# Morphine for chest pain increases death risk



## Jon (Mar 4, 2005)

While patients hospitalized for a heart attack have long been treated with morphine to relieve chest pain, a new analysis by researchers from the Duke Clinical Research Institute has shown that these patients have almost a 50 percent higher risk of dying. 

The researchers call for a randomized clinical trial to confirm their analysis. Meanwhile, they advise cardiologists to begin treatment with sufficient doses of nitroglycerin to relive pain before resorting to morphine. 

In their analysis of the clinical data and outcomes of more than 57,000 high-risk heart attack patients -- 29.8 percent of whom received morphine within the first 24 hours of hospitalization -- the researchers found that those who received morphine had a 6.8 percent death rate, compared to 3.8 percent for those receiving nitroglycerin. The increase in mortality persisted even after adjustment for the patients' baseline clinical risk. 

"The results of this analysis raise serious concerns about the safety of the routine use of morphine in this group of heart patients," said Duke cardiologist Trip Meine, M.D., who presented the results of the Duke analysis Nov. 10, 2004, at the American Heart Association's (AHA) annual scientific sessions in New Orleans. 

Read More HERE: http://www.defrance.org/artman/publish/article_1106.shtml


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## Jon (Mar 4, 2005)

This is very scary - What is EVERYONE supposed to do for Chest Pain - MONA (not in order) Morphine, Oxygen, Nitrates, Asprin. That's been the gold standard for years.

Jon


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## Summit (Mar 4, 2005)

> *The researchers call for a randomized clinical trial to confirm their analysis. Meanwhile, they advise cardiologists to begin treatment with sufficient doses of nitroglycerin to relive pain before resorting to morphine. *


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## Jon (Mar 4, 2005)

> _Originally posted by Summit_@Mar 4 2005, 03:16 PM
> *
> 
> 
> ...


 Yes - there hasn't been a randomized, multi-center trial yet, but the signs are there that it MIGHT be a bad thing.

Jon


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## medic03 (Mar 4, 2005)

sorry, I'm still giving my pt's morphine. it gets rid of their chest pain and it helps reduce preload and afterload, so in my book, it's a good thing.


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## Jon (Mar 4, 2005)

> _Originally posted by medic03_@Mar 4 2005, 08:25 PM
> * sorry, I'm still giving my pt's morphine. it gets rid of their chest pain and it helps reduce preload and afterload, so in my book, it's a good thing. *


 I don't disagree, but as I said, after the O2 and ASA and Nitro, then Morphine.

It will be intresting to hear what comes out of this, and if there is any discussion at EMS Today


Jon


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## medic03 (Mar 4, 2005)

> _Originally posted by MedicStudentJon+Mar 4 2005, 08:39 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (MedicStudentJon @ Mar 4 2005, 08:39 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-medic03_@Mar 4 2005, 08:25 PM
> * sorry, I'm still giving my pt's morphine. it gets rid of their chest pain and it helps reduce preload and afterload, so in my book, it's a good thing. *


I don't disagree, but as I said, after the O2 and ASA and Nitro, then Morphine.

It will be intresting to hear what comes out of this, and if there is any discussion at EMS Today


Jon [/b][/quote]
 ****, I was suppose to give o2 and nitro?  Hmmm, that's why my partners always looked at me funny when I said "no thanks, I'm fine" when they opened up the o2 bottle and handed me a NRB.  It was for the pt!  ohhhh......   I feel stupid now....     lol, ahhhh, just kidding.  remember people, BLS before ALS.   In my protocols, I can start tridil drips (liquid nitro if you didn't know) and between the O2 and bumping up the tridil, that almost always gets rid of the active chest pain.  I get to bump up to as high as I need to go as long as the BP stays over 90. I do give MSO4 on quite a few cases, but always go with increasing the tridil first.


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## Jon (Mar 4, 2005)

> _Originally posted by medic03_@Mar 4 2005, 08:46 PM
> * In my protocols, I can start tridil drips *


 COOL!

Around here, ALS can't initiate tridal, but can transport with it between facilities, and titrate it to effect with written Physician orders.

Jon


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## medic03 (Mar 4, 2005)

> _Originally posted by MedicStudentJon+Mar 4 2005, 08:51 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (MedicStudentJon @ Mar 4 2005, 08:51 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-medic03_@Mar 4 2005, 08:46 PM
> * In my protocols, I can start tridil drips *


COOL!

Around here, ALS can't initiate tridal, but can transport with it between facilities, and titrate it to effect with written Physician orders.

Jon [/b][/quote]
 funny story about tridil.  I was in an ER once giving report when I saw some nurses running next to a pt that passed out in another bed. He was on a tridil drip and there was a new NR that just started training. This guy still had chest pain, so she was asked to increase his tridil drip.  Now for me, I run tridil in incriments of 10mcg.  my concentration is 50mg in 250cc of D5W and I start at 10 mcg and go up from there.  10mcg is = 3cc for my transports, so I go up by 3cc when I bump it up.  Well this pt was on 2cc an hour and they wanted to bump it up a little bit. for some reason, she forgot the (.) when typing the rate into the pump and set it for 200 cc an hour.  Well the guy got about 3 min worth of the infusion and passed out.  They turned off the drip and the guy was fine, but its kinda funny and scary at the same time.


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## Firechic (Mar 4, 2005)

Interesting article, but I wonder what type of MIs were included in the study. 
In my system, unless a 12 lead is obtained - NTG cannot be given. It is contraindicated in inferior MIs with right ventricular involvement and posterior MIs.
Our present protocols are very much different from the good ole days of just squirting some NTG for CP and watching the BP.
Does anyone else have this in their protocols?


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## Wingnut (Mar 4, 2005)

Our protocols (for BLS) are nitro for any CP as long as the BP is 90 or higher. Of course it doesn't really count since all our rigs are ALS, and I'm not sure what thier protocols are. I know they use MONA as well, but I would THINK that nitro would be the first choice, then asa, then morphine. Morphine seems like a last resort for an MI, simply for comfort???


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## medic03 (Mar 5, 2005)

> _Originally posted by Firechic_@Mar 4 2005, 09:16 PM
> * .....NTG cannot be given. It is contraindicated in inferior MIs with right ventricular involvement and posterior MIs......... *


 NTG is not contraindicated in inferior wall MI's, you just have to be cafeful about bottoming out your pt's BP. IF you are going to give NTG to these pt's, just have an IV started just in case they drop their BP, but you can give it to them.


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## medic03 (Mar 5, 2005)

> _Originally posted by Wingnut_@Mar 4 2005, 09:59 PM
> * ......... but I would THINK that nitro would be the first choice, then asa, then morphine. Morphine seems like a last resort for an MI, simply for comfort???................ *


 MSO4 isn't just for comfort. It does take the pain away, but it also reduces afterload and preload. That reduces the workload of the heart which then makes the heart use less O2 which = better for your pt.  Actually with any chest pain, it's always O2 first, give the ASA (which has nothing to do with pain) then NTG for pain and then MSO4 if needed.


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## Firechic (Mar 5, 2005)

> *NTG is not contraindicated in inferior wall MI's, you just have to be cafeful about bottoming out your pt's BP. *



AH!     BUT...I said inferior MIs with right ventricular involvement - and yes! NTG is an absolute contraindication.

Have a good one!


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## medic03 (Mar 6, 2005)

> _Originally posted by Firechic_@Mar 5 2005, 11:41 PM
> * AH!     BUT...I said inferior MIs with right ventricular involvement [/u....... *



 you may have got me this time, but it isn't the last time you'll hear from me!     :lol:


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## Wingnut (Mar 6, 2005)

Thanks Medic03 for learnin' me something


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## Jon (Mar 6, 2005)

> _Originally posted by medic03+Mar 6 2005, 04:47 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (medic03 @ Mar 6 2005, 04:47 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-Firechic_@Mar 5 2005, 11:41 PM
> * AH!   BUT...I said inferior MIs with right ventricular involvement [/u....... *



you may have got me this time, but it isn't the last time you'll hear from me!     :lol: [/b][/quote]
 Ok: I want to see literature on this, becuase I've never heard of this.


My understanding is that the reason for uing nitro is to vasodilate the coranary vasculature, therefore allowing blood to flow around a possible clot, and perhaps saving the cardiac muscles.


Again, I'm only in -P school, so I'm the first to say I'm not the best to say this.

got a call..

Jon


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## Firechic (Mar 7, 2005)

Here are some articles I found (sorry, don't know the websites):
* American Health Consultants
   Emergency Medical Reports Volume 22, number 9 - April 23,2001
* The American Journal of Cardiology
   Volume 83, Feb 1, 1999
   "Importance of Posterior Chest leads on pts with suspected MI, but nondiagnostic, routine 12-lead ECG"
* The New England Journal of Medicine
   Volume 330 No. 17  "Right Ventricular Infarction"

Happy reading!


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## Jon (Mar 7, 2005)

> _Originally posted by Firechic_@Mar 7 2005, 12:39 PM
> * Here are some articles I found (sorry, don't know the websites):
> * American Health Consultants
> Emergency Medical Reports Volume 22, number 9 - April 23,2001
> ...


 Ok - Thanks.  I will look into these.

Jon


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