt and issue, call medical control and ask for orders. Put the monkey on their back and treat accordingly. I would have bitched you out myself, you ran outside of ACLS protocol and you practiced medicine without a license. Also, you lack understanding of the true reason why Morphine is giving for AMI.

Tough lesson to learn I hope you learned it well. Take it upon yourself to research each drug, right sided AMI, and review your ACLS/STEMI protocol. When you work outside of protocol you make yourself liable. Time is tissue and you dropped the ball on this call. Good luck next time..

Hu? :scratch:

Take care,

chbare.

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Posted · Report post

First off, Morphine is used primarily for coronary artery vasodilation not for pain management. That is the secondary use for Morphine along with anti-anxiety (which helps decrease respirations to allow more 02 into the tissues).
:shock:

Medic was that sarcasm or have you missed much of the lastest studys?

I hope for sarcasm as well. Morphine is not, in fact, given for its vasodilation properties..primarily. It is a nice side effect, but the pain management is the primary goal of the morphine. Not as an anxiolytic, but as a narcotic analgesic..big difference. Basically, no pain, no morphine. There is better pharmacology for vasodilation, and I hope you would understand that..

Nitro is given for its effect on the coronary circulation, in hopes of some vasodilation and getting additional blood flow to the tissue distal to the occlusion. I think that Fentanyl is a good alternative to morphine, if you are allowed to use it.

I would not think the doc would chastise you for using the fentanyl, although I think with the vitals you cited, morphine would have been acceptable. Its a comfort thing at this point IMHO. Judicious use of nitro is also not out of the question. Its largely situational and comfort based, again in my opinion.

As for going out of ACLS and practicing medicine without a license...WTF :?

ACLS guidelines are just that..guidelines. If the protocols allow fentanyl for pain, then this is perfectly acceptable.

I dont think the OP messed up, I think others are still too attached to their protocol books :evil: (again with the monkeys 8) )

again.....my opinion :argue::)

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Posted · Report post

Yeah, I had a vision of the monkeys throwing their poo at another monkey because he was doing something they thought was different. "Every MI patient needs MONA ya know. Why? Because we give every MI patient MONA."

Take care,

chbare.

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Posted · Report post

The doc maybe somewhat old school and going by what has been done for years. Chest pain= NTG (if hypotensive try a moderate fluid challenge to bring up BP), ASA, MS. If BP allows, repeat NTG and MS. Titrate either to BP. I would only consider the Fentanyl if pain was 9/10. I know I might get jumped on this but...if having a lot of anxiety call med.control for 2-4 mg. Valium. I'd never done it, but have seen it done.

Maybe the doc thought that going with Fentanyl was "jumping ahead" a little too much.

Ask another doc in the ED and see what he/she says.

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I know some of the newer studies are showing that morphine increases the death rate. Where I currently work, both in EMS or Surgical ICU, we are using morphine for the vasodilation properties along with nitro. Nitro being the primary drug obviously. Maybe his protocols are different but my protocols for EMS is morphine. If they have an allergy to morphine you omit the narcatic. They just added fentanyl to the protocols but it is replacing demerol and is used for long bone fractures.

I am sarcastic sometimes, sorry if it causes confusion. So, I'm not saying every patient needs MONA but obviously THIS patient did.

I should stop posting when I first wake up :?

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I know some of the newer studies are showing that morphine increases the death rate. Where I currently work, both in EMS or Surgical ICU, we are using morphine for the vasodilation properties along with nitro. Nitro being the primary drug obviously. Maybe his protocols are different but my protocols for EMS is morphine. If they have an allergy to morphine you omit the narcatic. They just added fentanyl to the protocols but it is replacing demerol and is used for long bone fractures.

I am sarcastic sometimes, sorry if it causes confusion. So, I'm not saying every patient needs MONA but obviously THIS patient did.

I should stop posting when I first wake up :?

I agree, if available to with Dermerol before Fentanyl. IMHO

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Again, pain management should be the primary goal. If we are concerned about blood pressure, I see no problem with fentanyl. I am not sure that the said patient "needed" MONA. I think the OP took a conservative approach. Blood pressure was borderline and the OP made a judgment call. I will take a step back on the V4R. It looks like one was performed showing changes. However, it does not sound like RVI was definitively confirmed. This is good practice and gives you additional information to base your decision making. I agree that fluids are helpful if no other problems exist. Holding off on NTG while giving a fluid bolus is not a bad call IMHO. However, saying somebody "screwed up" for holding off on NTG with the said pressure? Your heart loves hypotension and crap coronary perfusion pressures, especially when it is infarcting.

Why would demerol be a better agent for pain control in the said patient? Why would demerol be a better choice over fentanyl?

Take care,

chbare.

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I'm glad y'all cleared that up. I didn't see a problem with the treatment rendered until I saw MT's original reply. He seemed so sure about it that, for just a moment, I thought maybe I was the one who was behind the times. I've treated three MIs in the last five years, so I'm not exactly Mr. Cardiology these days. Glad to know I wasn't losing my mind. Yet.

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Demerol is a terrible drug..and it is being removed from a LOT of formularys, as far as I am aware..

-Just sayin' :D

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...but the pain management is the primary goal of the morphine. Not as an anxiolytic, but as a narcotic analgesic..big difference.

Okay, yeah. I admit that morphine is not considered a primary anxiolytic. ...Although in my experience a decrease in pain pretty soon after relates to a decrease in anxiety, as well. Maybe call it a secondary anxiolytic? In either case, a comfortable, relaxed and pain-free MI patient is better than an anxious one in lots of pain. Fenanyl probably does a good job of that as well, and if it is in-protocol I don't see what the problem is.

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Demerol is a terrible drug..and it is being removed from a LOT of formularys, as far as I am aware..

-Just sayin' :D

Why do you think Demerol is such a terrible thing? It lasts longer then MS. It releives pain and from my experience is more effective. Anxiety tends to be less, unless the patient is for some reason fightng the effects for some reason. Sure, It might not be the first or second drug of choice, but at least it is an option.

Also if someone is given NTG. especially a drip, the headace that can/ will be brought on by it may need the Demerol to releive it.

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Why do you think Demerol is such a terrible thing? It lasts longer then MS. It releives pain and from my experience is more effective. Anxiety tends to be less, unless the patient is for some reason fightng the effects for some reason. Sure, It might not be the first or second drug of choice, but at least it is an option.

Also if someone is given NTG. especially a drip, the headache that can/ will be brought on by it may need the Demerol to releive it.

For the dose necessary, onset may be a bit slower than morpine and the duration of action is shorter. The duration of morphine is 4-6 hrs, where the duration for demerol is 2-4 hrs.

Interactions with SSRI can be devestating, and a lot of people take SSRI. Some retrovirals cause levels to become toxic very quickly. :?

CNS side effects are significant, including seizures. Normeperidine, it active metabolite is accumulated in the system. If the patient has a seizure disorder, this drug is not well suited for them.

The drug should be used very cautiously in the elderly due to decreased renal function (normeperidine accumulation increased) and can increase the chance of anticholinergic effects in this population.

Finally, meperidine is not reversed by narcan and may, in fact, precipitate seizures .

There is not a positive point for demerol vs. morphine, fentanyl, or ketorolac that I have seen lately. Given the plethora of probable untoward effects, meperidine is not used in any hospitals around here, and is certainly not well suited for prehospital administration. IMHO..

...The old 'morphine cannot be used for biliary colic because it causes spasms at the sphincter of oddi' argument is bunk..No study I have read has linked this with any clinical evidence..

One more word.. studies have shown that the pain relief in severe biliary colic is the same with ketorolac as it is with demerol..(Journal of emergency medicine 2001; 20(2); 121-4)

This is a short answer to why I think demerol is a terrible drug, especially with so many alternatives available for emergency services :D

edit:

firedoc..why do you think fentanyl was jumping ahead? This is a very good, fast acting opiod with very few side effects or contraindications. This is, in my opinion, a very good drug for pain...any pain.

Is it lack of familiarity with the drug, or do you have a specific reason??

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Posted · Report post

Seeing a couple of misconceptions here.

Coronary Vasodilation is really a secondary perk to both Morphine and Nitro. We give both in order to cause a systemic, peripheral drop in SVR and thusly preload. Lower preload essentially results in a decrease in the need for cardiac oxygen consumption because of less work. Please review Frank Starling's Law...

ALSO, and for some reason not many remember this, but Duke performed a pretty big landmark study years ago that showed that Morphine administration for MI resulted in a 50% increased mortality among patient's who had received it. Remember that histamine release? Well histamine happens to be a big mediator in the inflammatory process. This is especially crucial given the finding, released just the other day at the AHA's annual meeting, that shows just how much of a role inflammation plays in MI.

Duke Morphine Study

TIME Article: "Statins May Halve Heart-Attack Risk"

Your "Doctor" may not read up on the literature, but you might as well. Granted, one study from one institution does not categorically make Morphine a bad drug (I think the study specifically referred to Non-STEMIs), but it is something to think about.

Pain causes anxiety and Fentanyl is definitely an excellent sedative and pain reliever. The cardiac and physiologic issues associated with anxiety can be detrimental. Treating a patient with right-side involvement (ST elevation in V4R in the presence of inferior wall elevation) is a tricky endeavor. By no means would I always rule-out nitrates, but I would heavily consider a fluid bolus so long as my patient wasn't also in eminent cardiac failure (possible APE).

I like Fentanyl and I think it is an excellent EMS drug for all kinds of uses. The problem is that it gets pushed in micrograms and has a much larger potency in comparison to Morphine. I think some medical directors shy away from allowing its use for fear of abuse and incompetent administration.

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Just to nitpick, that paper isn't really research per-se. It is a retrospective, non-randomized analysis of data taken from another larger study. It raises some questions, no doubt, but it's scientific relevance pretty much stops at identifying the need for further research.

It is a good thing to keep in mind though... In general I don't give morphine to my ACS patients at all, but that probably has more to do with the fact that it is locked up behind two keys in the safe and takes too long to set up + administer. :D

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Just to nitpick, that paper isn't really research per-se. It is a retrospective, non-randomized analysis of data taken from another larger study. It raises some questions, no doubt, but it's scientific relevance pretty much stops at identifying the need for further research.

It is a good thing to keep in mind though... In general I don't give morphine to my ACS patients at all, but that probably has more to do with the fact that it is locked up behind two keys in the safe and takes too long to set up + administer. :D

True, good catch. No true "controls," experimental parameters, or randomization to speak of. Like I said, there are limitations to the study, but it is important to consider. I think the recent information regarding the role of inflammation definitely calls for additional study.

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True, good catch. No true "controls" or experimental parameters to speak of. Like I said, there are limitations to the study, but it is important to consider. I think the recent information regarding the role of inflammation definitely calls for additional study.

Yep..I didn't think too much new came from this. There has been evidence for a while that inflammation played a huge part in AMI. We have been teaching, against convention, that reproducible chest pain does not preclude AMI. Simply because of this fact that inflammation is present. I would like to see more studies, any studies for that matter, about the efficacy of different analgesics in AMI, and the roles they play in outcome to discharge.

You have brought up some good points, guys..I wish it would rub off on some others :roll:

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Agree, the safety and side effect profile of demerol can be concerning. Again, I still think fentanyl is a good alternative to morphine.

Take care,

chbare.

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Not to stray too far from the OP, but am I the only one here who simply is not terribly impressed with Morphine as an analgesic? Seriously. As much Morphine as I have given in the last thirty-five years, I sometimes feel like I have taken almost half that much myself, through various injuries, including the most recent one. It just doesn't do shit for me, pain wise. And I have had way too many patients tell me the very same thing over the years. I have always enjoyed much faster and better pain relief from Demerol than from Morphine. And Fentanyl simply blows them both away.

Morphine has never even been good as an anxiolytic or sedative for me. Doesn't even make me drowsy. Demerol and Fentanyl hit the spot quickly. And again, in my experience, they seem to do the same with most of my patients.

Of course, there is no doubt in my mind that much of the ineffectiveness we see with Morphine is the result of the monkey practice of dribbling it in by 2mg increments instead of just slamming it. That is cruel and ignorant. If your patient is in enough pain that you notice it, go big or go home.

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