# Morphine vs. toradol, kidney stones.



## NYMedic828

So what have you guys found works better with the assumption of kidney stones?

Does toradol being anti-inflammatory outweigh the greater pain suppression of opiates?

Does the lowering of BP via morphine reduce the pain at all?



I've never given either for kidney stones, was just a thought that came to mind.


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## Doczilla

I've given toradol, fentanyl, and morphine for kidney stones. I have to say that toradol seems to provide the longest lasting, more specific relief. 

Toradol dilates the ureter while supressing the intense inflammatory response associated with renal calculi. this assists in passing as well as preventing that spasmotic, colicky pain that comes with it. Combined with an alpha blocker, its even better. 

Also, in general, 30mg of I.V toradol is equivalent to 10mg of morphine from an analgesia standoint. 

Lastly, the constipation that eventually comes with serial doses of opiates only makes the colicky pain worse if they haven't passed it.


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## DrankTheKoolaid

Toradol in combination with Reglan works magic renal stones


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## NYMedic828

Doczilla said:


> Also, in general, 30mg of I.V toradol is equivalent to 10mg of morphine from an analgesia standpoint.




That's really interesting, I didn't think toradol was quite that strong.

So, not to get off topic but say I have an extremity fracture, giving 30Mg toradol IV will actually be stronger than 5mg of morphine?

I imagine the difference in the above case is the more rapid onset of relief with morphine.


Another side note, any contraindications to giving morphine in conjunction with toradol? (epocrates says none, just thought id ask)


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## Doczilla

There's no absolute interactions. Remember that most PO opiate preperations come with NSAIDS, if you count APAP. (Some do. ) 

The only thing is , traditional NSAIDS  (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.


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## DrankTheKoolaid

It seems alot of people, not just forum readers underestimate the power of NSAIDS.  If you get a chance read Soto Omoigui ( Author of the Anesthesia Handbook) Law of Pain which states all pain is caused by imflammation, which would explain why NSIADS and other AI drugs work so well.


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## Doczilla

I agree. Alot of people don't realize that the APAP in Percocet, vicodin, and others is what controls somatic pain. The opiates just slow pain signals through GABA and opiate receptors.


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## mycrofft

NYMedic828 said:


> So what have you guys found works better with the assumption of kidney stones?
> 
> Does toradol being anti-inflammatory outweigh the greater pain suppression of opiates?
> 
> Does the lowering of BP via morphine reduce the pain at all?
> 
> 
> 
> I've never given either for kidney stones, was just a thought that came to mind.



Why would reduction of BP help pain, other than maybe migraine?

We used Toradol for torso pain (renal, cholecystitis) and found to work very well. Some patients also experienced some sedation, just as rare ibuprofen users report.


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## NYMedic828

mycrofft said:


> Why would reduction of BP help pain, other than maybe migraine?
> 
> We used Toradol for torso pain (renal, cholecystitis) and found to work very well. Some patients also experienced some sedation, just as rare ibuprofen users report.



Wasn't sure whether or not pressure exerted by higher BP would put any more force behind the calculi or not. Guess that's a no.


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## NYMedic828

Doczilla said:


> There's no absolute interactions. Remember that most PO opiate preperations come with NSAIDS, if you count APAP. (Some do. )
> 
> The only thing is , traditional NSAIDS  (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.



So would you say that for a fracture, immediate treatment opiates are preferred as for something more muscular in nature, toradol may be better?


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## Doczilla

Yeah that's why most places will give you a 7 day course of opiates then switch you to NSAIDS. Sprains are a different story, but differentiating between fractures and sprains as difficult If you don't know where to look. 

Anyone here use the ottowa ankle rules?


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## Dwindlin

Doczilla said:


> The only thing is , traditional NSAIDS  (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.



Controversial.  Evidence isn't great either way.

www.ncbi.nlm.nih.gov/pubmed/20552333
www.ncbi.nlm.nih.gov/pubmed/19240368


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## mycrofft

Don't know about osteoblasts and clasts, but NSAIDS taken right after the fx could aggravate bleeding, no?


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## truetiger

Why not both? My partner had a call last week in which he used 50mg of toradol with 50mcg of fentanyl to treat severe pain from panreatitis.


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## Veneficus

It looks to me reading this thread that there is a begining of a cultural bias here. 

In EMS and in medicine in general in conservative countries, there is an almost cyclic aversion to the use of stronger pain medications. 

The idea that pain is caused by inflammation is not ground breaking or revealing. The kininogen system is interconnected with inflammation and clotting, you cannot get through 5 chapters of any reputable pathophys texts without having that pounded into you.

I like to use a combination of opioid and NSAID for most pain outside of renal.

I like to explain it to patients as "a shot and a beer."  

The opioid for breakthrough pain control, and the nsaid for maintenence. It seems to work very well.


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## the_negro_puppy

We don't carry NSAIDs other than Aspirin which can only be used for suspected mycardial isachaemia/AMI.

Morphine is our only option, alos possible methoxyflurane.

We are rolling out fentanyl, with IN first for children then slowly allows IV use for ACPs/


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## truetiger

Why has fentanyl been slow to catch on?


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## the_negro_puppy

truetiger said:


> Why has fentanyl been slow to catch on?



Not too sure. Other services in AUs already use it. 

Our current indication is intranasal for paeds:

1.5 mcg/kg repeated once at 1mcg/kg after 10 mins. Total max 100mcg/kg


Our ICPs can give it to adults: 25-50mcg repeated at up to 50mcg every 5 mins, no max dose. The plan is to roll this capability down to use once our service has been using the drug for a while.

We have only just got Zofran as well. 4mg for adults, iv/im and 0.1 mg/kg for paeds 3 years and older.


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## NYMedic828

truetiger said:


> Why has fentanyl been slow to catch on?



Here in NYC, we have morphine and fentanyl.

It is VERYYYYY rare that someone goes back to the station to replace a vial of fentanyl. We have had 8 spare vials for about 7 months now.

Its actually pretty rare for morphine too. And thats on standing orders for isolated extremity injuries.

Personally, im a fan of pain control. Why should a legitimate patient be in pain if they don't have to be. The problem is, my partners in NYC are not.

Where I volly it doesn't matter, I'm in charge 99% of the time there is no one above an AEMT with me.

Pain management is just taboo it seems on an NYC ambulance. I don't know if it comes from laziness or poor education.

We carry zofran, morphine, fentanyl. We could be doing a lot of help to some of those constant abdominal pains we get.


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## OzAmbo

truetiger said:


> Why has fentanyl been slow to catch on?


Supply v demand issue here

Demand outstripped supply so much that services haev put off its ontroduction as the uice wasn't available to be used.

Id almost place bets that once more manufacturing capacity comes online that we may ditch morph completely for fentanyl and hopefully ketamine


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## med51fl

My department only has the option of morphine for pain management.  There are those of us that are pushing for fentanyl, but are having a hard time moving forward with it.  The biggest issue for us in regards to pain management is getting the crews to use it.  There seems to be an almost absolute avoidance to give anything for pain.  The most common excuse is "we were pretty close to the hospital".

Morphine is cheap and IVs are easy I say.


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## OzAmbo

med51fl said:


> The most common excuse is "we were pretty close to the hospital".
> 
> Morphine is cheap and IVs are easy I say.


Wow, thats dissappointing... or negligent:sad:


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## AnthonyM83

Doczilla said:


> I've given toradol, fentanyl, and morphine for kidney stones. I have to say that toradol seems to provide the longest lasting, more specific relief.
> 
> Toradol dilates the ureter while supressing the intense inflammatory response associated with renal calculi. this assists in passing as well as preventing that spasmotic, colicky pain that comes with it. Combined with an alpha blocker, its even better.
> 
> Also, in general, 30mg of I.V toradol is equivalent to 10mg of morphine from an analgesia standoint.
> 
> Lastly, the constipation that eventually comes with serial doses of opiates only makes the colicky pain worse if they haven't passed it.


I could spend a day reading through a pharmacology book and feel like I kind of learned something, but then I spend a minute reading EMTLife and someone summarize a specific topic and feel like I actually learned something for the day... Thanks.


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## Melclin

OzAmbo said:


> Supply v demand issue here
> 
> Demand outstripped supply so much that services haev put off its ontroduction as the uice wasn't available to be used.
> 
> Id almost place bets that once more manufacturing capacity comes online that we may ditch morph completely for fentanyl and hopefully ketamine



I hope not. I don't trust the hospital. You could send them to the market with your favourite cow; tell them to get some real analgesia and you can bet your bottom dollar they'll come back with the magic beans. And not the kind that makes a colles fracture feel better. 

I'd prefer to hang onto the lasting analgesia and add to it if possible.


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## NYMedic828

We don't have much issue with supply/demand in NYC.  Mainly because people almost never treat for pain so it doesn't use up our supply. :unsure:

I wish I could work medic/emt and not have a grumpy old set in their ways never did any self education partner who I have to make decisions with...

If I suggested calling for orders for morphine to my partners they would probably say that's ridiculous we can be at the hopsital in 15 minutes why bother, and they aren't even in that much pain. Also ridiculous because who are you to say what their pain tolerance really is?

My one partner, senior to me, also told someone the other day that etomidate will shut down your respiratory drive after 2 minutes...

Story of my life.


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## firetender

*A keeper!*



AnthonyM83 said:


> I could spend a day reading through a pharmacology book and feel like I kind of learned something, but then I spend a minute reading EMTLife and someone summarize a specific topic and feel like I actually learned something for the day... Thanks.


 

If we used testimonials, we'd use this!


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## the_negro_puppy

The whole "we're nearly at the hospital doesn't fly here.

A 10 minute drive to hospital turns into 20 minutes once we've unloaded and been triaged. This can be another 5-10 minutes if its busy to be allocated and offload into a bed. The nurse then has to do a basic hx and assessment., then beg a physician to write up orders for analgesia. IV access needs to be obtained too if the analgesia is IV. That's on a good day. Most of the time we are 'ramped' (stuck with patients on our stretchers) for 30-60-90-120 minutes at a time. They are still in our care regardless of being at hospital. I've had to start IVs in hospital and give IV morph while ramped as its nearly impossible to get the hospital to give any.

I frequently push more analgesia as we are pulling into hospital if the patient needs it. This is due to the above delays. Pain management is one of the few things we can do that makes a difference in pre-hospital care.


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## Doczilla

At least you didn't have a CCRN tell you etomidate was a paralytic


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## NYMedic828

Doczilla said:


> At least you didn't have a CCRN tell you etomidate was a paralytic



succinyltomidate?


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