# Morphine for facial/airway burns.



## NYMedic828 (Jan 10, 2013)

So a friend of mine had his medic state skills test today.

He failed trauma because he gave morphine to a burn patient with facial burns.

Our protocol in NYC allows standing order morphine for burns (up to 5mg) with a bolded note "Morphine shall not be given in the presence of burns to the face or airway."

So he failed because he gave morphine, mind you his proctor was egging him on with "hes screaming in pain what are you gonna do?"


So why is it contraindicated? Is it histamine/swelling related? If it is, wouldnt fentanyl be the logical move?


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## the_negro_puppy (Jan 10, 2013)

I would like to know the answer too, airway burns is a precaution for morphine for us in our protocols.


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## Nattens (Jan 10, 2013)

Believe it is due to Morphine's action on the CNS causing Respiratory depression therefore a loss of airway control in the patient with respiratory burns. The loss of airway control being one of the reasons why it makes a good sedative agent for maintenance of inbutation.


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## NYMedic828 (Jan 11, 2013)

Nattens said:


> Believe it is due to Morphine's action on the CNS causing Respiratory depression therefore a loss of airway control in the patient with respiratory burns. The loss of airway control being one of the reasons why it makes a good sedative agent for maintenance of inbutation.



All do respect I don't think that is it.

The respiratory depression from 5mg of morphine in the majority of patients is non-existent.

Sedative doses of morphine far exceed 5mg and a patient would be unconscious before hypoventilation fully set in.




If I had to take a guess, I imagine the reason is not to enhance the release of histamine aiding in further inflammation but im not quite sure it works this way in the case of morphine binding to histamine.


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## Nattens (Jan 11, 2013)

NYMedic828 said:


> All do respect I don't think that is it.
> 
> The respiratory depression from 5mg of morphine in the majority of patients is non-existent.
> 
> Sedative doses of morphine far exceed 5mg and a patient would be unconscious before hypoventilation fully set in.



Fair enough, my guess was a wild stab, there is a reason why my training sidebar has "Student" in it.

You do mention a "majority" of patients, would it be possible that the guideline is trying to cater to the minority that may have a altered conscious/respiratory depression reaction from a dose as low as 2.5mg-5mg? Or maybe if airway burns are already causing respiratory depression due to the swelling the resp depression effect from morphine could tip them over the edge?


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## Smash (Jan 11, 2013)

Burns - - > oedema-- > airway compromise. Morphine - - > histamine release - - > worse swelling? I 

I have no idea but either way it's absolute bull****, and 5mg of morphine for burns is homoeopathic... 

Sorry for brevity on phone late for work.


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## Rykielz (Jan 11, 2013)

If it's written in the protocol you need to know it. As for the reasoning... I have no clue and it does sound kinda lame.


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## Veneficus (Jan 11, 2013)

I agree with Smash, it sounds like paranoia over anaphylactoid reaction. 

5mg of morphine to a severe burn isn't going to do S**t. 

I have given upwards of 90mg (yes that is 9 0 ) to severe burn patients over the course of 20-30 minutes and it barely does anything.

A specific group of mediciations, PCN and morphine being among them can cause anaphylactoid reaction, it is similar but a different mechanism, and is not as likely to become life threatening. 

It is also why so many people report allergies to these meds.

I am really starting to think NYC should get rid of all that ALS equipment they never use and just drive around with leeches and hot pokers.


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## Smash (Jan 11, 2013)

NYC ALS equipment:


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## abckidsmom (Jan 11, 2013)

Smash said:


> Burns - - > oedema-- > airway compromise. Morphine - - > histamine release - - > worse swelling? I
> 
> I have no idea but either way it's absolute bull****, and 5mg of morphine for burns is homoeopathic...
> 
> Sorry for brevity on phone late for work.



Homeopathic! Ha!

I have 20 MG morphine, and 200 mcg fentanyl. Severe burns get a helicopter just because I barely have the meds I need to wait 15 minutes for them to get there. 

It's so sweet to see something like this happen in testing. Gives me hope that EMS is on the way. Yessir. 

I would advise my friend to gather documentation and challenge that, especially since its written into the protocol.


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## usalsfyre (Jan 11, 2013)

Not to mention the majority of facial burns don't equal airway burns....

The fact that the proctor was essentially pushing him to fail in a testing situation is indicative of how broken the system is.


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## Clare (Jan 11, 2013)

IV morphine is great stuff, but there are some things it just doesn't quite make the grade on, burns are one of them, ketamine is much better provided you can get it within a reasonable time frame.

5 mg of morphine is probably a little low for somebody who has significant burns, burns are often excruciatingly painful.  1 mcg/kg of fentanyl is probably a better option.

I have only seen a couple of patients with very significant burns and I have to say they are not for me.  I can handle most anything except burns, they give me the absolute creeps.


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## Thricenotrice (Jan 11, 2013)

usalsfyre said:


> Not to mention the majority of facial burns don't equal airway burns....
> 
> The fact that the proctor was essentially pushing him to fail in a testing situation is indicative of how broken the system is.



Taking a stab at the OPs question;
I would be willing to guess that according to the people that write the guidelines and protocols, facial burns are close enough to airway burns, due to the possibility of inhaling the gases, and the close proximity to the airways. - to them. 

As for the reasoning behind the reasons not to give it, I will second the histamine release, and the rare possibility of an anaphylactoid reaction


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## KellyBracket (Jan 11, 2013)

Did the examiner perhaps think that morphine was not the right answer because intubation was supposed to be the next proper step?

In reality it's a silly point. Giving morphine while preparing for airway control is just fine. And yeah, 5 mg of morphine might as well be a 60x dilution...


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## MSDeltaFlt (Jan 11, 2013)

Yeah, that scenario is so wrong on multiple levels.  I have no idea how he could have failed the station.


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## NYMedic828 (Jan 11, 2013)

KellyBracket said:


> Did the examiner perhaps think that morphine was not the right answer because intubation was supposed to be the next proper step?
> 
> In reality it's a silly point. Giving morphine while preparing for airway control is just fine. And yeah, 5 mg of morphine might as well be a 60x dilution...



I believe it was facial burns and the patient is in severe pain, stating such. Don't think intubation came into question but I wasn't there.

Outside of improper protocol, I don't see whats wrong with treating the patients pain.

I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?



MSDeltaFlt said:


> Yeah, that scenario is so wrong on multiple levels.  I have no idea how he could have failed the station.



Because he gave a treatment that was contrary to protocol, regardless of the protocol being contrary to sound medical care.

It is certainly unfair that the tester egged him on about severe pain.


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## MSDeltaFlt (Jan 11, 2013)

Morphine contrary to sound medical care on facial burns?!?  I've worked in a burn center and I have never heard of such for any reason.


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## NYMedic828 (Jan 11, 2013)

MSDeltaFlt said:


> Morphine contrary to sound medical care on facial burns?!?  I've worked in a burn center and I have never heard of such for any reason.



I'm agreeing with you. I think you misread.

I am stating that the reason he failed was:

Gave a treatment contrary to the protocol.

The reason he shouldn't fail is

The protocol is contrary to standard medical practice.


He shouldn't fail for being right when the system is wrong.


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## MSDeltaFlt (Jan 11, 2013)

Ah.  Yes I did misread you.


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## medictinysc (Jan 12, 2013)

According to http://www.ncbi.nlm.nih.gov/pubmed/6172999

High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.

does that sound like a small amount like 5mg morphine,  or does it sound like a lot more??????  it is even given / min??????  

if the med control is using a study like this to base his/her decision on "pain control"  for burn victims, then maybe they might want to take away the shocks on our ambulances too..... the bounciness could put a pt to sleep therefore occluding the pt's airway>>>>>  SARCASIM


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## NYMedic828 (Jan 12, 2013)

medictinysc said:


> According to http://www.ncbi.nlm.nih.gov/pubmed/6172999
> 
> High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.
> 
> ...



Honestly I don't think the problem stems from the medical directors being foolish. Our (well, my former) medical directors happen to be very respected doctors in the region but other EMS providers I cannot say the same for.

Had this been a real patient and during treatment the provider called the doc and said "I would like to request a discretionary order to administer morphine outside of protocol" he would look almost certainly be approved.

Unfortunately, the protocol is for standing order morphine and when your body of providers is vastly undereducated as they are in 90% of EMS systems, you can only allow so much leniency. 

My purpose in making this thread was to essentially ensure that there wasn't some actual medical contraindication to morphine in this scenario that I never heard of.

The unfortunate factor in these situations is that now my friend will have it in his head, as a new provider, that a treatment he believed to be and was correct about is in fact wrong and should not be considered in the future in a real situation. Not a very good way to mold new paramedics into anything but a cookbook provider.


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## usalsfyre (Jan 12, 2013)

NYMedic828 said:


> Unfortunately, the protocol is for standing order morphine and when your body of providers is vastly undereducated as they are in 90% of EMS systems, you can only allow so much leniency.



Horse puckey.

It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up. 

I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.


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## NYMedic828 (Jan 12, 2013)

usalsfyre said:


> Horse puckey.
> 
> It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up.
> 
> I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.



I've never been to a system outside of NYC/LI so my perception is purely based on my region.

But out here, the common thought process is that 10mg of morphine will put someone to sleep. Fentanyl is far too dangerous (100ug max) to give to just about anyone and analgesia administration isn't worth our time. (People don't grasp the concept of equivalent dosing)

I once suggested to call med control to give a blatantly snapped tib-fib fractured child (ped struck) IN fentanyl and my partner thought I was insane and going to kill the kid. So, the poor kid suffered the entire bumpy ride to the ER.

No one gives analgesia most of the time which means they never see it work and how little 5-10mg or 100mcg actually is so they keep this thought process in their head.

It actually boggles my mind that people think hypoventilation from opiates will set in BEFORE altered mentation and loss of consciousness. Like the patient is going to forget to breathe when they are awake...

This is what I deal with.


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## Veneficus (Jan 12, 2013)

medictinysc said:


> According to http://www.ncbi.nlm.nih.gov/pubmed/6172999
> 
> High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.
> 
> ...



A study of 15 patients from 1982? Really?


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## Veneficus (Jan 12, 2013)

usalsfyre said:


> Horse puckey.
> 
> It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up.
> 
> I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.



The paranoia about various medications is not limited to paramedics. I have met doctors and nurses who think if you give 2mg of morphine the patient is going to suddenly die. 

I have heard more than one provider with a story of "I once had a patient..."

Various "safety" agencies latch on to this like it is the word of God, but I think it requires perspective. 

Around the world, on average, 1:350,000 people undergoing general anesthesia die. So I think we can agree that GA, is probably the extreme side of pain/anxiety/awareness management.

There are probably millions (I have no idea the number) of doses of analgesia with opioids or antianxiety with benzos given daily around the world. We hear about "I once saw a patient..."

I have given thousands, perhaps 10s of thousands of doses of analgesia with and without benzos in my career. So what is the number needed to harm?

1:million?
1:5 million?
1:10 million?

So somebody somewhere (in this case NYC) thinks that it is reasonable to withold analgesia or prescribe an ineffective dose of it because 1:God knows how many of millions of people might have a bad reaction?

If we did that we wouuld never prescribe tylenol. It certanly wouldn't be OTC in every civilized country in the world. 

Hell, we wouldn't do any procedure or prescription at all at those rates. 

What would medicine be like if a surgeon had a bad outcome doing a procedure and his solution was to never do that procedure again?

Because it is no different from a doctor having a bad medication reaction and never prescribing that medication again.

I have no doubt, somebody some where at some point is going to have an adverse reaction. But it doesn't mean we stop treating everyone else because of it. That is bad medicine.

If we can send patients home on warfarin but cannot "trust" paramedics to give morphine, never mind we send patients home with their own morphine, then somebody's *** needs to lose their job. 

Either the medical director (council) which is my first pick, because obviously their quality control responsibilities for those working under them are not being met, or the providers, because they are so incapable they should be driving a taxi not an ambulance. 

No union should protect people who suck. Neither should management. That includes the medical director.


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## Clare (Jan 12, 2013)

> I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?



Yup, benzodiazepines do not provide any analgesia, the patient can be in significant pain and have all of the physiological insult that comes along with it yet still be sedated, hence why opiates are used in combination with midazolam, although it's no longer formally described within the CPG


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## johnrsemt (Jan 14, 2013)

In my old area we could give Morphine up to 10mg, 5mg doses 5-10 minutes apart.  It only put one person to sleep.     In the ED only had one person stop breathing (allergic reaction)  and we bagged her till the Benadryl kicked in.
  Fentanyl we could give up to 200mcg:  100mch, 2nd and 3rd doses of 50mcg    it worked great.   I gave 100mcg to a patient with a pressure of 70/30 with HR of 150.  Her blood pressure went up when her heart rate dropped to 80 when the pain went away.

   Pain management is something (sometimes the only thing) that we can do pre hospital;  I hate it when some medical directors won't let us do it.

Here we are supposed to start with 2mg Morphine  titrated to pain to a max of 10mg;  Fentanyl we start with 50mcg.


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## HMartinho (Jan 16, 2013)

I think in nowadays there is a big "Hypochondriasis" about morphine and opioids. At least I see what happens in Portugal, where patients screaming in pain, receiving intravenous paracetamol/acetaminophen (1 g diluted in 10 ml saline, perfused within 15 to 30 minutes), instead of morphine, tramadol, fentanyl, and so on. Which, obviously, is a joke, and a true "insult" to the patient with severe pain.


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## BigLouie2314 (Jan 19, 2013)

Coming from a major east coast burn center...Morphine, Morphine, Morphine. And i laugh at anyone who says anything less than 15mg doses.

If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered. 

If the pt has facial and/or airway burns, first priority before any pain management should of course be intubation. RSI the pt, then worry about pain management. Burns are one of the most painful injuries a person can have. Good practice would be to use fentanyl during your RSI process (also be wary of thier blood pressure and the use of versed in these pt's. They also may be hyperkalemic or burns greater than 24hrs which would be a contraindication to the use of Succinylcholine in RSI. I go with Vecuronium as a standard.) and then once the pt is successfully intubated, give morphine. 

As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)

One thing to remember with burns, and I learned this from our Burn ICU surgeons, is that burns are extremly painful and there never is enough pain management for them.


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## Veneficus (Jan 20, 2013)

BigLouie2314 said:


> If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.



Why something short acting like fent?



BigLouie2314 said:


> As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)



What made you pick 15mg?


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## usalsfyre (Jan 20, 2013)

BigLouie2314 said:


> Coming from a major east coast burn center...Morphine, Morphine, Morphine. And i laugh at anyone who says anything less than 15mg doses.


And if 10 seems to work? I agree, 15 is an odd number...



BigLouie2314 said:


> If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.


It's interesting you choose a near anesthetic dose of fent for unintubated patients but for intubated patients you you mention a dose of morphine that didn't even raise my eyebrows. 



BigLouie2314 said:


> If the pt has facial and/or airway burns, first priority before any pain management should of course be intubation.


The majority of patients with simple facial burns don't require intubation. In fact, very, very few do. 



BigLouie2314 said:


> RSI the pt, then worry about pain management.


Unless of course your patient is so agitated from pain you literally can't do anything till pain management on board. My standard approach for major burns in the past has involved a good bit of fent IN right off the bat. Take care of one of there patients and you might see why. 



BigLouie2314 said:


> Burns are one of the most painful injuries a person can have. Good practice would be to use fentanyl during your RSI process


Diprivan or ketamine would be a far better choice.



BigLouie2314 said:


> (also be wary of thier blood pressure and the use of versed in these pt's.


Why? The fluid shift in burns happens way later. That's why the Parkland formula is for 24 hours. Without concurrent trauma hypotension is not something I'd even think about...in fact they're probably going to be pretty hypertensive.



BigLouie2314 said:


> They also may be hyperkalemic or burns greater than 24hrs which would be a contraindication to the use of Succinylcholine in RSI. I go with Vecuronium as a standard.)


Why? While I like roccuronium a lot more than sux this isn't a situation I'd shy away from it. Again, the hyperkalemia issue comes along later. Do you understand the electrolyte shift and the hows/whys if it? And if their facial burns are >24hrs old, why the hades am I RSI'ing them? It's a pretty good bet the airway is not an issue at that point. 



BigLouie2314 said:


> and then once the pt is successfully intubated, give morphine.


Or start a diprivan or fent/versed drip so they're knocked out enough they don't remember this ordeal.



BigLouie2314 said:


> As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)


Again, why 15mgs. Odd dosing. If your transporting a lot of burn patients why not push for Diluadid?


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## mogleyisme (Jan 20, 2013)

This is going to sound dumb, but I don't think it was mentioned at all. Did he check BP before administration, haha.

In Florida, Orange County, we can give morphine to burn patients as long as it's indicated.


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## usalsfyre (Jan 20, 2013)

mogleyisme said:


> In Florida, Orange County, we can give morphine to burn patients as long as it's indicated.


When the flaming fornication is it NOT indicated for burns?!?!?

Are you sure you didn't mean contraindicated (and the contraindications get pretty relative quite honestly)


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## mogleyisme (Jan 20, 2013)

usalsfyre said:


> When the flaming fornication is it NOT indicated for burns?!?!?
> 
> Are you sure you didn't mean contraindicated (and the contraindications get pretty relative quite honestly)



Can't think of any reason why not


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## Veneficus (Jan 20, 2013)

usalsfyre said:


> Again, why 15mgs. Odd dosing. If your transporting a lot of burn patients why not push for Diluadid?



I asked because I have seen morphine packaged in 15mg/1ml vials. They look like the regular vials only instead of an orange cap they have a lime green one. (Brighter than the versed caps.)


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## Melclin (Jan 21, 2013)

NYMedic828 said:


> I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?
> 
> 
> 
> ...


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## CarlHoma (Jan 26, 2013)

I attended a burn care program given by Dr. Daniel Lozano from Lehigh Valley Hospital in Allentown, PA a few weeks ago and he was against administering morphine because of the histamine release it is thought the cause.  According to  Dr. Lozano they do not administer morphine at all in their burn center.  Instead I believe they use dilaudid with fentanyl for breakthrough pain.  

With that said ... sounds like the registry proctor was a little full of himself.  I do not believe that administering morphine to a trauma patient is a critical fail unless the proctor is considering it "Uses or orders a dangerous or inappropriate intervention"  (nremt.org/nremt/downloads/P301%20NREMT.pdf[/).  In that case the proctor may want to visit a proctologist for cranial impaction.

Just my humble opinion ... I could be wrong.
Carl


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## jacob6493 (Jan 28, 2013)

NYMedic828 said:


> I believe it was facial burns and the patient is in severe pain, stating such. Don't think intubation came into question but I wasn't there.
> 
> Outside of improper protocol, I don't see whats wrong with treating the patients pain.
> 
> ...



In response to treating patient's pain, here in PA we are free to go on burns anywhere with as long as airway has been managed, including possible early intubation, and the patient is negative for normal pain med contraindications. We have Fentanyl, MS and Nitrous.

As for the scenario some else may have mentioned this but I believe the airway/intubation could be a potential critique point. You know the rule, BLS before ALS.


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## usalsfyre (Jan 28, 2013)

jacob6493 said:


> You know the rule, BLS before ALS.


You would do well to strike that phrase from your vocabulary.


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## seamedic (Jan 30, 2013)

Just had a case on our boat where a crew member got splashed with caustic soda. 1st,2ed and 3rd burns to his face, rt side of his skull, just about all of his rt arm up to his armpit and back. When I talked with our Doc's about px control, they advised to give Vicodin. I could not believe it, but my pt said he did not need anything for px. One tough fishermen.


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## Carlos Danger (Jan 30, 2013)

BigLouie2314 said:


> If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.



7-8 mcg/kg? Is that a typo? 

I agree that fentanyl is a better drug for prehospital use. Faster onset, more stable hemodynamic profile, more consistent dose-dependent effects, more titratable. Just better all the way around.

An excellent combo in burn patients is 100mcg of fent, 12-25mg of promethazine, and 1-2mg of versed. This gives an excellent synergistic effect and in an average sized patient you'll almost always get decent analgesia and anxiolysis for a 20-30 minutes or so.

As for the OP's question, it is the histamine release they are afraid of. At least that's the rationale that I've heard before.


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## Melclin (Jan 31, 2013)

jacob6493 said:


> and the patient is negative for normal pain med contraindications.



What do you and/or your system consider to be "normal pain med contraindications"? I can't think of anything in particular that would be 'normal'.


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## Veneficus (Jan 31, 2013)

Melclin said:


> What do you and/or your system consider to be "normal pain med contraindications"? I can't think of anything in particular that would be 'normal'.



If I had to guess, profound hypotension.

However, most often easily remedied with fluid infusion.


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## Handsome Robb (Jan 31, 2013)

jacob6493 said:


> You know the rule, BLS before ALS.



Dumb rule.

That's like "treat the patient not the monitor". 

Do what's in your best interest for your patient. 

A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now. Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS".  Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra. 

Facial burns =/= airway burns, despite what your EMT/Paramedic text tells you. Also, soot/burns in the nares doesn't always indicate airway involvement requiring intubation either. 

6-7 mcg/kg of fent sounds like a lot, but honestly on the one and only burn patient I've had I wish I could have gotten up that high for my max dosing. 300 didn't touch the poor fella. That's getting up into the dosing where you'd need to be worried about intercostal rigidity though. I know it can happen with smaller doses as well but it's generally associated with high dose, rapid IVP. That plus circumferential burns to the torso would make for a fantastically fun patient to attempt to ventilate in the prehospital field, especially with a BLS airway... 

I agree with better options for an induction agent than fentanyl but I can't really speak further on that seeing as we don't RSI. Never have done it, tubed plenty of dead people, a few near-dead ones, but never sedated, paralyzed and intubated a live one outside of OR rotations during school.  I will say ketamine is potentially wandering its way into our pain/sedation management protocol in the near future. Doubt we will ever have diprivan as an option but who knows.


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## Veneficus (Jan 31, 2013)

Robb said:


> A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now. Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS".  Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra.



You forgot: "If they live at all, and with what level of deficit" even if they do make it out of the hospital after a prolonged stay.

(just trying to help)


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## KellyBracket (Jan 31, 2013)

Just gave 25 of morphine to someone with facial burns last night. 

Haven't heard officially, but I think I passed.


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## Veneficus (Jan 31, 2013)

KellyBracket said:


> Just gave 25 of morphine to someone with facial burns last night.
> 
> Haven't heard officially, but I think I passed.



I don't think it counts if you do it after you already passed.


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## Carlos Danger (Jan 31, 2013)

Robb said:


> Dumb rule.
> 
> A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now.



It's not a dumb rule at all. 

BLS maneuvers are not "shenanigans". BLS procedures are indicated far more often than ALS procedures. And BLS procedures are always the rescue when ALS procedures fail. I remember seeing a study a while back that said that ALS procedures positively impacted patient outcomes something like 2% or 3% of the time, and most of those were cases of severe pediatric asthma, where early epi, magnesium, and continuous nebs can be truly life-saving. That's pretty much inline with my experience, I'd say.

"BLS before ALS" doesn't mean that you forgo ALS procedures where they are indicated. It means that you don't expose the patient to a risky ALS  procedure when BLS maneuvers work just fine, and you don't rush an ALS procedure because you are too impatient to do BLS.

In the realm of airway management, BLS before ALS means that you never paralyze someone that you don't think you can mask ventilate. It also means that when you start having trouble intubating, the very first thing you should do is revert to "BLS" BVM ventilation. 

Paramedics kill patients all the time by not adhering to this rule. And it is honestly one of the main reasons why many higher-level clinicians think poorly of paramedics.



Robb said:


> Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS".  Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. _Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra. _



Huh? 

Why would a patient who was cric'd rather than ETI'd need to spend "a lot longer" in the hospital and rehab facility?  

You do realize that any patient who requires intubation for airway burns is pretty much guaranteed to end up trached anyway?



Robb said:


> Facial burns =/= airway burns, despite what your EMT/Paramedic text tells you.



I think your approach is backwards, quite frankly.

First of all, it is not true that just because someone's face is burned, their airway is going to close off in a few minutes. Airway burns are actually quite rare, even in severe facial burns. 

There may be risks in waiting, but there is also risks involved in prehospital RSI. I do not think prehospital RSI should be done "electively".....it should only be done when a truly pressing need for intubation exists.

I think if the likelihood of airway burns seems high (close proximity to flame in enclosed spaces, steam burns, hoarseness), then early intubation is probably indicated.

But if none of those indicators exists, then the likelihood of airway burns is small and the risk of RSI probably significantly outweighs the risk of waiting. 

In the worst-case scenario, a cric is a perfectly appropriate option and should have zero impact on their long-term clinical course. 



Robb said:


> 6-7 mcg/kg of fent sounds like a lot, but honestly on the one and only burn patient I've had I wish I could have gotten up that high for my max dosing. 300 didn't touch the poor fella. That's getting up into the dosing where you'd need to be worried about intercostal rigidity though.



Adding a small dose of a benzo (1-2 mg of versed is best, if you have it) will significantly potentiate fentanyl and make these patients a lot more comfortable. Promethazine or droperidol are helpful as well, if you have them.

Intercostal rigidity is, frankly, not really worth worrying about. It is very rare, and usually not life-threatening when it does happen. If it does compromise ventilation, titrated doses of nalaxone are usually effective at reversing it. I would never withhold fentanyl for fear of rigidity.  

And 6-7 mcg/kg of fent IS a lot, not matter how you look at it. I'm not saying a dose that high is never required, but it is a lot of drug, especially in a heavier patient.




Robb said:


> I agree with better options for an induction agent than fentanyl but I can't really speak further on that seeing as we don't RSI. Never have done it
> 
> I will say ketamine is potentially wandering its way into our pain/sedation management protocol in the near future.
> 
> Doubt we will ever have diprivan as an option but who knows.



Fentanyl is not an induction agent. It can be used as an adjunct but the only time I've ever heard of it used as the primary agent is in neonates. It is rarely if ever used alone in adults. 

Ketamine is a good drug. Hopefully it continues to gain in popularity in EMS.

I doubt you'll ever see propofol either. It is not appropriate for prehospital use, IMO. Without a lot of experience with it, it's just too easy to bottom out BP, and that can be devastating in TBI patients, which is that vast majority of RSI's done prehospital. I just don't see a need for that risk when there are other induction agents that have much safer hemodynamic profiles (etomidate, ketamine). ED docs aren't even allowed to use propofol for induction in many facilities.


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## Veneficus (Jan 31, 2013)

old school said:


> Adding a small dose of a benzo (1-2 mg of versed is best, if you have it) will significantly potentiate fentanyl and make these patients a lot more comfortable. Promethazine or droperidol are helpful as well, if you have them.



In my experience, 1-2mg of versed is too low of a dose, even when trying to synergize opioids. 

I have also used a midazolam/fent/promethazine cocktail, and even then you are looking at 5+ of versed and 25-50mg of promethazine (IV) in addition to whatever opioid gets you significant reduction.



old school said:


> And 6-7 mcg/kg of fent IS a lot, not matter how you look at it. I'm not saying a dose that high is never required, but it is a lot of drug, especially in a heavier patient..



I am not sure fent isthe best choice for burns anyway, comparitively to morphine, it is short acting.



old school said:


> Ketamine is a good drug. Hopefully it continues to gain in popularity in EMS.



Since it is argubly the best for a hemodynamically unstable patient, i am not really sure what the resistance to it is. 



old school said:


> I doubt you'll ever see propofol either. It is not appropriate for prehospital use, IMO. Without a lot of experience with it, it's just too easy to bottom out BP, and that can be devastating in TBI patients, which is that vast majority of RSI's done prehospital. I just don't see a need for that risk when there are other induction agents that have much safer hemodynamic profiles (etomidate, ketamine). ED docs aren't even allowed to use propofol for induction in many facilities.



I am always interested when people claim tha etomidate is better for hemodynamic profiles. The "safety" seems exaggerated compared to what it is. 

Ketamine is still the only agent that is considered hemodynamically safe in anesthesia.

In any event, slow titration, along with increased fluid as needed, I think is still a reasonable strategy no matter what agent you are using.

The fact that facilities restrict ED docs does not sound  like a reflection of their ability to use it. It sounds more political to me. It is even difficult to argue for safety, because not giving a medication is always "safer" than using one. That doesn't lessen the indication or usefulness though.

P.S. I have not heard of a rash of paramedic assisted death as of late either. The "paramedics kill people all the time" assertation is a little over the top.


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## Carlos Danger (Jan 31, 2013)

Veneficus said:


> In my experience, 1-2mg of versed is too low of a dose, even when trying to synergize opioids.
> 
> I have also used a midazolam/fent/promethazine cocktail, and even then you are looking at 5+ of versed and 25-50mg of promethazine (IV) in addition to whatever opioid gets you significant reduction.



5mg isn't a bad dose either for most patients, but that's about the most I would use if I'm just trying to potentiate fentanyl. It's generally considered that opiate potentiation in a patient with a lot of pain who you want to keep spontaneously breathing requires a very small dose of versed. If they are still in pain after that, then they need more opiate, not more benzo. 



Veneficus said:


> I am not sure fent isthe best choice for burns anyway, comparitively to morphine, it is short acting.



Fent is much better IMO because of it's rapid onset and more predictable effects. It is much more lipid soluble than morphine, so it crosses the BBB quicker and more reliably. IV fent reaches peak effect in 5-10 min, compared to 25-30 min for IV morphine. Also, it doesn't cause histamine release, which can negatively effect hemodynamics and also contribute to more uneven absorption into the CNS. It's shorter duration of action (30-45 min compared to 3 hours for morphine) contributes to it's safety profile.

It's just easier to titrate and safer to give larger doses of than morphine.



Veneficus said:


> Since it [ketamine] is argubly the best for a hemodynamically unstable patient, i am not really sure what the resistance to it is.



I think the resistance is primarily due to many ED docs just not being familiar with it. Even though it's been around since the 60's, my understanding is that it basically wasn't used at all for several decades. It has gained in popularity recently, but it's effectively a brand new drug for familiarity purposes. And I think to many docs it's kind of looked as being "one of those weird anesthesia drugs".

Ketamine does have some drawbacks compared to etomidate. It increases ICP, which is bad considering that most prehospital RSI's are done on TBI patients. It also reduces coronary blood flow and increases Mv02, so it's not safe to use in someone with severe CAD. 



Veneficus said:


> I am always interested when people claim tha etomidate is better for hemodynamic profiles. The "safety" seems exaggerated compared to what it is.





Veneficus said:


> Ketamine is still the only agent that is considered hemodynamically safe in anesthesia.



Have you ever done inductions with propofol? Why do you think ketamine is hemodynamically safer that etomidate?

Ketamine generally isn't really used much as an induction agent in anesthesia. It can be, but when it is used that way, it's usually for a specific reason, such as being used in conjunction with propofol for a total IV anesthesia technique. Or for it's analgesic properties in a patient who you don't want to give a lot of opiates to. 

You can probably argue that on a non-cardiac patient, ketamine and etomidate are equally safe. But etomidate is definitely more hemodynamically stable than either propofol or ketamine, which makes it the best drug to use in a patient population that can include both TBI patients with ICP concerns, and hypotensive trauma patients.

Ketamine causes a centrally-mediated SNS stimulation that causes increases in BP and HR, whereas propofol decreases both BP and HR. 

Etomidate, on the other hand, neither decreases nor increases BP or HR. 

This is from *Clinical Anesthesia by Barash*:
_"Consequently, etomidate is considered to be the induction agent of choice for poor-risk patients with cardiorespiratory compromise as well as in those situations in which maintenance of normal blood pressure is crucial (e.g. cerebrovascular disease)"._

This from *Miller's Anesthesia*:
_The minimal effect of etomidate on cardiovascular function sets it apart from other rapid-onset anesthetics. An induction dose of 0.3 mg/kg of etomidate given to cardiac patients for noncardiac surgery results in almost no change in heart rate, MAP, mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, stroke volume, cardiac index, and pulmonary and systemic vascular resistance. A large dose of etomidate, 0.45 mg/kg (which is 50% larger than a normal induction dose), also produces minimal changes in cardiovascular variables._




Veneficus said:


> In any event, slow titration, along with increased fluid as needed, I think is still a reasonable strategy no matter what agent you are using.



The thing is, we shouldn't be slowly titrating anything in an RSI. RSI needs to be a simple, rapid procedure where the meds are given quickly and have little effect on hemodynamics. 

Also, if you have a patient with increased ICP due to a TBI and you drop their BP significantly, you just increased their likelihood of mortality by 50%. Ditto if their SBP is already is already in the 70's and you drop it into the 40's because you pushed the prop a little fast.  



Veneficus said:


> The fact that facilities restrict ED docs does not sound like a reflection of their ability to use it. It sounds more political to me. It is even difficult to argue for safety, because not giving a medication is always "safer" than using one. That doesn't lessen the indication or usefulness though.



But it's not a case of it being "safer to not give a medication", because there are other drugs which work just as well for RSI, and are safer and easier to use.

Propofol takes practice to learn to use safely. It's not rocket science, but until you've done lots of inductions with it on healthy people, you just aren't going to be good at using it. And until you are good at using it on healthy patients, you certainly have no business using it on really sick people who are much more susceptible to the negative effects that it can produce. 

There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?


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## Veneficus (Jan 31, 2013)

old school said:


> 5mg isn't a bad dose either for most patients, but that's about the most I would use if I'm just trying to potentiate fentanyl. It's generally considered that opiate potentiation in a patient with a lot of pain who you want to keep spontaneously breathing requires a very small dose of versed. If they are still in pain after that, then they need more opiate, not more benzo.



I have not used it to try and potentiate fent, mostly in conscious sedation (probably boardering on TIVA in some instances) and post op pain management where the goal was to try and keep the patient sedated.  



old school said:


> Fent is much better IMO because of it's rapid onset and more predictable effects. It is much more lipid soluble than morphine, so it crosses the BBB quicker and more reliably. IV fent reaches peak effect in 5-10 min, compared to 25-30 min for IV morphine. Also, it doesn't cause histamine release, which can negatively effect hemodynamics and also contribute to more uneven absorption into the CNS. It's shorter duration of action (30-45 min compared to 3 hours for morphine) contributes to it's safety profile.



I probably give preference to morphine because I am very familiar with it. I find it very predictable. I also like it more because of its longer effect. 



old school said:


> It's just easier to titrate and safer to give larger doses of than morphine.



What would you consider a large dose?



old school said:


> I think the resistance is primarily due to many ED docs just not being familiar with it. Even though it's been around since the 60's, my understanding is that it basically wasn't used at all for several decades. It has gained in popularity recently, but it's effectively a brand new drug for familiarity purposes. And I think to many docs it's kind of looked as being "one of those weird anesthesia drugs"..



That is interesting.



old school said:


> Ketamine does have some drawbacks compared to etomidate. It increases ICP, which is bad considering that most prehospital RSI's are done on TBI patients.



To my understanding this was demonstrated to be transient and that ketamine may be more beneficial in the long term.



old school said:


> 1.Have you ever done inductions with propofol? 2.Why do you think ketamine is hemodynamically safer that etomidate?



1. In theatre
2. No small part becase I was taught that way. There has been a lot of publicity on how safe etomidate is, but many providers I know have had negative outcomes with it and strongly caution against thinking it is a "safe drug."

Peds anesthesia here uses ketamine a lot and I have neither seen nor heard of any adverse reaction.

I think the CAD caution you mentioned earlier is not really suited to the trauma and emergency population as a whole. Obviously a gereatric patient might be differnet.



old school said:


> Ketamine generally isn't really used much as an induction agent in anesthesia. It can be, but when it is used that way, it's usually for a specific reason, such as being used in conjunction with propofol for a total IV anesthesia technique. Or for it's analgesic properties in a patient who you don't want to give a lot of opiates to.



A very agreeable statement.



old school said:


> You can probably argue that on a non-cardiac patient, ketamine and etomidate are equally safe. But etomidate is definitely more hemodynamically stable than either propofol or ketamine, which makes it the best drug to use in a patient population that can include both TBI patients with ICP concerns, and hypotensive trauma patients.



That is my argument. Along with the above mentioned ICP data with ketamine.



old school said:


> This is from *Clinical Anesthesia by Barash*:
> _"Consequently, etomidate is considered to be the induction agent of choice for poor-risk patients with cardiorespiratory compromise as well as in those situations in which maintenance of normal blood pressure is crucial (e.g. cerebrovascular disease)"._
> 
> This from *Miller's Anesthesia*:
> _The minimal effect of etomidate on cardiovascular function sets it apart from other rapid-onset anesthetics. An induction dose of 0.3 mg/kg of etomidate given to cardiac patients for noncardiac surgery results in almost no change in heart rate, MAP, mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, stroke volume, cardiac index, and pulmonary and systemic vascular resistance. A large dose of etomidate, 0.45 mg/kg (which is 50% larger than a normal induction dose), also produces minimal changes in cardiovascular variables._



That is not the only entry in Miller's about etomidate, in the 7th edition there are entries that also issue the same cautions of etomidate that I raised. 



old school said:


> Also, if you have a patient with increased ICP due to a TBI and you drop their BP significantly, you just increased their likelihood of mortality by 50%. Ditto if their SBP is already is already in the 70's and you drop it into the 40's because you pushed the prop a little fast.



I agree, but I would argue it comes down to familiarity, I have never been witness to neurosurg anesthesia in 2 hospitals use anything but propofol and fent.   



old school said:


> But it's not a case of it being "safer to not give a medication", because there are other drugs which work just as well for RSI, and are safer and easier to use..



I see your point, but I argue that the drug you are familiar with is the safer and easier to use.



old school said:


> There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?



Despite my distaste for emergency medicine, I think they are capable people at what they do and can be taught to use any tool safely and efficently. Most of the patients I have seen them RSI in the sates are not hemodynamically unstable. The few that I have seen here in Europe, it is done by anesthesia anyway, and usually the decision on what is used is individual. I have seen anesthesia use propofol to RSI an unstable trauma (who was taken right to theatre from the ED) and without ill effect. 

I have noticed a very wide variety in anesthesia practice around the world.


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## Dwindlin (Jan 31, 2013)

old school said:


> There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?



Yes they do.  Also, most hate being called "MDA's", they are Anesthesiologists.


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## VFlutter (Jan 31, 2013)

Dwindlin said:


> Yes they do.  Also, most hate being called "MDA's", they are Anesthesiologists.



Agree on both points especially the last, many consider it degrading or disrespectful.


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## Dwindlin (Jan 31, 2013)

Veneficus said:


> That is not the only entry in Miller's about etomidate, in the 7th edition there are entries that also issue the same cautions of etomidate that I raised.



In his defense that is straight out of the 7th edition.  Etomidate is pretty darn hemodynamically stable, about the only group of people it isn't stable in is severe valvular disease.

Having said that, it's not what I would choose first for RSI/sedation.


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## Carlos Danger (Jan 31, 2013)

Veneficus said:


> I have not used it to try and potentiate fent, mostly in conscious sedation (probably boardering on TIVA in some instances) and post op pain management where the goal was to try and keep the patient sedated.


I used to work as a flight nurse for a program that was contracted with a burn center to transport their accepted patients to them. These were usually very fresh injuries and the transports often involved several hours outside of the hospital, so I learned a lot about early burn management and I got pretty good at keeping them comfortable.

One of the most interesting things I learned was how to use small doses of benzos to potentiate opiates. If you are already giving decent amounts of opiates, it doesn't take much midazolam to really make the patient a lot more comfortable. Anti-emetics help as well.

If the patient was ventilated, I would usually use a fentanyl infusion along with the versed or propofol infusion. If the patient was not ventilated, I would give a few mg of versed and an antiemetic up front, then boluses of fentanyl every 20 minutes or so. 

If the patient had already received an adequate dose of a long acting opiate (hydromorphone or morphine), then I would use morphine if they required further analgesia. Which they always did, because a dose of analgesia that is adequate to keep a patient comfortable in a hospital bed is often not adequate to keep them comfortable during transport. 



Veneficus said:


> I probably give preference to morphine because I am very familiar with it. I find it very predictable. I also like it more because of its longer effect.
> 
> What would you consider a large dose?



I agree that familiarity is a lot of it.

For prehospital transports that are usually around 30 minutes or less, typical doses of fentanyl might be 200 or 300 mcg in divided doses. 

As you know, the equivalent dose of morphine is roughly 20-30 mg.

In my experience, 200-300mcg of fentanyl is more reliable and has less side effects than 20-30 of morphine, plus a faster onset. But again, it probably comes down mostly to what you are most familiar with.




Veneficus said:


> I think the CAD caution you mentioned earlier is not really suited to the trauma and emergency population as a whole. Obviously a gereatric patient might be differnet.


If I were the medical director of an EMS agency, my paramedics would have ketamine available. Though for RSI, I would rather they use etomidate in most cases, especially in cases of increased ICP or in cardiac patients. 




Veneficus said:


> Despite my distaste for emergency medicine, I think they are capable people at what they do and can be taught to use any tool safely and efficently. Most of the patients I have seen them RSI in the sates are not hemodynamically unstable. The few that I have seen here in Europe, it is done by anesthesia anyway, and usually the decision on what is used is individual. I have seen anesthesia use propofol to RSI an unstable trauma (who was taken right to theatre from the ED) and without ill effect.



I don't doubt that most ED MD's can learn to safely use propofol, and I'm not personally against it. But at the same time, I just don't see a need when there are other meds available that don't take experience to learn to use. I don't think most ED docs get much experience using propofol during their training, and it does take some practice to learn to use it safely.


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## Carlos Danger (Jan 31, 2013)

Dwindlin said:


> Yes they do.  Also, most hate being called "MDA's", they are Anesthesiologists.



Oh well. I don't particularly like being called an "ambulance driver", but I know that no disrespect is meant, so I don't take any.

Funny, you never hear gastroenterologists complain about being called "GI docs" or orthopedic surgeons complain about being called "orthopods", or emergency medicine physicians complain about being called "ER docs".

"Anesthesiologist" doesn't exactly roll of the tongue....or the keyboard.


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## Dwindlin (Jan 31, 2013)

old school said:


> Oh well. I don't particularly like being called an "ambulance driver", but I know that no disrespect is meant, so I don't take any.
> 
> Funny, you never hear gastroenterologists complain about being called "GI docs" or orthopedic surgeons complain about being called "orthopods", or emergency medicine physicians complain about being called "ER docs".
> 
> "Anesthesiologist" doesn't exactly roll of the tongue....or the keyboard.



But it is disrespectful, whether that is the intent or not.

Yes, actually there are many physicians out there who dislike being referred to by those nicknames.  How often do people outside of your social/professional circles hear you say you don't like being called "ambulance driver"?  My guess is not too many, same thing applies to doctors.


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## Jeremy89 (Jan 31, 2013)

Anyway, enough semantics about titles and names...

With regards to the OP's question-  I haven't seen anyone bring up Narcan. Most agencies I know of are required to carry it if the have the capability to give narcs.  Of course, that's going with the whole 'dosage causing sedation' theory. Sure, I understand if you begin to lose their airway it'll reverse the opioid effect, but that won't do anything for the histamine release. But if that's really the major concern of these MD's, why couldn't they add Benadryl to the protocol, with morphine for burns?  I dunno, just a thought..


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## Carlos Danger (Jan 31, 2013)

Dwindlin said:


> But it is disrespectful, whether that is the intent or not.
> 
> Yes, actually there are many physicians out there who dislike being referred to by those nicknames.  How often do people outside of your social/professional circles hear you say you don't like being called "ambulance driver"?  My guess is not too many, same thing applies to doctors.



Hmm. Interesting stuff.


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## Veneficus (Jan 31, 2013)

Jeremy89 said:


> Anyway, enough semantics about titles and names...
> 
> With regards to the OP's question-  I haven't seen anyone bring up Narcan. Most agencies I know of are required to carry it if the have the capability to give narcs.  Of course, that's going with the whole 'dosage causing sedation' theory. Sure, I understand if you begin to lose their airway it'll reverse the opioid effect, but that won't do anything for the histamine release. But if that's really the major concern of these MD's, why couldn't they add Benadryl to the protocol, with morphine for burns?  I dunno, just a thought..



I would offer against thinking of using narcan as a solution to sedation and depression in patients with severe pain.

Using the example of another wound, but equally applicable in burns, in order to control pain, you must control both nociceptive and neurologic pain (remembered pain) which is pain anticipated. The fundamental reason for adding sedation to opioid management.

Acute reversal of both anesthesia and the lesser form, analgesia, increases both pain and awareness of pain, even if the person is not concious. This is easily learned and demonstrated with both clinical signs and vital sign changes during anesthesia in surgery, and equally applicable to prehospital analgesia. 

Basically your patient is depressed, unable to communicate with you, but can still be in considerable pain. 

If a surgeon cut you open and then immediately anesthesia was reversed, it would hurt like hell. For the duration of the reversal, no pain management would be adequete. 

Why would you do that to somebody?

(one of the reasons I like morphine over fent is because it more gradually loses effect over time) 

I would also point out that people can be in such pain that analgesia itself is no longer effective. In that case, depressing their respiratory drive and taking control of their respirations may be the only way to allow enough dosage for pain management.

Severe pain creates pathology. So in the critically ill, reducing pathology needs to be a goal. Prehospital may not have definitive treatment of underlying pathology but it does possess treatment to mitigate deletorious effects of pain. Even when that means anesthesia from large dose opioids or the now antiquated sedation facilitated intubation.

Specifically addressing the anaphylactoid reaction of various opioids, the question becomes, why would you want to? Part of the physiologic response of anesthesia is to reduction of cardiac output and BP. Decrease in these vital signs is a sign effectiveness. 

Managing this response is the other side of the coin of providing pain relief. 

Now it may be said that in prehospital, anesthesia is not done, only analgesia. But I do not think that fits the definition or the reality. 

Anesthesia is making sure the patient cannot feel pain, does not react to pain, and does not remember pain. 

While it is not as profound as general anesthesia, the goal of analgesia is the same. Which really makes the semantics of it how much treatment is required, not the type of treatment provided.

Afterall, if you had a ped who fractured a bone, moderate sedation is an indicated treatment prior to ortho consult. 

Wouldn't your goal be to make sure the child did not feel the pain or react to it? Do we not add benzos for their amnestic effect so the child does not remember or anticipate pain? (Do you remember anticipating the hurt of going to the doctor when you were younger because of your experience getting an injection for vaccination or other uncomfortable treatment of dx? Didyou want to go back to the doctor? Did you anticipate pain from the procedures?)

I should at least mention that the mechanism of histamine release caused by opioids such as morphine is slighly different than that of an allergic reaction at the molecular level. It is also dose dependant unlike a "standard" allergy attack.

Diphenhydramine is a first generation H1 blocker. Just like promethazine. The former is less sedative than the later, but still so. Adding benadryl may reduce vasodilation, but it will also deepen sedation. Epi would work directly against sedation, which would negate analgesia and require even higher doses.  

One of my anesthesia mentors likes to be as simple as possible and use as few agents as possible on any given patient. Consequently he uses propofol almost exclusively and adjusts the dose and fluid therapy to his liking. 

I am more fond of cocktails because of the philosophy of managig both types of pain while limiting the amount of agent used. That is the reason behind neuromuscular blockers. Otherwise, we could just use high-dose opioids for induction and anesthesia. Some services opposed to giving their medics neuromuscular blocks, still have high dose benzo admin to knock the patient down to the point of intubation. Which I think is foolish because it does the same thing in a less optimal and less safe way.

But for all of this, you really do not want to start playing mad scientist and mixing anymore chemicals than is required in the critically ill. It is a giant balancing game, and everything you add has to be balanced. The more you have to balance, the less likely you will succeed. 

Depressing a patient in severe pain is not a fail, it may be what you need.


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## Carlos Danger (Jan 31, 2013)

Veneficus said:


> (one of the reasons I like morphine over fent is because it more gradually loses effect over time)



This is a really good point, which I don't think I've ever considered.





Veneficus said:


> Some services opposed to giving their medics neuromuscular blocks, still have high dose benzo admin to knock the patient down to the point of intubation. Which I think is foolish because it does the same thing in a less optimal and less safe way.



The idea of disallowing NMB's (ostensibly because neuromuscular blockade "is dangerous"), yet allowing such high doses of sedatives that respiratory drive and airway reflexes are mitigated anyway - yet good intubating conditions are anything but assured - drives me absolutely insane. 

But that's a whole other topic for a whole other thread


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## Veneficus (Feb 1, 2013)

Just some things to add to the discussion

http://www.ncbi.nlm.nih.gov/pubmed/22094498

http://www.ncbi.nlm.nih.gov/pubmed/19573904

http://www.ncbi.nlm.nih.gov/pubmed/22965460

http://www.ncbi.nlm.nih.gov/pubmed/23118665

http://www.ncbi.nlm.nih.gov/pubmed/23114234

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461283/


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