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Impaled by fence

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We often worry about how "dirty" morphine is and histamine release; however, the evidence is all over the place. Anecdotally, I tend to shy away from morphine; however, that is personal bias. I've actually seen several studies where the efficacy and side effects profile of both drugs are fairly equivalent. While I personally tend to use fentanyl, I cannot condemn Dwayne for considering morphine at this point. If hypotension and additional information pointed to altered haemodynamics, I would not support the use of morphine.

A recent study abstract comparing the two agents in the prehospital environment:

http://www.ncbi.nlm.nih.gov/m/pubmed/21689900/

However, the presence of hypotension was considered part of the exclusion criteria.

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I think personally peoples fear of morphine and histamine or nausea is over-rated but like chbare, its just a personal thing.

Ketamine is a better analgesic than morphine in a patient who has haemodynamic problems and we think it is particularly good for traumatic pain.

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What angle did the post go in at? How did he end up on it? Trip while playing grab ass? Get thrown from a horse? Fall while standing on his truck driving it in?

In most scenarios that I'd imagine it most likely went in at a shallow angle, sounds like it pierced his Lat which is a pretty big muscle that bled for a bit but then spasm'd around the post making the external bleeding self limiting. And his vitals seem to support this assuming his rate and pressure are not chemically controlled.

The man ended up on the fence as the result of gardening accident, apparently he was on a step ladder near the fence trimming the branches of a tree in his yard when he lost his footing and fell directly on top of the dart.

As to where the dart impaled him, it appears to have entered on his right side near the serratus anterior and exited near the top of his latissimus dorsi.

I have a question for Kiwimedic and Runswithneedles, one of you said no fluids while the other said to run him with two large bore IV's at TKO, care to explain your reasoning behind your choices in how to handle fluids?

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It was me, the patient does not appear to be suffering from hypovolaemic shock therefore does not require intravascular volume replacement

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Neither person said that they would aggressively administer fluids. Having large bore access is probably not a bad idea and can be used to resuscitate with blood products if required after arriving at a medical facility.

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... If he required pain relief very quickly and we didn't have a drip in him I'd get the fireys to stop extrication, give him some entonox and IN fentanyl then have them resume cutting him out.

Man, I have entonox here again! I'm a very happy camper!

We often worry about how "dirty" morphine is and histamine release; however, the evidence is all over the place. Anecdotally, I tend to shy away from morphine; however, that is personal bias. I've actually seen several studies where the efficacy and side effects profile of both drugs are fairly equivalent. While I personally tend to use fentanyl, I cannot condemn Dwayne for considering morphine at this point. If hypotension and additional information pointed to altered haemodynamics, I would not support the use of morphine....

I've had nothing but really good luck (relatively speaking) with morphine, but because of that I've no comparable experience with Fentanyl. When I first started using it Fentanyl just seemed to be such a lightweight in the pain management ring that I didn't play with it much.

I know many worry about the hemodynamic effects, but I've not encountered them to any degree that has cause me much concern. And I've pushed it quite a bit.

The exception, as stated above, would be if I was concerned about compromising his hemodynamic status, even by a little bit, then certainly Fentanyl would be the better option. I've never worked with Ketamine.

But the patient description so far, his vitals, nor the injury as described give me any concern really that he's compensating, so morphine would still be my choice for the reasons mentioned previously.

CYA statement: As this wasn't answered before...Does this guy have anything on board that could be controlling his rate and pressure chemically? Because if so, then I'm going to have to step back and reconsider...

Dwayne

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How do you define the lightweightness of fentanyl? For example, you give 1 mg of morphine to a patient, you would expect a certain effect. (Average expectation value.) However, give a milligram (Ten times what most people often give.) of fentanyl to a patient. You would probably have a very different effect.

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How do you define the lightweightness of fentanyl? For example, you give 1 mg of morphine to a patient, you would expect a certain effect. (Average expectation value.) However, give a milligram (Ten times what most people often give.) of fentanyl to a patient. You would probably have a very different effect.

Yeah, I screwed the pooch in my previous statement. I think that it's effectiveness was possibly harnessed by my previous protocols. I've only had one place that I've worked that carried it and I believe that our protocol was 1mcg/kg to a max single dose of 100mcg. (It seems that even that dose needed to be split 50mcg, reassess, then 50mcg but I just don't remember) I can't remember if you were supposed to call then or not, but you could then give an additional 100mcg for a total of 200mcg.

I admit to only using it, maybe, 10 times or so. Each, with the exception of a high school football player with a dislocated shoulder were significant pain secondary to trauma. The shoulder loved it, but even then I didn't like it only because I was used to mixing benzos with morphine for dislocations so had to call medical control for advice, not having experience with Fentanyl and benzos.

And the first few times I used it I pushed 100mcg, but didn't really get the response that I'd hoped for or expected. We're taught that it should equate to approx. 10mg or morphine, right? Though in those few cases I would have predicted a more comfortable patient with 5mg of morphine instead of the full dose of Fentanyl....

So basically I know shit about it really, other than my initial experience made me feel hinky compared to pushing the drugs I was used to, and that I've not been in a situation since to mitigate the likely bogus hinky feeling with additional experience.

Man, I'm truly grateful that you brought that up. I think that tendency towards provider bias based on experiential comfort instead of quality data to choose interventions is a good thing for people to be aware of, and beware of, and monitor.

Dwayne

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Ok. I'm still having trouble picturing this, but from your description of serratus anterior and latissimus dorsi, it's basically punched through and is being held by the major muscles of the back, right? It pierced on the lower back and is coming out the upper back... so I'd put him on his left side... so we have questionable involvement of the chest cavity but it appears to be lower index of suspicion if I'm reading the position of the impalement right... any changes in patient presentation/condition once we get them in position of comfort and some meds on board?

Can't comment on fentanyl vs. morphine, but don't physicians prescribe medication all the time based on personal preference/past experience? They often have access to the data, but will go with what they've "seen work" before for patients... right? Everyone's got their favorites in the little magic basket o'pharm... and I don't think that's necessarily a bad thing as long as the indicators for a certain drug are there and the provider's willing to switch gears and use something they don't use as much if their first choice doesn't produce the desired effect in the patient...

Hell, you learn best by what you actually see happen, all the numbers in the world won't tell you more than treating a high number of people requiring a certain class of drug and watching different responses...

Wendy

CO EMT-B

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Wendy you make a good point about bias...

I've never really thought about it this way before, but I guess the ability to eliminate your own bias would be limited. While rereading a couple of posts I was thinking, "I've pushed buckets of morphine, why didn't I try Fentanyl more often just to get a good taste for it?" And I think that the reason is that most times when I need a narcotic I'm also not in a very good place to experiment. Most often I'm busy, and want to be able to manage each issue with the most confidence as it comes along...

Sorry for the side conversation, but I think that it's pretty interesting on many levels..

Dwayne

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