SQ MS in sickle cell crisis?

[mshow00]

I was reviewing our protocol over sickle cell crisis and it stated that we can give the pt MS IVP (standard 2-4mg) or SQ (2-5mg). I can't figure out why the SQ. Our protocol allows us the fastest and slowest onset with nothing in the middle. Why not IM? We only have protocols and equipment for IO in peds, so that is out. I have plan on seeing one of our medical control Drs on Tuesday to ask him this question, I am just attempting to see if I can find out sooner rather than later.

[Ridryder 911]

Morphine is also routinely administrered sub-q as a secondary route after administration IV or even IM. The good thing about the route is that the duration lasts longer. Therefore helps controls the pain and helps control breakthrough pain.

R/r 911

[ERDoc]

On true sicklers, just pop in the IV and give it that way. They are going to need lots of fluids anyway, so might as well get them started in the field.

[AnthonyM83]

What kinds of treatment are done for them at the ER?

I once had a patient strongly request the county hospital that was much further away. He said that when he does to certain hospitals they have special medicines that the local ERs don't all offer. At the time I assumed just a stronger pain med . . ?

[Riblett]

Anthony,

I have noticed the same thing among my few frequent sickle cell patients. One in particular, a 23 y/o male calls very frequently and wants to be taken to Duke (over an hour away) instead of the smaller community hospital. He says that "they don't do anything for me" at the community ED. This kid is a chronic caller and usually when he calls it has been progressively worsening for several days. The local ED has the same docs all the time and most of them are old and well seasoned. I think they are kind of stingy with the pain meds. But at Duke, a well known university/teaching hospital, there are fresh white coats (interns/residents) who are quick to give drugs every chance they get.

Maybe you can advise us on this ERDoc, but would there really be any harm having a family member drive him if he doesn't want to go to the local ED? I am thinking just from a system availability perspective, since we are out of service for a long time with this and this is not an acute thing. And the kid has a ton of narcotics at home. I can see him needing pain control, but if his codiene, oxycontin, oxycodone, phenergan, etc is not working, what good is my little bit of morphine really going to do?

[reaper]

As ERDoc stated. Someone in a true crisis will need fluids, along with pain control. When they reach the ED, they may end up getting a transfusion.

I have seen many medics blow off Pt's in a crisis. This is a very painful thing to go through. These Pt's take so many narcotics, over a long range of time, that they build resistance to some pain meds. They may take some powerful pain meds on a daily basis, so in crisis, they need some thing better for the pain.

If you work in an area with a lot of these Pt's, then I would suggest reading up on the process of the disease. It will help to enlighten some.

[ERDoc]

I'll post a link to the emedicine article that has much more comprehensive info. There is not much to do for SC pain. Lots of fluids (generally 3-4 L) and pain meds. Most SCD pts will have meds at home which they'll use before they go to the hospital. As for why one would want to go to a specific hospital, it may be because they know the docs at each place. Unfortuntely, SCD is one of the diseases that is used by drug seekers to get their fix, much like they use migraines. They may know that hospital X will give dilaudid like candy, while another will only give small doses of morphine. Maybe one hospital has better sandwiches?

Here is the emedicine article.

[crotchitymedic1986]

I am thinking morphine may be a bit strong for your SS patients. Much like the patient who has learned to go an hour away to get his narcs, once word gets out that you are giving morphine to these patients, they will always call the ambulance. Do you have a less potent narcotic like Fentanyl or Versed ?

[ccmedoc]

Sickle cell is a spectrum disorder, not simply sickle cell disease or not. There are different types, ranging from Sickle cell trait (that will not manifest as crisis) to sickle S (Hgb S) disease (sickle cell anemia). Some classify certain beta and alpha thalassemia in this disorder, but I think this is a minority..

The difference between Hgb C(SC) disease and Hgb S (SS) disease is genetic. Usually the SC is called sickle cell disease and presents with milder symptoms and discharge is quicker. The SS is termed sickle cell anemia, and symptoms are generally the more severe. These range from the joint pain to Gall stones, strokes, acute chest syndrome, priapism, to splenic sequestration (surgical emergency)..Some individuals may have SC for their whole life and never know it. They may attribute the pains to flu or other colds.

My guess in the difference between a patient wanting to go to a certain hospital is a direct correlation to how much the staff truly understands SS and SC disease. One may only need labs, fluid and pain control. The other may need labs, fluids, blood products, pain control, and other medications for secondary manifestations, such as itching.

If the staff is not accustomed to treating the SS patient, they will simply think they are drug seeking and not pay the attention that the disorder warrants. Some larger hospital have SS clinics that specialize in both inpatient and outpatient treatment.

I can see though, as ERDoc says, there are seekers in the population. Most clinics that see a lot of SS, and even some literature (as I have been told in seminars), will tell you that the number of sicklers that seek drugs for recreation is low. Further assessment of the patient to gain insight into the type of pain they are experiencing is acceptable if you suspect this, but don't make the person suffer while you interrogate them. 8)

Oh, and some hospitals do have better meals than others.This most likely also factors in to the persons having a lesser crisis...

Morphine is the drug of choice to start with as it is LESS potent that Fentanyl or Dilaudid. Versed is generally not used, in my experience, unless some anxiety or seizures accompany the crisis...Most patients do not respond well to the morphine, diphenhydramine, motrin,etc..and need to use more potent drugs. These people are generally on T3, vicodin, dilaudid...at home. I know from experience that MS or Fentanyl do not touch some of the individuals that are older with SS. I have heard that some like to administer the stadol or Nubain..Be careful with these in this population :roll:

This is a serious disorder and warrants some research by the members of this forum to understand better IMHO....

edit: Speaking further on MS..I meant to also state that the administration of MS is frequently based on the theory that this drug reduces the body's oxygen demand, acts as a vasodilator, and is very effective in relieving pain..This, along with the MS being easily controlled and tolerated by most patients, make it attractive as first line narcotic.....

Carry on.......... 8)