# Pain Management + unresponsive patient



## BF2BC EMT (Jun 10, 2013)

Looking for some discussion and wondering....

Are there any systems that allow for pain management in a trauma patient who is unresponsive.

'You pull up, noted multiple fractures, and pt is unresponsive'


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## Akulahawk (Jun 10, 2013)

BF2BC EMT said:


> Looking for some discussion and wondering....
> 
> Are there any systems that allow for pain management in a trauma patient who is unresponsive.
> 
> 'You pull up, noted multiple fractures, and pt is unresponsive'


I'm assuming that you mean a patient that is completely unresponsive and you're wondering if there's any sort of preemptive pain management protocol to cover the pain that will be felt when they regain consciousness... and beginning said pain management while in the field?

Given that many times we're either not allowed to medicate for pain, or we're limited to (usually) isolated extremity Fx, I doubt that such a protocol exists in any widespread manner in the US. Prehospital pain management in the US is horrible, generally speaking, and has been for quite a long time.


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## chaz90 (Jun 10, 2013)

Patients that are unresponsive due to trauma have some bigger issues to fry than managing pain. If the altered mentation is caused by hypoperfusion of the brain secondary to hypervolemia, most pain management protocols don't want you dumping opioids on top of that hypotension. If it's a direct insult to the head causing swelling and an increased ICP, a brain that is not allowing consciousness probably isn't allowing pain to get through to any conscious center of the brain either. In injuries this bad, pain management comes after the patient is stabilized and conscious enough to recognize or remember pain.


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## DrankTheKoolaid (Jun 10, 2013)

The only time it is in protocols here in my secondary LEMSA is post intubation during transfer. And that would for both continued sedation and analgesia to allow ETT/vent tolerance. Taking into consideration whatever pathophysiological insult the patient has received


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## Akulahawk (Jun 10, 2013)

Then you throw in what chaz posted as to _why_ we don't do pain management in patients this bad... there's little actual reason (in the immediate sense) to begin doing pain management in the field for them. Besides, as chaz said, patients that are so bad off that they're unconscious/unresponsive after a traumatic incident probably have bigger problems going on that have to be managed first.


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## BF2BC EMT (Jun 10, 2013)

Akulahawk said:


> Then you throw in what chaz posted as to _why_ we don't do pain management in patients this bad... there's little actual reason (in the immediate sense) to begin doing pain management in the field for them. Besides, as chaz said, patients that are so bad off that they're unconscious/unresponsive after a traumatic incident probably have bigger problems going on that have to be managed first.



I see, thanks for the responses.

With what Chaz is saying, would pain management be withheld if the trauma patient, was responsive/unresponsive throughout the transport. Awake and screaming-out cold, awake and screaming....


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## NomadicMedic (Jun 10, 2013)

If he could talk to me and was screaming from the pain, he would get medicated. 

If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.


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## Medic Tim (Jun 10, 2013)

DEmedic said:


> If he could talk to me and was screaming from the pain, he would get medicated.
> 
> If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.



This


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## Akulahawk (Jun 10, 2013)

BF2BC EMT said:


> I see, thanks for the responses.
> 
> With what Chaz is saying, would pain management be withheld if the trauma patient, was responsive/unresponsive throughout the transport. Awake and screaming-out cold, awake and screaming....





DEmedic said:


> If he could talk to me and was screaming from the pain, he would get medicated.
> 
> If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.


And if you can't do RSI or any other form of facilitated intubation, you medicate while the patient is awake and screaming. Unfortunately, occasionally you won't be able to medicate because the patient's injuries don't match what your protocols authorize (or the amount won't touch the pain anyway) or your OLMC won't give you orders for it...:sad:


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## Melclin (Jun 11, 2013)

DEmedic said:


> If he could talk to me and was screaming from the pain, he would get medicated.
> 
> If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.



This.

I'll add that if the patient obvious pain producing injuries is not completely unconscious but too combative to manage, opiates rather than benzos are the go. Opiates until they shut up, and let you treat them, then.. generally...RSI.


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## BEMS906 (Jun 11, 2013)

If a trauma pt is unresponsive, hypovolemia, be it absolute or relative is right up there on my concern list. Any type of narcotic would be a risk in dumping the pts pressure even more. I don't know that the question makes a lot of sense.


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## Handsome Robb (Jun 11, 2013)

We can medicate altered patients after a traumatic injury, just have to be cautious doing it.

Like everyone else said there are bigger things to worry about if they're completely unresponsive and they'll get some when they get RSId


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## BEMS906 (Jun 11, 2013)

What are you guys using for RSI ?  Fentanyl and versed.? We use paralytics and sedatives .no analgesics


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## STXmedic (Jun 11, 2013)

BEMS906 said:


> What are you guys using for RSI ?  Fentanyl and versed.? We use paralytics and sedatives .no analgesics



Although it is not in many protocols, analgesics should indeed be used in conjunction with paralytics and sedatives (unless you're sedating with something like Ketamine, which also has analgesic properties).


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## BEMS906 (Jun 11, 2013)

Never knew that. We use succ. And etomodate


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## usalsfyre (Jun 11, 2013)

BEMS906 said:


> Never knew that. We use succ. And etomodate



Not horrible (very commonly done in the ED even) but you should really be following it up with opiates and benzos (unless your using ketamine or propofol for continued sedation) post-intubation. The procedure hurts, the tube in their glottis hurts, the two in combination work much better than benzos alone.

That said, it's much better than the 5mg of versed and brutane...


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## NomadicMedic (Jun 13, 2013)

The RSI/pain management thread has been moved here: http://www.emtlife.com/showthread.php?t=35931


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## jefftherealmccoy (Jun 17, 2013)

Melclin said:


> This.
> 
> I'll add that if the patient obvious pain producing injuries is not completely unconscious but too combative to manage, opiates rather than benzos are the go. Opiates until they shut up, and let you treat them, then.. generally...RSI.



Why do you say opiates rather than benzos?

Our protocols deny us use of opiates if pt has head trauma (all we got is morphine, unfortunatly).  What i've seen is if the pt is combative, it's normally because they've cracked their head pretty good on something.  I've also seen a pt become combative as he bled out (feeling of impending doom).  Both cases we've used Valium.



BEMS906 said:


> Never knew that. We use succ. And etomodate
> 
> .



we use the same, but after we get the tube we follow it up with Valium and Rocuronium.


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## Akulahawk (Jun 17, 2013)

jefftherealmccoy said:


> Why do you say opiates rather than benzos?
> 
> Our protocols deny us use of opiates if pt has head trauma (all we got is morphine, unfortunatly).  What i've seen is if the pt is combative, it's normally because they've cracked their head pretty good on something.  I've also seen a pt become combative as he bled out (feeling of impending doom).  Both cases we've used Valium.
> 
> ...


I'm going to make an educated guess why opiates instead of benzos... Opiates can have sedative effects and produces some level of analgesia where benzos have sedative effects but don't have analgesic properties. In other words, benzos can sedate but "it" still hurts. Opiates can make "it" not hurt as much while possibly helping with sedation so the patient doesn't care that it hurts either...

Down side with either is that it can be possible to dump the patient's BP with administration of either. 

That's probably the logic behind the statement. I could be completely wrong because I'm not Melclin, nor do I work in the same part of the world... (Standard disclaimer, you know.  )


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## jefftherealmccoy (Jun 17, 2013)

Akulahawk said:


> I'm going to make an educated guess why opiates instead of benzos... Opiates can have sedative effects and produces some level of analgesia where benzos have sedative effects but don't have analgesic properties. In other words, benzos can sedate but "it" still hurts. Opiates can make "it" not hurt as much while possibly helping with sedation so the patient doesn't care that it hurts either...
> 
> Down side with either is that it can be possible to dump the patient's BP with administration of either.
> 
> That's probably the logic behind the statement. I could be completely wrong because I'm not Melclin, nor do I work in the same part of the world... (Standard disclaimer, you know.  )



here's my question for you (or anyone else for that matter)

What would you with a combative trauma pt with low-ish bp that is combative?  Morphine or valium?


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## Akulahawk (Jun 18, 2013)

jefftherealmccoy said:


> here's my question for you (or anyone else for that matter)
> 
> What would you with a combative trauma pt with low-ish bp that is combative?  Morphine or valium?


I would see if I can find an underlying reason for the patient being combative and attempt to medicate for that instead of simply sedating because the patient is combative.

I wouldn't limit my choices to just those 2 agents, if I had any choice in the matter. In particular, I would expect that some of the agents that are already listed in this thread would be somewhat decent choices for use in that particular situation, that being attempting to control a combative patient with a low-ish blood pressure who is in severe pain.

If I had to limit my choices to morphine and/or Valium, I would possibly consider using Benadryl along with the morphine in an attempt to limit the hypotension that morphine can cause because it does result in a histamine release. I would then consider probably using some small amount of Valium, as it would be potentiated by the morphine and thus hopefully requiring only smaller amounts of it to provide the desired results without too much drop in blood pressure.

Otherwise, I would very much expect that there are better agents than those two that could be used to medicate a patient that is in great pain happens to be also combative. Of course your other ultimate option would be to RSI the patient… That, of course, has its own risks… Some very serious ones, and I would not consider performing at RSI on a patient simply because he or she is combative.


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## Carlos Danger (Jun 18, 2013)

jefftherealmccoy said:


> Why do you say opiates rather than benzos?



Because you want to treat the cause of the combativeness to the best of your ability. 

If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.

If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.



jefftherealmccoy said:


> here's my question for you (or anyone else for that matter)
> 
> What would you with a combative trauma pt with low-ish bp that is combative?  Morphine or valium?



What do you mean by "combative"? Trying to beat you with a d-tank and jump out of a moving ambulance, or just anxious and not as cooperative as you'd like?

Do you mean after intubation? Or as a sedative for acute delirium secondary to a head injury or hypoxia?

For the former, a benzo should always be chosen over an opiate for sedation, and valium would probably have less effect on BP anyway. You can give some valium and some IVF and then work in a some morphine once their BP is stabilized some.

For the latter scenario, both morphine and valium are poor choices because of their long onset and propensity for hypotension in large doses.  I would try to avoid either. If you absolutely had to give something because the patient was seriously endangering himself and others, I'd do probably 20  of diazepam IV or IM. The best drug for this scenario is probably ketamine. Etomidate works well, too. Something with some neuroleptic effects like haloperidol or promethazine mixed with some midazolam is an excellent combo to dart a combative patient. 



jefftherealmccoy said:


> protocols deny us use of opiates if pt has head trauma (all we got is morphine, unfortunatly).



It sounds like your protocols are in need of some serious updating. There is no reason to withold analgesia from a patient with head trauma. In fact, prior to RSI, fentanyl is a great pre-treatment. 

Also, there are much better drugs than morphine and valium for prehospital use. Fentanyl and midazolam both have faster onset and shorter duration, and fentanyl has fewer hemodynamic effects than morphine. Ketamine is great to have, as well.


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## Wheel (Jun 18, 2013)

Halothane said:


> Because you want to treat the cause of the combativeness to the best of your ability.
> 
> If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.
> 
> ...



This is true, but there are many uneducated providers running around scared of fentanyl. I rarely see it used in my service, despite a better side effect profile. Everyone considers it "the big guns," as if equivalent doses don't exist.


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## Carlos Danger (Jun 18, 2013)

Wheel said:


> This is true, but there are many uneducated providers running around scared of fentanyl. I rarely see it used in my service, despite a better side effect profile. Everyone considers it "the big guns," as if equivalent doses don't exist.



In a patient who is very stable and just in a lot of pain from an isolated extremity fracture or something like that, morphine is a good drug, especially when used in conjunction with non-opioids.

But in a sick patient with actual or potential hemodynamic compromise, I'm a lot more comfortable giving moderate to large doses of fentanyl than I am equivalent doses of morphine. Fentanyl can also be used as an adjunct in various ways that morphine cannot, or at least not as easily.

IMO, fentanyl is more useful, more predictable, easier to give, and for those reasons safer and more appropriate for prehospital use than morphine. Especially by those who don't necessarily know a lot about the drugs they are giving.


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## jwk (Jun 18, 2013)

No perception of pain = no pain management.  And if you have a comatose patient, there is also no need to treat them for "pain" simply because some protocol says you should because they have an ETT in place.


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## Trashtruck (Jun 18, 2013)

jwk said:


> No perception of pain = no pain management.  And if you have a comatose patient, there is also no need to treat them for "pain" simply because some protocol says you should because they have an ETT in place.



Perfectly stated.
Succinct with no jargon.


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## Akulahawk (Jun 19, 2013)

Halothane said:


> Because you want to treat the cause of the combativeness to the best of your ability.
> 
> If the patient is hypoxic, then the treatment is improvement of ventilation. If the patient is hypotensive, then the treatment is IVF or vasopressors. If the patient is in pain, then the treatment is analgesia. Benzos are not analgesics.
> 
> ...



This is actually closer to the answer that I wanted to give but didn't have a whole lot of time to write it. Morphine and Valium wouldn't be my first choice of drugs to use...because as you said, there are better drugs. It's too bad we never had access to them out here, and probably won't any time soon.


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## Melclin (Jun 19, 2013)

Can't a bloke have a beer without getting drawn into a conversation about sedating head injured patients? 



jefftherealmccoy said:


> here's my question for you (or anyone else for that matter)
> 
> What would you with a combative trauma pt with low-ish bp that is combative?  Morphine or valium?



My reasoning in regards to the opiates over benzos is, as others have correctly stated, that in general its a good idea to treat the actual problem rather than cover it up. 

The idea is that you're actually treating their pain rather than just sedating them beyond the point of being able to experience it. For a perfectly compliant patient with an isolated femur fracture, we don't sit there and give midaz until they are so unconscious that they are no longer capable of experiencing pain. That would be absurd and dangerous. We treat their pain directly, such that they can be sitting there talking to us but still be relatively comfortable. This means they get relatively less of the drug in question which hopefully equals less of an affect on conscious state, haemodynamics etc. Why should it be significantly different for a pt who also has a head injury. I would argue that it is more important for a patient with a head injury given the deleterious affects of hypotension, hypoventilation & hypoxia. 

I would argue because it is more likely to actually treat the cause (or part there of) of their agitation and because we really can't say for sure that their head injury makes them incapable of experiencing pain, that the lower doses involved, relatively speaking, make this both a safer and more humane way of treating these patients. A much better way to effectively sedate to facilitate assessment/treatment/pre-oxygenation for RSI. 

I have applied, and seen others apply, the same logic to combative ROSC patients, combative intellectually disabled patients (pain or frustration is almost always the cause of their combativeness in my experience), and also children who have had too much red cordial. A little fentanyl and they're happy to sit there and stare at you with a stupid grin while you prepare for whatever torturous procedure you have in mind. 

If not fentanyl, I would still prefer morphine over diaz or midaz. The risk of hypotension is ridiculously overstated with opiates. The vast majority of patients I see have a return to normal BP (either up or down). That said, it is the kinds of patients we're talking about who are most at risk...the hypovolaemic kind. The problem is similar with benzos though and for the reasons stated, I'd still argue you're ganna get more bang for your buck (and therefore, less adverse reactions) with an opiate.  




Halothane said:


> If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.




Absolutely....and RSI may shortly follow if appropriate. However, I don't know that I agree that the combativeness is rarely because of pain. Sure their head injury is a problem and they can be combative from that alone, but I strongly believe their is a subset of multi-trauma pt whose combativeness can be quelled with analgesia. My admittedly limited experience with even small amounts of morph or fent in these patients has been convincing and the idea overall is not mine alone...I was taught it by other far more senior Intensive Care paramedics who have considerable experience in the matter. I believe based on experience, the idea is even tentatively supported from an official point of view to facilitate preparation for RSI.


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## Carlos Danger (Jun 19, 2013)

Melclin said:


> Absolutely....and RSI may shortly follow if appropriate. However, *I don't know that I agree that the combativeness is rarely because of pain.* Sure their head injury is a problem and they can be combative from that alone, but* I strongly believe their is a subset of multi-trauma pt whose combativeness can be quelled with analgesia.* My admittedly limited experience with even small amounts of morph or fent in these patients has been convincing and the idea overall is not mine alone...I was taught it by other far more senior Intensive Care paramedics who have considerable experience in the matter. I believe based on experience, the idea is even tentatively supported from an official point of view to facilitate preparation for RSI.



I wonder if our differing views aren't due to differing opinions on what constitutes "combativeness"?

Many, many times I've seen patients who were agitated, anxious, and somewhat uncooperative due to to pain. These patients often calm with analgesia.

But, I rarely (if ever) have encountered someone who was actually _combative_ - violent and irrational - because of pain alone. 

I certainly haven't seen everything, so perhaps it is more common than I realize. But it seems to me that a safer assumption is that increased ICP or some other organic problem is the cause of combativeness in a trauma patient.


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## Melclin (Jun 20, 2013)

Halothane said:


> I wonder if our differing views aren't due to differing opinions on what constitutes "combativeness"?
> 
> Many, many times I've seen patients who were agitated, anxious, and somewhat uncooperative due to to pain. These patients often calm with analgesia.
> 
> ...



Probably a slightly different picture of combativeness, yes. I was talking more along the lines of the first. The patient who pulls away from you when you try to take a BP, maybe groans some slurred obscenities at you, makes general, uncoordinated attempts to pull their IV, etc.

Why the safer assumption? I'm not saying we have to make a choice between elevated ICP and pain as the cause of agitation in a head injured multi-trauma patient. What I'm saying is that its worth considering the idea that it might be both. We assume its _purely_ the head injury, but I'm saying its a good idea to consider that in the setting of that head injury and in their irrational state, the pain of their other traumatic injuries may exacerbate their combativeness. If you treat their pain, they may become more easy to deal with prior to RSI/transport to facility that can RSI them.


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## jefftherealmccoy (Jun 20, 2013)

Halothane said:


> Because you want to treat the cause of the combativeness to the best of your ability.
> 
> If a patient is combative, it is rarely because of pain, however. A combative trauma patient should be assumed to have a head injury.
> 
> ...



Yes, our protocols need to be redone.  I eagerly await the day that happens.  We only carry valium and morphine.  I wish to high hell that we carried fentanyl.  I came from an agency that had it and I miss it so.  

I had a pt that was bleeding out from a large head lac and his LOC went from helpful and hurting to swinging at us and trying to jump off the cot as his blood pressure dropped (no brain bleed on CT).  We figured the feeling of impending doom set in and he just wanted to get out of there.  We ended up pushing valium instead of fentanyl because of the contraindication of head injury (we even tried calling the ED and asking for fentanyl, which the doc denied).  



Melclin said:


> The risk of hypotension is ridiculously overstated with opiates.
> .



From what I've heard from the ED staff is that they prefer opiates over benzos because they can reverse the opiates with narcan.  I've yet to see when benzos (valium and versed) have tanked a blood pressure, but I've seen a few times in my short career where opiates have.  I know it's a possiblility with both, but is it truly more likely with benzos than opiates?


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## Carlos Danger (Jun 20, 2013)

jefftherealmccoy said:


> Melclin said:
> 
> 
> > The risk of hypotension is ridiculously overstated with opiates.
> ...



I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression. 

It won't happen with the 2-5 mg doses that are commonly used in EMS, but once you get very far north of 10mg or so - which is the kind of dose you need to have any real sedating affect on an agitated patient - you can drop the BP pretty significantly.

Versed can drop pressure too, if they are volume depleted and SNS-dependent. 

I suppose if I had to reverse something, I'd rather reverse an opioid OD than a benzo OD, but I think it's best to use drugs the way they are meant. Sedative meds are for sedation, pain meds are for pain. 

You'd need to give an awful lot of either drug to require reversal......


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## MountainMedic (Jun 20, 2013)

EMCrit has some good stuff on this.

Delirium Tremens is perhaps best treated with repeated boluses of Valium, at 10 mg each dose (IVP). Striking, huh?

In my short career I've seen Fentanyl tank a pressure a few times, but every time the pt had something very clearly wrong with them that explained the tanking. We also tend to simplify how fentanyl acts on BP - it doesn't really work directly. Rather, it acts as a sympatholytic, and simply unwinds all those compensatory mechanisms that are hiding what's really going on. Since in most cases of exsanguinating trauma the benchmark MAP for survival is 65-80 (LOW), you're really unlikely to do any harm administering small doses of fentanyl. My 2 cents. 

I've also seen MDs give it in cases of clear head injury (confirmed SAH), citing that its sympatholytic effects will drop ICP more than its opioidergic effects will raise it.


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## jefftherealmccoy (Jun 20, 2013)

Halothane said:


> I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression.



I agree.  I've seen opiates tank a blood pressure.  I dropped a pt's BP substantially with just 2mg morphine.  I have yet to see benzos tank a blood pressure.  I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine.  Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.  

We use morphine specifically for hypertensive crisis, we don't use benzos.  I took this as the drug that is more likely to cause a drop in BP to be morphine.  Am I wrong?


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## VFlutter (Jun 20, 2013)

jefftherealmccoy said:


> I agree.  I've seen opiates tank a blood pressure.  I dropped a pt's BP substantially with just 2mg morphine.  I have yet to see benzos tank a blood pressure.  I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine.  Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.
> 
> _*We use morphine specifically for hypertensive crisis,*_ we don't use benzos.  I took this as the drug that is more likely to cause a drop in BP to be morphine.  Am I wrong?



:blink: What do you use morphine for during a hypertensive crisis? Headache? 

Theoretically any drug with anxiolytic properties has the propensity to lower blood pressure.


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## jefftherealmccoy (Jun 20, 2013)

We use morphine and nitro specifically for the hypotensive side effects.  We also use it for pulmonary edema.


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## VFlutter (Jun 20, 2013)

jefftherealmccoy said:


> We use morphine and nitro specifically for the hypotensive side effects.  We also use it for pulmonary edema.



no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.


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## jefftherealmccoy (Jun 20, 2013)

Chase said:


> no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.



True, but none in use in high-dee-hoe.


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## jefftherealmccoy (Jun 20, 2013)

Or utah for that matter.


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## Handsome Robb (Jun 20, 2013)

jefftherealmccoy said:


> We use morphine and nitro specifically for the hypotensive side effects.  We also use it for pulmonary edema.



Ever heard of rebound/reflex hypertension with nitro? Or seen it? 

A little counterproductive for those patients in a hypertensive crisis. 

We carry metoprolol but have no protocol for it except for STEMI patients who meet certain parameters. Medics call for orders for it though all the time and get them.


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## TheLocalMedic (Jun 21, 2013)

Had a hypertensive crisis this evening.  Younger guy with a history of BP spikes, taking metoprolol and called for a headache, dizziness and nausea.  Pressure was over 250 systolic.  

Called in for an order for nitro (because we don't carry any beta blockers) and got denied by base.  I painted as clear a picture as I could, but they just shut me down.  GRRRRRRRRR....  I asked to speak with the doc afterwards and she wouldn't give me the time of day.  I think I've been in EMS since before she even started med school, but...

I even explained to her that when I call in for orders that I'm not so much asking for permission as telling them what I plan to do and following our "protocols" by contacting base first, but got stonewalled...


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## jefftherealmccoy (Jun 21, 2013)

Robb said:


> Ever heard of rebound/reflex hypertension with nitro? Or seen it?
> 
> A little counterproductive for those patients in a hypertensive crisis.
> 
> We carry metoprolol but have no protocol for it except for STEMI patients who meet certain parameters. Medics call for orders for it though all the time and get them.



Heard of it.  Never seen it.  I figured that the nitro/morphine combo is just a quick fix until we can get the pt to the ED and get them some more long term treatment.  If we had beta blockers, I'd use 'em.  Until we get 'em, I'll use what we got.


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## Melclin (Jun 21, 2013)

jefftherealmccoy said:


> From what I've heard from the ED staff is that they prefer opiates over benzos because they can reverse the opiates with narcan.  I've yet to see when benzos (valium and versed) have tanked a blood pressure, but I've seen a few times in my short career where opiates have.  I know it's a possiblility with both, but is it truly more likely with benzos than opiates?



While I do feel morphine is safer than a benzo, the opiate/benzo at equivalent doses (whatever that means) argument was perhaps not one I should have mentioned as it isn't really important to my point and it seems to have confused things. Additionally the type of patient you mention is not the kind of patient I was talking about. I don't quite understand why this has required so much discussion to clarify; maybe I haven't made myself clear. Maybe I shouldn't post on contentious issues when I've had a few beers. 

Again: In the patient with both a head injury and an obvious pain producing injury, who is agitated and resisting your attempts to do the necessaries, I'd suggest that people consider the possibility that pain may be playing a role in their agitation. If you treat their pain directly it may take, relatively speaking, less of an analgesic than a sedative (and hopefully haemodynamically safer, with less affect on their conscious state if that is a concern) and it seems intuitively to be a more humane option. This is a treatment I've used and seen used with apparent success and one I'm fond of, so I thought I'd mention it. 



Halothane said:


> I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression.
> 
> It won't happen with the 2-5 mg doses that are commonly used in EMS, but once you get very far north of 10mg or so - which is the kind of dose you need to have any real sedating affect on an agitated patient - you can drop the BP pretty significantly.
> 
> ...



Bolded for emphasis, because it goes to heart of my original argument. I really had not meant to create a "benzos Vs opiates for sedation: which is safer" kind of debate. My point was to consider treating the underlying problem and to consider that pain may play a role in the agitation of certain patients. 





jefftherealmccoy said:


> I agree.  I've seen opiates tank a blood pressure.  I dropped a pt's BP substantially with just 2mg morphine.  I have yet to see benzos tank a blood pressure.  I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine.  Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.
> 
> We use morphine specifically for hypertensive crisis, we don't use benzos.  I took this as the drug that is more likely to cause a drop in BP to be morphine.  Am I wrong?



Yep, didn't deny morph can, especially in certain patients (I did specifically mention the added risk in volume depleted patients). 

RE the hypertensive crisis stuff, I think thats probably faulty logic. I don't think its as simple as one drug being the most likely to cause hypotension.


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## MountainMedic (Jun 21, 2013)

Chase said:


> no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.



Labetalol? Doesn't that last for up to 12h? Metoprolol and esmolol FTW.


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## KellyBracket (Jun 21, 2013)

TheLocalMedic said:


> Had a hypertensive crisis this evening.  Younger guy with a history of BP spikes, taking metoprolol and called for a headache, dizziness and nausea.  Pressure was over 250 systolic.
> 
> Called in for an order for nitro (because we don't carry any beta blockers) and got denied by base.  I painted as clear a picture as I could, but they just shut me down.  GRRRRRRRRR....  I asked to speak with the doc afterwards and she wouldn't give me the time of day.  I think I've been in EMS since before she even started med school, but...
> 
> I even explained to her that when I call in for orders that I'm not so much asking for permission as telling them what I plan to do and following our "protocols" by contacting base first, but got stonewalled...



Just wondering - why did you feel so strongly about lowering this patient's BP? That is to say, what were you trying to prevent by dropping the BP?

(This is pretty off-topic, I realize.)


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## Carlos Danger (Jun 22, 2013)

MountainMedic said:


> Labetalol? Doesn't that last for up to 12h? Metoprolol and esmolol FTW.



IV is more like 2-3 hours.

Commonly used for hypertensive crisis.


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## Handsome Robb (Jun 22, 2013)

Halothane said:


> IV is more like 2-3 hours.
> 
> Commonly used for hypertensive crisis.



Seems like either metoprolol or labetalol in the emergency setting. 

All I've ever seen used at least.


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## VFlutter (Jun 22, 2013)

Robb said:


> Seems like either metoprolol or labetalol in the emergency setting.
> 
> All I've ever seen used at least.



Hydralazine IV also works well for patients who are Beta Blocker intolerant.


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## Handsome Robb (Jun 22, 2013)

Chase said:


> Hydralazine IV also works well for patients who are Beta Blocker intolerant.



Touché sir. Also seen that used as well but not nearly as often.


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