# Nitrous Oxide vs. Morphine Sulfate



## rhan101277 (Apr 2, 2009)

I just wanted to see what areas have the protocols to use nitrous oxide?  Over in Alabama you can use it.  Does it last longer than morphine?  What are the pro's and con's of using each?  Is there anything that makes one better than the other?


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## AJ Hidell (Apr 2, 2009)

Nitrous is a beautiful thing, if you can get it.  It's just such a logistical nightmare that few systems carry it anymore.

Pros:  Works faster than morphine.  Stops working as soon as you take it off.  Is patient titrated, so you don't have to worry about giving too much.  No allergies.  Low if any hemodynamic effects.  Doesn't require an IV.

Cons: Limited to 50 percent concentration in the U.S. (except in very rare, very advanced systems), which may not be enough in many cases.  Is heavy and very inconvenient to carry, so it rarely leaves the ambulance, meaning it is unavailable on the scene.  Pt. has to be fully co-operative for it to be used.  The demand valve mask is uncomfortable for many patients, who feel smothered by it and won't tolerate it.  One of the biggest cons, and the reason that a lot of systems drop it from their service, is because of the abuse potential.  There are simply too many immature, unprofessional people in U.S. EMS who will play with it like it's a toy, wasting it.

In the U.S., Nitrous Oxide has to be mixed at the time of use, from separate oxygen and Nitrous cylinders, which makes the apparatus extremely expensive.  In Canada, Australia, and Europe, Nitrous Oxide is available in a single, pre-mixed cylinder, making it a lot easier to carry and dispense.

Overall, I love having Nitrous available.  I find it especially useful in orthopedic trauma.  But given a couple of narcotic options, I can certainly live without it.


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## rhan101277 (Apr 2, 2009)

So even though morphine is injected intravenously, getting it into the bloodstream immediately, its still faster for the nitrous to get to the bloodstream via gas exchange?


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## bonedog (Apr 2, 2009)

Nitrous is excellent. Used by BLS here. Self administered, can be used by BLS when the patient isnot prescribed NTG for cardiac pain.
No need for an antagonist as it wears off quick. As with any Rx it does have its' limitations.

I have used it as an adjunct for relocating #/dislocations with circulatory impairment. A little M&M, and let them self administer until their LOC decreases and the proceedure can be performed quickly with little muscle tension.


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## Aidey (Apr 3, 2009)

What AJ said. I personally love Nitrous and wish my service now had it, but they don't. 

I find it great for a number of patients. Those allergic to opoids; those who are chronic pain patients that are already on high doses of opoids; orthopedic injuries that have already been given the max dose of opoids I can give and the are still at a 2 or 3 and just need something to take the edge off; Abdominal pain that I'm not allowed to give IV analgesics to etc.


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## AJ Hidell (Apr 3, 2009)

rhan101277 said:


> So even though morphine is injected intravenously, getting it into the bloodstream immediately, its still faster for the nitrous to get to the bloodstream via gas exchange?


Yes.  But it is not entirely because of potency or route of administration.  You usually have to carefully titrate morphine in at a slow rate to avoid undesirable side effects and monitor for sensitivity.  By the time you've gotten a therapeutic dosage safely in, a good ten minutes or more may have passed.


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## LucidResq (Apr 3, 2009)

Oh Nitrous... 

I have been in pain and put on N20, and on other occasions - an opiate or opioid. I'd rather have the N20. I felt it was more effective, and I've never had any negative effects on N20, while narcotics have always tended to give me some degree of nausea and/or a strange uncomfortable sense of constantly being either too hot or too cold. However, once upon a time the dentist had to switch my N20 flow to O2 because I became too loopy to keep my mouth open or follow commands. This was after being on it for well over an hour, though. 

Just curious though - how do you manage discontinuing N20 in the prehospital setting? I would be kind of pissed if I was in serious pain and you took me off that stuff shooting me back into pain within a few seconds.


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## akflightmedic (Apr 3, 2009)

LucidResq said:


> Oh Nitrous...
> 
> I have been in pain and put on N20, and on other occasions - an opiate or opioid. I'd rather have the N20. I felt it was more effective, and I've never had any negative effects on N20, while narcotics have always tended to give me some degree of nausea and/or a strange uncomfortable sense of constantly being either too hot or too cold. However, once upon a time the dentist had to switch my N20 flow to O2 because I became too loopy to keep my mouth open or follow commands. This was after being on it for well over an hour, though.
> 
> Just curious though - how do you manage discontinuing N20 in the prehospital setting? I would be kind of pissed if I was in serious pain and you took me off that stuff shooting me back into pain within a few seconds.



We do not discontinue it prehospitally, it is self administered. That means when your hand can not hold the delivery device to your face, you are self dosing. As soon as pain starts to reemerge, you lift your hand to your face and start toking on the pipe again. As medics, we will never hold the device to a patient's face as that is improper administration of the drug.


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## Melbourne MICA (Apr 3, 2009)

*Nitrous*

We use Methoxyflourane as a transport non IV analgesia also with good effect. In some respects its a little bit more practical than Nitrous based on your anecdotes - Its effects continue for several minutes after administration. It's also self administered and inhaled.

It's a great distracting analgesia if I can put that way. It takes the top off the pain without hindering the pain exam at ED much like Nitrous. Great with abdos and trauma in particular. A couple of big whiffs when you're putting on the Donway for example. Nice. By the way it doesn't come in a cylinder - it's a liquid poured into the analgiser, a small green long whistle looking object.

As far as Morph goes I think there are practicalities involved such as the delay between last analgesic admin en-route to hospital and the next time they will be given decent relief in ED. I tend to give an IV Morph bolus a few minutes before I get there so the effect will overlap the next dose by the docs and at the same time not confuse the reliability of the ED pain exam, especially in trauma and abdo stuff. 

Seems like a good approach over that 10-15 or so minute time frame as you arrive and handover, triage delay, transfer to bed, prep and exam by Ed staff etc. The pt can still take whiffs on the whistle all the while.

Nitrous has been considered here as well but was questionable given some of the negatives some of you have mentioned. We also are recruiting a lot of very young staff so abuse may be a problem. There also OH&S issues as well to consider - our Methoxy is under review for that very reason - gas in an enclosed environment etc. 

Still a mix of short acting pain relief plus more persistent and powerful analgesia like Morph, Fentanyl and Ketamine seems like a great combination.
( A short anecdote - an elderly woman to whom I gave Methoxy once, asked me later if you can get it in a six pack!!!! 

I can't begin to imagine the nitrous stories. 

MM


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## Sasha (Apr 4, 2009)

> We also are recruiting a lot of very young staff so abuse may be a problem.



Drug abuse is not something limited to the young.


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## downunderwunda (Apr 4, 2009)

Melbourne MICA said:


> We use Methoxyflourane as a transport non IV analgesia also with good effect. In some respects its a little bit more practical than Nitrous based on your anecdotes - Its effects continue for several minutes after administration. It's also self administered and inhaled.
> 
> It's a great distracting analgesia if I can put that way. It takes the top off the pain without hindering the pain exam at ED much like Nitrous. Great with abdos and trauma in particular. A couple of big whiffs when you're putting on the Donway for example. Nice. By the way it doesn't come in a cylinder - it's a liquid poured into the analgiser, a small green long whistle looking object.
> 
> ...


One problem with Methoxyflurane as described in this post is the risk of renal damage when administered to BOTH patient & officer, especially in confined spaces. The recommendation is for officers not to administer any more than 2 per day.

I dont know if Victoria do it, but although there is a facility to attact O2 to the inhaler, that isnt recommened. This is due to the flash point being reduced from around 75C to 36C. 

Not real good on hot summers day hey.

On a side note, the other drug advantage that I use regularly, apart from morphine, is Fentanyl, however, it is administered intra nasally. This is effective, although the take up is a little slow. 

Entonox has all but gone unfortunatley, for all but maternity cases here, although we had a chopper doc put a patella dislocation back in with it one day..........


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## Melbourne MICA (Apr 4, 2009)

*Abuse*



Sasha said:


> Drug abuse is not something limited to the young.



Quite right Sasha.

MM


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## jochi1543 (Apr 4, 2009)

AJ Hidell said:


> One of the biggest cons, and the reason that a lot of systems drop it from their service, is because of the abuse potential.  There are simply too many immature, unprofessional people in U.S. EMS who will play with it like it's a toy, wasting it.



That's so bizarre...I know it's called laughing gas, but the only reaction I've ever seen patients have to it is nausea/vomiting/lightheadedness - nothing pleasant.


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## PapaBear434 (Apr 4, 2009)

I'll agree with AJ.  I've seen it in use, and it's simple to use and administer, but very expensive.  And also as he said, too many idiots playing with it.

Wish my system used it, but understand why they don't.


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## bonedog (Apr 5, 2009)

Heard at a substance abuse meeting one night " I used 2-26 ouncer's a day"..." I was using 6 grams/day"... "I was doing 10,000 pound/day"....^_^


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## mycrofft (Apr 6, 2009)

*Around 1980 Nitrous was heralded as the latest thing.*

Dangerous substance in an enclosed space due to potential for fire and second hand gas. Many dentists have stopped using it because of these. MAybe it was the nose mask they used.
Most if not all the nitrous abusers I have seen were college age or younger. They used to fall out of dorm room windows to the street.

Morphine has other pharmaceutical effects beside just pain relief. Every drug has to be weighed by ALL it's effects.


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## bonedog (Apr 7, 2009)

An open window and vent fan on works wonders. Pretty much useless for airevac's, unless you want the pilots trying new stunts.

Sure glad no one smokes on car anymore....B)


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## Juxel (Apr 7, 2009)

AJ Hidell said:


> In the U.S., Nitrous Oxide has to be mixed at the time of use, from separate oxygen and Nitrous cylinders, which makes the apparatus extremely expensive.



I'm curious...when did this standard take effect?  We stopped carrying Nitrous about...5 years ago?  Maybe longer now, I can't recall for sure, but it was due to cost.  When we had it, it was in a bag similar to the portable O2 bag, just with a smaller tank.  There was only one tank and it worked marvelously.  I loved it for peds especially.


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## MMiz (Apr 7, 2009)

Juxel said:


> I'm curious...when did this standard take effect?  We stopped carrying Nitrous about...5 years ago?  Maybe longer now, I can't recall for sure, but it was due to cost.  When we had it, it was in a bag similar to the portable O2 bag, just with a smaller tank.  There was only one tank and it worked marvelously.  I loved it for peds especially.


While I've never used it, I've never seen it distributed in two tanks.


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## AJ Hidell (Apr 7, 2009)

Juxel said:


> I'm curious...when did this standard take effect?


Hmmm... not sure when.  It's been that way as long as I can remember, which is a little over thirty years.  You're awful close to Canada up there.  Are you sure you weren't on a Canadian ambulance?  

*Here* is an article by Dr. Bledsoe that mentions it.


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## Vonny (Apr 7, 2009)

We use Nitrous Oxide / Entonox for pain relief, we use a mask that is held by the patient and we also use a mouth piece instead of a  mask if the patient prefers this.  Its great for pain of dis-located joints and fractures while we splint or traction.  It is also used to relieve the pain of labour in childbirth.  I have  been on the patient end of Entonox and found it to be like having a few too many drinks. It wears off fast with no residual effects.  
Ours comes in a managable size cylinder that must be turned upside down several times to mix the gasses before administering it.  We have a semi - fixed cylinder in the ambulance and a porti bag to carry it out to a scene.

We would NOT use it in cases of Alterd LOC, intoxicated or drugged people, pneumothorax or head and maxillofacial injuries and some other conditions.

It is a very good way to deliver pain relief in a BLS setting.
We have not had any abuse problems with it so far.


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