Fentanyl with MI

[Niftymedi911]

For all of you I fully appriciated everyone's post. Here is some answers to you'alls questions.

Why didnt I bolus and then NTG and MS??? Perhaps if you read it correctly I put the word PERSISTENT HYPOTENSION in there. My fluid bolus did not change it in fact had gone down a few points by the time i got to the ED. There was no way I was going to give someone NTG with a B/P not responding to fluids. I gave the Fentanyl for pain management and agitation. Fentanyl treats both of that. The patient was literally try to get up and walk around the back of my truck.

Here's the other factor. One week ago, the pt's RCA was 95% blocked. A stent was placed but after discharge they never took their prescribed medications. I knew this after interviewing my patient and that's why I chose not to try anything further then ultra diesel and some fentanyl.

On scene time was 7 minutes, transport was 13 minutes, Time from STEMI called on scene to balloon deploy: 56 minutes.

Thank You guys for all your support, opinions and answers.......

I personally hate doing "by the book" because you will never have a BTB patient. So Y treat them that way?

[spenac]

Morphine makes me nervous because it is so unpredictable. 0.1 mg/kg will snow one patient, have another vomiting violently, and won't even touch a different patient. Push it too fast and they puke, push it too slow and it does nothing. It seems like everyone reacts to this drug differently, and there are a lot of negative side effects. I would much rather have a drug that is more consistent and predictable so that I can feel like I am actually doing some good more of the time.

And by the way our morphine for ACS protocol is 2mg Q 5 mins up to 6mg. Knowing how rarely 2mg touches anyone, I can't imagine that it makes much of a difference for these patients either. Another reason not to bother with it.

Our protocol calls for 2-6mg initial dose then titrate to relief. One service I can keep giving as long as patient needs it the other service up to a total of 20mg. If pain is severe and vitals are good I usuall start with 6mg and keep adding as needed.

[fiznat]

Good topic Nifty.

[spenac]

Good topic Nifty.

It really is. I almost forgot that this site was about improving medical care and not about bashing everyone and wasting time in chat. Good job.

[firedoc5]

For the dose necessary, onset may be a bit slower than morphine 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 devastating, 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

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??

I was referring to Demerol only if NTG and MS had little or no effect. Unfortunately I've seen some docs "rule out cardiac" just because the NTG and MS didn't eluviate pain. #-o Between what I've seen over the years and what has been adm. to me, the next thing used was Demerol if the NTG and the MS did not work. Sure it might not last as long as Fentanyl, but for the time that it is effective it can be beneficial for the pain, any anxiety, especially if the chest pain is not cardiac and relieve stress better than MS, IMHO.

If I read, and remember right, the OP went straight to the Fentanyl, by passing NTG and MS. Why go straight to Fentanyl when NTG or MS may have worked, and Demerol (even though not always considered or used as often as in the past) could still be a possibility. I might be wrong, but could it be said that too many Medics rely on Fentanyl too much, or have faith in it only?

I by no means against the use of Fentanyl, but there are other options that may take care of it just as well.

I've been tested for chest pain since April and as early as this last weekend. All cardiac problems ruled out. I even kept telling the doc that it was not cardiac pain. But I was already in a doc's office for a nero conduction test. He asked if I was having any pain and I said I was having some chest pain and that it was not cardiac. He insisted that I went to the ER. I told them it was not cardiac. But they started me on a NTG drip, no SL Nitro. and gave me MS. None of it helped. Of course they put me in over night. Still all cardiac tests negative. Did an upper GI, negative other then slight GURGE which was old.. They finally gave me Demerol and I did better. I still hurt but it relieved it some.

But what I'm trying to say, that in my book O2, ASA, SL NTG, MS, then choice of Demerol and Fentanyl.

I'm not saying the Medic was wrong, it's just suprising to me he went straight to the Fentanyl

[fiznat]

Why go straight to Fentanyl when NTG or MS may have worked...

Hypotension? Right sided involvement?

Also, I doubt the OP carried Demerol. I don't know of many ambulance services that do...

[firedoc5]

Hypotension? Right sided involvement?

Also, I doubt the OP carried Demerol. I don't know of many ambulance services that do...

We didn't carry Demerol, but I think they do now. They use it more for trauma, such as extremity fx. I wish we did have Fentanyl in my day, I would have used it, but not necessarily as the first drug of choice for MI. I might be wrong, but I don't think Demerol effected BP that much.

[Niftymedi911]

No demerol..... MS, Fentanyl. Versed, and Ativan

[firedoc5]

No demerol..... MS, Fentanyl. Versed, and Ativan

Valium and MS was ALL we carried as far as pain management went. I know of at least 12 yrs. it was argued that we needed more, such as Demerol , Versed and Antivan for those freaking out. We did finally get Thorazine about 1991

[ERDoc]

Firedoc, the OP was correct in skipping the Nitro and Morphine given the pt's pressure. Fentanyl is a short acting drug which has minimal BP affects (great for trauma pt). Demerol has too many really bad side effects that can be avoided using other meds. Why use something so dangerous when better alternatives are available?