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Fentanyl with MI


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#1 Niftymedi911

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Posted 11 November 2008 - 02:48 PM

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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#2 mshow00

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Posted 11 November 2008 - 03:07 PM

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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#3 chbare

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Posted 11 November 2008 - 03:20 PM

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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#4 p3medic

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Posted 11 November 2008 - 03:28 PM

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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#5 fiznat

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Posted 11 November 2008 - 05:10 PM

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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