# Patient with distracting injuries



## EMS Patient Care Advocate (Sep 27, 2011)

You are toned to meet a vehicle carrying a passenger involved in a vehicle fire in a POV now driving towards the hospital. Meet POV, man jumps out covered in approx 40% burns, majority 2nd degree and 3rd to hands, arms, shoulders, legs, arms and legs appear to be circumferential. All burned areas of skin peeling, some bleeding to left hand. The Airway is dry, white. All hair on head singed. 

Pt states "I was coming down a hill, breaks went out and I crashed into trees.  I was unable to get out of the vehicle immediately and it burst into flames"

Unable to stop him he gets into the ambulance and sits on edge of stretcher.
Pt refuses backboard, collar, or sitting back to be secured to transport. Pt is CAOx4 PPTE with 10/10 pain from burns-Id say this counts as distracting injury. Pt states he cannot/will not tolerate anything against his skin, stretcher/backboard/burn blanket. Pt has no midline neck or back pain. Distal Neurological exam somewhat unreliable due to severe burns to arms, legs and hands-However patient is able to move all extremities.

Would you use force and restrain?
Do you allow a patient who had no other contraindications to refusal of care other than a distracting injury? Then discuss this with doctor and document.
You are unable to obtain a BP, alternative placements also burned. All clinical signs of circulation, mentation and distal pulses intact.
No RSI available prehospital.


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## the_negro_puppy (Sep 27, 2011)

EMS Patient Care Advocate said:


> You are toned to meet a vehicle carrying a passenger involved in a vehicle fire in a POV now driving towards the hospital. Meet POV, man jumps out covered in approx 40% burns, majority 2nd degree and 3rd to hands, arms, shoulders, legs, arms and legs appear to be circumferential. All burned areas of skin peeling, some bleeding to left hand. The Airway is dry, white. All hair on head singed.
> 
> Pt states "I was coming down a hill, breaks went out and I crashed into trees.  I was unable to get out of the vehicle immediately and it burst into flames"
> 
> ...



If this patient is alert and orientated, of adult age, not intoxicated albeit influenced by pain with no mental illness or impairment using force and restraining him would constitute assault.

The best bet would be try and reason with him "Lie back so I can give you pain relief"

or give analgesia then see if we he comply with immobilisation.

This is a very strange question and it would be extremely unlikely to ever be encountered.

In regards to RSI. If you had serious suspicion of airway burns you should explain the procedure to the patient and why it is necessary. Once he is anaesthetised you could then take the necessary c-spine and other precautions. If he is mobile, with nil neuro deficits or neck  the chance of c-spine injury is low. Obviously due to massive distracting injury and mechanism of injury one would no clear his c-spine in the field.


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## EMS Patient Care Advocate (Sep 27, 2011)

the_negro_puppy said:


> If this patient is alert and orientated, of adult age, not intoxicated albeit influenced by pain with no mental illness or impairment using force and restraining him would constitute assault.
> 
> The best bet would be try and reason with him "Lie back so I can give you pain relief"
> 
> ...



Patient did have distracting injury/Pain so you assault concern has a conflict. So if they have a distracting injury but everything else is in tact where do you stand?
This cant be that silly or unlikely, this was my patient last night. I can link the brief news article of the crash if needed.
Im saying RSI is not an option. You dont have protocols or medication available in this system.


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## Aidey (Sep 27, 2011)

Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.


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## NomadicMedic (Sep 27, 2011)

Agreed. This guy needs pain management and fluids. And a fast ride to a facility that can manage burns. 


Sent from my iPhone.


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## EMS Patient Care Advocate (Sep 27, 2011)

Aidey said:


> Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.



Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.


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## EMS Patient Care Advocate (Sep 27, 2011)

n7lxi said:


> Agreed. This guy needs pain management and fluids. And a fast ride to a facility that can manage burns.
> 
> 
> Sent from my iPhone.



Fluid bolus in route. Do you worry about the parkland formula prehopital? 18g established in one area not burned, secured with gauze. Nearest facility provided RSI and air medical met us there to transport to proper facility.


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## Aidey (Sep 27, 2011)

Aidey said:


> Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.





EMS Patient Care Advocate said:


> Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.



That includes anything resembling immobilization.


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## fast65 (Sep 27, 2011)

As others have already said, pain management is our priority at this point. This gentleman isn't going to let us do anything until we can manage his pain, at least a little bit. Once we get some morphine on board we can start trying to convince him to let us put him on a backboard. This goes without saying though, we need to start fluid replacement ASAP as well. 

I would really like to RSI this guy, but, if you don't have that option, I suppose it's kind of irrelevant at this point.


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## EMS Patient Care Advocate (Sep 27, 2011)

fast65 said:


> As others have already said, pain management is our priority at this point. This gentleman isn't going to let us do anything until we can manage his pain, at least a little bit. Once we get some morphine on board we can start trying to convince him to let us put him on a backboard. This goes without saying though, we need to start fluid replacement ASAP as well.
> 
> I would really like to RSI this guy, but, if you don't have that option, I suppose it's kind of irrelevant at this point.



If only RSI ! Yeah needless to say the report to the truama center included the statement- "Well he walked out of the ambulance" 
I hope I get an A on my documentation-ick:wacko:


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## Tigger (Sep 27, 2011)

I'm confused as to why this patient would be a candidate for c-spine precautions. Maybe the MOI has you suspecting a c-spine compromise, but he did after all drive to your location and then walk into your ambulance. It seems highly unlikely to me that someone who has already done all this (including escaping a burning car), would be able to provide the force to change a stable c-spine injury to a deficit causing one in the back of the ambulance. 

I understand that you can't actually clear c-spine because of the distracting injuries, but were there any other aspects of the assessment that pointed you towards c-spine precautions? 

In this case, I can't see how a backboard is going to provide any benefit to the patient, and I am not going to implement an intervention based on what  protocol says. If it is going to put the patient in severe pain and there is nothing screaming c-spine injury besides MOI, I don't I'll bother with a board. I will document heavily, however.


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## EMS Patient Care Advocate (Sep 27, 2011)

Tigger said:


> I'm confused as to why this patient would be a candidate for c-spine precautions. Maybe the MOI has you suspecting a c-spine compromise, but he did after all drive to your location and then walk into your ambulance. It seems highly unlikely to me that someone who has already done all this (including escaping a burning car), would be able to provide the force to change a stable c-spine injury to a deficit causing one in the back of the ambulance.
> 
> I understand that you can't actually clear c-spine because of the distracting injuries, but were there any other aspects of the assessment that pointed you towards c-spine precautions?
> 
> In this case, I can't see how a backboard is going to provide any benefit to the patient, and I am not going to implement an intervention based on what  protocol says. If it is going to put the patient in severe pain and there is nothing screaming c-spine injury besides MOI, I don't I'll bother with a board. I will document heavily, however.



I Agree 
 I think a stable fracture may be made worse if moved the correct way- that would then cause neuro deficit and cause a problem beyond just a spinal FX if it impedes on the nerves.-Not the case I hope for this patient. Also He wasn’t exactly doing jumping jacks :rofl:
 I did palpate and assess spine- distal motor and sensory very unreliable-though moved everything well, he did tell me his back was fine. I was hoping this would stir some conflict as I have c-spine/backboard debates a lot. I did document very heavily.


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## Slinky (Sep 28, 2011)

EMS Patient Care Advocate said:


> Would you use force and restrain?
> Do you allow a patient who had no other contraindications to refusal of care other than a distracting injury? Then discuss this with doctor and document.
> You are unable to obtain a BP, alternative placements also burned. All clinical signs of circulation, mentation and distal pulses intact.
> No RSI available prehospital.



I'm confused as to why you would even think about forcing an alert and oriented adult into spinal immobilization.  A distracting injury is a contraindication to clearing c-spine, not overriding a patient's right to refuse any treatment.  If you feel c-spine precautions are necessary, strongly recommend it and if the pt refuses, simply document it and let the receiving hospital staff know.  Competent adults get to make the decisions about their care, even if it is not in their best interest.


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## epipusher (Sep 28, 2011)

I agree with with strongly suggesting the c-spine precautions. Maybe suggest once more after pain meds. Document accordingly.


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## Aidey (Sep 28, 2011)

Aidey said:


> Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.





EMS Patient Care Advocate said:


> Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.





Aidey said:


> That includes anything resembling immobilization.



Let me rephrase again. Anyone who even thinks the words "backboard" or "c-collar" is getting locked out of my ambulance.


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## EMS Patient Care Advocate (Sep 28, 2011)

Aidey said:


> Let me rephrase again. Anyone who even thinks the words "backboard" or "c-collar" is getting locked out of my ambulance.



I guess Ill drive :sad:


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## EMS Patient Care Advocate (Sep 28, 2011)

Slinky said:


> I'm confused as to why you would even think about forcing an alert and oriented adult into spinal immobilization.  A distracting injury is a contraindication to clearing c-spine, not overriding a patient's right to refuse any treatment.  If you feel c-spine precautions are necessary, strongly recommend it and if the pt refuses, simply document it and let the receiving hospital staff know.  Competent adults get to make the decisions about their care, even if it is not in their best interest.



I didnt think of it until I asked the doctor after he stated to the truama center that the pt walked out of the ambulance. My question to the doctor was " Is there something you suggest I could have done more?" His actual answer was "other than using brute force-no, document document document."
I would never ever do this to my patient- I was seeing in there were emt's out there convinced backboards need to "always" be used when the possibility of needing one is there. 
Plus I like talking about this stuff. Am I innapropriate?


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## EMS Patient Care Advocate (Sep 28, 2011)

epipusher said:


> I agree with with strongly suggesting the c-spine precautions. Maybe suggest once more after pain meds. Document accordingly.



yes, and again after the hospital provided RSI. It was implied at that point for transfer


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## usafmedic45 (Sep 28, 2011)

> Patient did have distracting injury/Pain so you assault concern has a conflict.



Being distracted doesn't excuse the legal right to self-determination.  Just chart it and deal with it as best you can. Keep in mind that forcibly restraining someone is more likely to displace an otherwise stable spinal fracture than letting the person just sit there.  I say stable because if it weren't stable, the patient would likely know about it already and/or be dead because of it.


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## usafmedic45 (Sep 28, 2011)

> His actual answer was "other than using brute force-no, document document document."
> I would never ever do this to my patient- I was seeing in there were emt's out there convinced backboards need to "always" be used when the possibility of needing one is there.
> Plus I like talking about this stuff. Am I innapropriate?



It's not inappropriate per se, but it does get kind of tiresome when we have debates over rather simplistic things.


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## EMS Patient Care Advocate (Sep 28, 2011)

usafmedic45 said:


> It's not inappropriate per se, but it does get kind of tiresome when we have debates over rather simplistic things.



Ok, I will back off. Makes sense. Sorry


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## usafmedic45 (Sep 28, 2011)

EMS Patient Care Advocate said:


> Ok, I will back off. Makes sense. Sorry



It isn't a huge deal if there is an honest question, but I know several of the more prominent members of this forum have commented that you tend to start threads over anything you hear about (or so the perception is).  Personally, I have no serious problem with it- so long as you are judicious and receptive to constructive criticism- but you should be aware of how others perceive these threads at times.


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## EMS Patient Care Advocate (Sep 28, 2011)

usafmedic45 said:


> It isn't a huge deal if there is an honest question, but I know several of the more prominent members of this forum have commented that you tend to start threads over anything you hear about (or so the perception is).  Personally, I have no serious problem with it- so long as you are judicious and receptive to constructive criticism- but you should be aware of how others perceive these threads at times.



How things are perceived is important to me. I also dont always know what other perceptions are without hearing them. Thank you for letting me know. I guess I never know what else will spike good conversation, thats why I have been librally posting. I had a feeling something was up.


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## Bullets (Sep 28, 2011)

i wouldnt have even thought of spinal immobilization once the patient denied neck or back pain.

Only issue is securing the patient to the bench seat with a lap belt. i would have tried to get him to sit on the cot, and remove any other clothing while enroute to the trauma center


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## Akulahawk (Sep 28, 2011)

Spinal precautions on a patient who may have pos MOI, but exam shows neg findings? I don't think so... My concerns with this guy is getting him basically naked (providing for some modesty) getting a line started as sterile a manner as I can,  getting orders for much morphine, I think he may need more than I have in the truck... Then start working on fluid replacement via Parkland. Followed by get him to a burn center and continually reassess for the need to intubate him.


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## EMS Patient Care Advocate (Sep 28, 2011)

Is there any concern giving morphine when you cannot obtain a BP due to peripheral site being burned? Or clinical assessment sufficient? Nice replys.


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## NomadicMedic (Sep 28, 2011)

I'd have no problem giving him morphine. 


Sent from my iPhone.


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## epipusher (Sep 28, 2011)

Nasal Fentanyl FTW


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## EMS Patient Care Advocate (Sep 28, 2011)

epipusher said:


> Nasal Fentanyl FTW



you were able to get an 18g, would u still go nasal vap ?


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## epipusher (Sep 28, 2011)

EMS Patient Care Advocate said:


> you were able to get an 18g, would u still go nasal vap ?



 I would give the IN dose prior to, or at the same time as obtaining i.v. access.


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## EMS Patient Care Advocate (Sep 28, 2011)

epipusher said:


> I would give the IN dose prior to, or at the same time as obtaining i.v. access.



I think that is a good idea.


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## Handsome Robb (Sep 29, 2011)

Your doing more harm than good forcing him onto a backboard. Give him so fent IN then get a line enroute. 

There are other options to control this guys airway, nasal intubation anyone? He will probably tolerate it better once you get the fent on board as well.


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## usafmedic45 (Sep 29, 2011)

> Is there any concern giving morphine when you cannot obtain a BP due to peripheral site being burned?



Just chase it with diphenhydramine.  Most of the hypotension associated with morphine is due to the associated histamine release.  Diphenhydramine is an effective way to minimize the risk of it.  Besides, you'll be obtaining vascular access so any hypotension is easily corrected.


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## Akulahawk (Sep 29, 2011)

usafmedic45 said:


> Just chase it with diphenhydramine.  Most of the hypotension associated with morphine is due to the associated histamine release.  Diphenhydramine is an effective way to minimize the risk of it.  Besides, you'll be obtaining vascular access so any hypotension is easily corrected.


If I have a protocol allowing (or can get an order for) a diphenhydramine chaser with morphine administration, I'd absolutely do it. AFAIK, we don't have access to other opiates out here (yet?) for pain control. :wacko:


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## Handsome Robb (Sep 29, 2011)

Akulahawk said:


> AFAIK, we don't have access to other opiates out here (yet?) for pain control. :wacko:



No fentanyl? That's crazy. If you didn't have another narcotic option besides morphine and really were uncomfortable giving it I'd go for nitronox. Sure it's not nearly as strong, but something is better than nothing...

We have Fentanyl 1-2 mcg/kg max single dose of 100 mcg either IV or IN with a total max dose of 300 mcg IV or 2.5 mcg/kg IN and then can call and get orders for more if we really need it. Second option is morphine 2-5 mg IV q 15 mins no max. Intermediates (me until I finish school) have nitronox provided it isn't contraindicated.

Our medical director is pretty liberal about pain management.


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## usafmedic45 (Sep 29, 2011)

Honestly, my take on anything approaching serious burns is that it's an indication for ketamine with or without intubation.  Nothing short of aggressive dose of narcotics coupled with good sedation or flat out dissociation is adequate for pain control in these situations.


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## Aidey (Sep 29, 2011)

We can't do conscious sedation, but we can RSI. My plan for major burn patients is to give them the max doses of fent and versed and RSI. It is the only humane thing I can do if there burns are bad.


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## usafmedic45 (Sep 29, 2011)

Aidey said:


> We can't do conscious sedation, but we can RSI. My plan for major burn patients is to give them the max doses of fent and versed and RSI. It is the only humane thing I can do if there burns are bad.



If I can even remotely justify (and I usually can) RSI in these cases, I would take that approach as well.  You are right that it is often the only humane thing that can be done, at least from a legal perspective.


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## Akulahawk (Sep 29, 2011)

usafmedic45 said:


> Honestly, my take on anything approaching serious burns is that it's an indication for ketamine with or without intubation.  Nothing short of aggressive dose of narcotics coupled with good sedation or flat out dissociation is adequate for pain control in these situations.


The few burn patients I've seen have required a lot of narcotics for adequate pain control. The last emergent burn patient I saw (flown in, I was on ground transport for the short ride from the pad) got 350 mcg fentanyl and that still wasn't enough. And yes, the patient was still breathing at a normal rate and depth. Good SpO2 if I recall... Fortunately, no airway involvement. This was about 8 years ago. 

Believe me, that left a HUGE impression with me about burns and pain control...


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## Akulahawk (Sep 29, 2011)

NVRob said:


> No fentanyl? That's crazy. If you didn't have another narcotic option besides morphine and really were uncomfortable giving it I'd go for nitronox. Sure it's not nearly as strong, but something is better than nothing...
> 
> We have Fentanyl 1-2 mcg/kg max single dose of 100 mcg either IV or IN with a total max dose of 300 mcg IV or 2.5 mcg/kg IN and then can call and get orders for more if we really need it. Second option is morphine 2-5 mg IV q 15 mins no max. Intermediates (me until I finish school) have nitronox provided it isn't contraindicated.
> 
> Our medical director is pretty liberal about pain management.


I just double checked our meds list out here and nitronox, fentanyl, ketamine... all still not on the list. We do have morphine and midazolam though. Diazepam was removed from the list several years ago. Our morphine max dose is 30 mg, in 10 mg increments q 5 min titrated to effect - for burns. For other trauma types, we can max-out at 20 mg, given in 2-5 mg increments q 5 min as long as there's no head or torso injury, GCS 15, and BP >90 for each incremental dose.


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## Melclin (Sep 29, 2011)

I don't really know why you'd even bother thinking about collar or boards in this pt. He self extricated, drove to you and walked to the ambulance. What on earth is a collar and board going to provide that laying reasonably still won't.


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## dstevens58 (Sep 29, 2011)

There are a lot of things you would wish to do, but with a completely oriented and alert and under no compromising chemical influence......

document both the offer of treatment and their refusal and let it go with that.  Don't focus on what you want to do, focus on what the patient will allow you to do for them.


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## EMS Patient Care Advocate (Sep 29, 2011)

awesome information and to see different pain managment protocols. Ohhh yea ketamine would have been his godsend. Im enjoying the thread hope its getting better for you too.


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## Handsome Robb (Sep 29, 2011)

Akulahawk said:


> I just double checked our meds list out here and nitronox, fentanyl, ketamine... all still not on the list.



We don't have ketamine here either and a little bird just told me they took nitronox away. Not sure if that is just from Intermediates or completely gone. Gonna grab a new book tomorrow and find out. 

For medics they can do analgesia and sedation for "Pain in association with large muscle mass (such as femur) fracture or severe back pain" Pt must have a GCS of 13 or better and be hemodynamically stable, SBP >90.

As long as proper documentation accompanied this with burns, I don't see why it would be inappropriate. Same analgesic dose along with 2-5 mg midazolam aiming for pain <5/10 and a Bloomsbury score of 0-1. 

The other option we have for burn patients is if they are outside 'the loop' geographically and meet criteria for a burn center
"1. Partial-thickness burns of greater than 10% of the total body surface area  
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints  
3. Third-degree burns in any age group  
4. Electrical burns, including lightning injury  
5. Chemical burns  
6. Inhalation injury  
7. Burn injury in patients with preexisting medical disorders that could complicate  management, prolong recovery, or affect mortality  
8. Burn injury in patients who will require special social, emotional, or rehabilitative intervention"

We can request HEMS transport to UC Davis Burn Unit. They will either meet us enroute or we will go directly from the ambulance to the aircraft at the hospital and bypass the ED. They have RSI and other sedation options.


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## jjesusfreak01 (Sep 29, 2011)

Our max narcotic dose is doubled for pain management in burn patients, and a quick call to the medical director will raise that to whatever level the medic deems appropriate.


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## usalsfyre (Sep 30, 2011)

The last real burn pt I had required 200mcgs of fent nasally before I could get him to sit still enough to even move the cot or get a BP. He was an MVC also. Any attempt to board him would have been more injurious than putting him in a position of "comfort".


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## Slinky (Oct 2, 2011)

usafmedic45 said:


> Just chase it with diphenhydramine.  Most of the hypotension associated with morphine is due to the associated histamine release.  Diphenhydramine is an effective way to minimize the risk of it.  Besides, you'll be obtaining vascular access so any hypotension is easily corrected.



I believe that the morphine induced hypotension due to histamine release is seen predominately at high levels of morphine administration (studies done at 1 mg/kg during anesthesia).  Isn't most morphine induced hypotension at the EMS street level due to other factors, such as hypovolemia?  I don't think 5-20 mg of morphine causes much hypotension due to a histamine release.


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