# Fentanyl; Why even carry Morphine?



## NYMedic828 (Jul 27, 2012)

Here in NYC as I've stated in the past we RARELY utilize pain management but we do carry fentanyl and morphine Carpu-jets.

If i suggested IN fentanyl for a ped injury to most partners, they would stare me down with a wtf look. 

Our fentanyl stock almost never changes unless something expires. Same goes for morphine.

But anyway, what's the purpose of even having morphine when fentanyl doesn't cause as many adverse reactions?

To my understanding, fentanyl binds more selectively reducing side effects prevalent with morphine and it doesn't cause the histomine response that morphine does.

Fentantly is discretionary here for anything but a hypotensive patient needing pain management

Is the reason out of fear that we will give too much and not be able to reverse it as easily as morphine?

I just don't understand why we even bother with morphine, fent just seems all around superior?


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## rogersam5 (Jul 27, 2012)

I don't either, in Maine we don't carry morphine unless there is a recognized drug shortage of fentanyl and all the hospital pharmacy can give us is morphine


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## NYMedic828 (Jul 27, 2012)

Truthfully I think one main reason is they don't trust our providers, and with good reason. If I was the medical director I wouldn't.

Most people here in NYC/ LI if you asked them what morphine/fent does all they could tell you is they reduce pain because they are opiate agonist. All they know "fentanyl is stronger and omg dangerous!"


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## Veneficus (Jul 27, 2012)

NYMedic828 said:


> Here in NYC as I've stated in the past we RARELY utilize pain management but we do carry fentanyl and morphine Carpu-jets.
> 
> If i suggested IN fentanyl for a ped injury to most partners, they would stare me down with a wtf look.
> 
> ...



There is no such thing as a "superior" drug. Only a different one. 

There are pros and cons to both. 

It depends on things like whether or not the side effects are desired. I use promethazine rather frequently over ondosterone on purpose. I want the patient sedated and sleepy. (side effects) The fact that it helps reduce n/v, and is a 1st generation antihistamine (just like benadryl) is a bonus in my book. 

Plus since it is a sedative, you don't have to add a benzo to your mix. 2 drugs instead of 3. 

morphine also supposedly lasts longer. Which is good if the patient is going to sit in the ED for a while. Not to mention if you have a pt with GI discomfort and diarrhea, the fact that it relieves pain and causes constipation doesn't go amiss.

Provider comfort actually has a fair role in the mix as well. It is just like backup airway adjuncts. It is better to be great with 1 or 2 than familiar with a dozen.

Calling fent "better" is just too over simplistic.

Sounds like what you need is medical direction that calls people on the carpet for not using pain control.


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## NYMedic828 (Jul 27, 2012)

I'm not sure if it's an issue with people being fearful of utilizing pain meds or just a matter of complete laziness. My opinion is 9/10, it's the latter.

I have stopped mentioning the idea of it to my partners unless the patient is in massive pain. They always go nahhh well be at the hospital in 5 minutes why bother. 

My theory is, why force them to have pain if you have a solution. You want to be considered more than an ambulance driver, then prove it to the patient.

When I'm working in my volunteer department, I'm almost guaranteed to be the sole paramedic available which is much more desirable in my mind. Rarely do I have a partner i actually feel I can truly consult with. I'm a newish medic but that's even more the reason I shouldn't be teaching my teacher...


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## Anjel (Jul 27, 2012)

We carry morphine for cardiac chest pain. 

Not pain management, that is what fentanyl is for.


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## NYMedic828 (Jul 27, 2012)

Anjel1030 said:


> We carry morphine for cardiac chest pain.
> 
> Not pain management, that is what fentanyl is for.



Is the theory behind this further more prolonged preload/after load reduction in conjunction with NTG, while also providing analgesia?

We had morphine as a medical option for chest pain but it has since been removed and NTG is the sole primary treatment now. 

I would think the nausea potential of morphine could make some worse as well if an antiemetic is not also available to you.


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## Anjel (Jul 27, 2012)

NYMedic828 said:


> Is the theory behind this further more prolonged preload/after load reduction in conjunction with NTG, while also providing analgesia?
> 
> We had morphine as a medical option for chest pain but it has since been removed and NTG is the sole primary treatment now.
> 
> I would think the nausea potential of morphine could make some worse as well if an antiemetic is not also available to you.



More so reducing oxygen demand and reducing the size of an infarct. 

Is what we were taught in class.

And we do have zofran.


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## NYMedic828 (Jul 27, 2012)

Anjel1030 said:


> More so reducing oxygen demand and reducing the size of an infarct.
> 
> Is what we were taught in class.
> 
> And we do have zofran.




I can't say I have heard of it physically reducing infarct? I guess in theory if you can dilate the vessel that much more, more can fit around the blockage but at that point I would think loading more nitrates would cause far more profound dilation? 

If it actually reduced infarct directly I imagine it would be considered first like treatment.

We just got zofran in NYC but in my volly department we only have morphine.


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## Christopher (Jul 27, 2012)

Anjel1030 said:


> More so reducing oxygen demand and reducing the size of an infarct.
> 
> Is what we were taught in class.



I've been entertained by the bulk of textbooks which espouse the theory that morphine is useful in cardiac chest pain, as the literature does not share this outlook. The best you get is, "we should study this and find out if morphine actually does what we think it does."

Gross GJ. Role of opioids in acute and delayed preconditioning. J Mol Cell Cardiol 2003;35(7):709-18.


> These results, although preliminary, suggest that opioids may have the potential for treating acute or chronic myocardial ischemia in man.



Welch TD, et al. Modern Management of Acute Myocardial Infarction. Curr Probl Cardiol 2012;37:237-310:


> Opioids are not known to influence clinical outcome in AMI.



Worse still, the CRUSADE trial seemed to show that Morphine isn't the best choice in cardiac chest pain as it actually may increase mortality.


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## nocoderob (Jul 27, 2012)

NYMedic828 said:


> I have stopped mentioning the idea of it to my partners unless the patient is in massive pain. They always go nahhh well be at the hospital in 5 minutes why bother.
> 
> My theory is, why force them to have pain if you have a solution.



Never understood that, "Only 5 mins out," nonsense. You wouldn't with hold oxygen since you are only "5 out."

I agree, you can help, so why not? People seem to forget that the pt has to be evaluated and orders given before they recieve pain management at the ED. That is most assuredly going to be much longer than "5 minutes."


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## fast65 (Jul 27, 2012)

We carry both fentanyl and morphine, in fact, we just got fentanyl a few months ago to replace butorphanol. 

We also are carrying morphine for cardiac chest pain, as well as for part of the CHF treatment line. That being said, I find morphine to be most useful when I do IFT's, as it tends to last longer than fentanyl, requiring less frequent dosing. 

For most people, I use fentanyl as a first line for pain management. Most of our transport times are 5-10 minutes, so I'm a fan of the quick onset, and although studies have found no appreciable difference in the efficacy of fentanyl over morphine, in my experience, fentanyl works a little better.

As vene said, each drug has it's pros and cons, and it's difficult to say that one is better than the other.


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## Christopher (Jul 27, 2012)

fast65 said:


> We also are carrying morphine...for part of the CHF treatment line.



Morphine and CHF doesn't have a good outlook either, starting in the early 2000's its usage has been questioned.

Mosesso VN, et al. Prehospital Therapy for Acute Congestive Heart Failure: State of the Art. Prehosp Emerg Care. 2003;7:13-23. [PubMed]


> Its popularity in treating pulmonary edema is due to its vasodilatory and antianxiety effects, although morphine’s vasodilatory effects are transient and the result of histamine release. Recently, concerns have been raised over the use of morphine in treating acute CHF in the ED. A retrospective study of the ED management of APE and intensive care unit (ICU) admissions showed that morphine administered in the ED was associated with significant increases in ICU admissions and the need for endotracheal intubations (ETIs) when compared with sublingual captopril. Additionally, a prospective study of morphine treatment in prehospital APE showed that the drug was minimally effective as single therapy or in combination with nitrates.



More recently the ADHERE trial was fairly damning in its analysis of morphine and CHF:

Peacock WF, et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205-9. [PubMed]


> Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.


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## fast65 (Jul 27, 2012)

Christopher said:


> Morphine and CHF doesn't have a good outlook either, starting in the early 2000's its usage has been questioned.
> 
> Mosesso VN, et al. Prehospital Therapy for Acute Congestive Heart Failure: State of the Art. Prehosp Emerg Care. 2003;7:13-23. [PubMed]
> 
> ...



I'll take a more in depth look into those studies, thanks! 

I haven't personally used it in CHF, but like I said, it's an option in our treatment guidelines. I'll look into it's use a little bit more, and maybe I'll talk to my medical director to see what his thoughts are.


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## Christopher (Jul 27, 2012)

fast65 said:


> I'll take a more in depth look into those studies, thanks!
> 
> I haven't personally used it in CHF, but like I said, it's an option in our treatment guidelines. I'll look into it's use a little bit more, and maybe I'll talk to my medical director to see what his thoughts are.



We got rid of morphine/lasix and added ACE inhibitors for CHF after reviewing the literature. We still carry lasix, but its for prolonged transports or medical control only with pediatric pulmonary edema.


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## NYMedic828 (Jul 27, 2012)

We still have morphine for pulmonary edema but not suspected MI.

I don't know anyone who has given it for APE though.

We also have 1-2mg of versed for APE, I assume the reason is as an anxiolytic for that "drowning" feeling...


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## KellyBracket (Jul 27, 2012)

Christopher said:


> ...
> Worse still, the CRUSADE trial seemed to show that Morphine isn't the best choice in cardiac chest pain as it actually may increase mortality.



Read the study, and I just can't imagine that the result would stand up in a prospective trial.

I think the key is that is was a NSTEMI population. They're a heterogeneous population, with comorbid problems mixed up with their troponin releases. Probably morphine administration was just a marker for their level of sickness, in a way that wasn't adjusted for in the analysis. As long as you don't give grams of it, morphine one of the safer meds out there.

And yeah, for EMS, I agree that fentanyl should be the standard. Good stuff.


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## Smash (Jul 27, 2012)

Sorry, double post


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## Smash (Jul 27, 2012)

I think Vene covered the question if fentanyl entirely. 

For pulmonary edema I think small doses of versed would be a much better idea given the concerns over morphine.  
I'm not a fan of the CRUSADE registry, I think it probably unfairly gives morphine a bad rap. Nonetheless I think there are other, possibly better options. 

We unfortunately still carry furosemide and are expected to use it. Worse, if we manage to get away without giving in the ED will typically have a spaz and pour 200mg into the poor unsuspecting patient straight away.  I wouldn't necessarily like to see furosemide removed entirely, I would just like a bit more discretion (and to have our docs brought up to speed)


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## Smash (Jul 27, 2012)

And while I was double posting Kelly covered why the CRUSADE registry is a bit of a crock. Thanks!


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## Christopher (Jul 27, 2012)

KellyBracket said:


> Read the study, and I just can't imagine that the result would stand up in a prospective trial.
> 
> I think the key is that is was a NSTEMI population. They're a heterogeneous population, with comorbid problems mixed up with their troponin releases. Probably morphine administration was just a marker for their level of sickness, in a way that wasn't adjusted for in the analysis. As long as you don't give grams of it, morphine one of the safer meds out there.



I agree that a prospective trial is likely to show something different, or at least differences between subgroups (however defined). But I do feel this matches well with how EMS treats chest pain, fairly indiscriminately in terms of protocol based medication administration. In this sense I'd favor fentanyl.



KellyBracket said:


> And yeah, for EMS, I agree that fentanyl should be the standard. Good stuff.



I enjoy the predictability in terms of pain control and hemodynamics. I also enjoy not having to give antiemetics as often (and less benadryl). I have noticed that longer pushes with morphine are usually well tolerated.

It's been almost a non-issue though as I have fentanyl and dilaudid too and almost never pick morphine.


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## Christopher (Jul 27, 2012)

Smash said:


> For pulmonary edema I think small doses of versed would be a much better idea given the concerns over morphine.



I enjoy 1-2 mg of ativan in these cases as they stay a bit more "with it" (the plural of anecdote is data, right?).

And by "I enjoy" I mean the patient enjoys...


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## 18G (Jul 27, 2012)

I love fentanyl! 

I've had better success with pain management when using fentanyl than with morphine. Fentanyl is a great drug especially for EMS. It is super fast acting, good hemodynamic profile (ie minimal hypotensive effect since no histimine release), and much less prevalence of N&V and pruritus. The short half life is deemed a plus too for field use. If a patient get's a little too much, its effects are gonna wear off much quicker then with morphine. 

While there is a lot of good about fentanyl, fentanyl does carry a risk of rigid chest wall syndrome more so in the pediatric population. Rigid chest wall has been associated more so with the concentration and rate of administration - in other words, dilute the fent and administer it slow and you will greatly reduce the chance of inducing a rigid chest wall. 

I use fentanyl for transfers up to 2-3hrs long sometimes and redosing during that time isn't a big deal at all and it seems that more frequent dosing with fentanyl is better than the less dosing with morphine - just my observation of course. Pt's seem to get much better control of their pain with fentanyl. 

It's been said that morphine has more of an anxiolytic effect than fentanyl does which is something to maybe consider in certain patients. With morphine, I see it often given together with an antiemetic to head off any nausea the morphine may cause - like Vene said, why give two drugs when you can get by with giving one? 

I prefer fentanyl for chest pain and CHF to mitigate the sympathetic response. For CHF, we can reduce preload with aggressive nitrates, CPAP and some systems ACE inhibitors. 

My unit carries both morphine and fentanyl.


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## Veneficus (Jul 28, 2012)

KellyBracket said:


> Read the study, and I just can't imagine that the result would stand up in a prospective trial.
> 
> I think the key is that is was a NSTEMI population. They're a heterogeneous population, with comorbid problems mixed up with their troponin releases. Probably morphine administration was just a marker for their level of sickness, in a way that wasn't adjusted for in the analysis. As long as you don't give grams of it, morphine one of the safer meds out there.
> 
> And yeah, for EMS, I agree that fentanyl should be the standard. Good stuff.



Interesting along the same lines, I was reading some papers last year on reports of endophines causing endocardial capilary constriction and subsequent q-wave infarction.

As morphine works on the same receptors, it seems only logical that giving morphine to nstemi pts who are often considered to have endocardial infarcts, would make the situation worse.

Just another bump in the road of protocol based medicine I think. The single treatment that cures all remains elusive.


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## the_negro_puppy (Jul 28, 2012)

We have just introduced Fentanyl IN for paeds with ICPs also able to give IM/IV to adults. So they will introduce Fentanyl IV/IM to us as well. One rumour is that they want to get rid of morphine all together and just have fent. I have never used the drug though we have started stocking 100mcg/2ml amps


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## Jon (Jul 28, 2012)

nocoderob said:


> Never understood that, "Only 5 mins out," nonsense. You wouldn't with hold oxygen since you are only "5 out."
> 
> I agree, you can help, so why not? People seem to forget that the pt has to be evaluated and orders given before they recieve pain management at the ED. That is most assuredly going to be much longer than "5 minutes."




Concur 110%. Paramedics have a responsibility to perform appropriate medical care and reduce suffering. Failing to do so isn't cool. Aggressive prehospital treatment is seldom wrong.


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## 18G (Jul 28, 2012)

Yeah. Only 5mins out and then 45mins until a nurse gets around to giving the pain med in the ED. 

I give pain med in the unit no matter if I'm just pulling into the ED parking lot.


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## medic417 (Jul 28, 2012)

Why are we only talking about keeping only one type of pain med.  You should have multiple choices and use what is best for your current patient.  

Also anyone withholding pain meds need to lose certification and face prison.  You have caused harm when you allow people to suffer.


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## 18G (Jul 28, 2012)

medic417 said:


> you have caused harm when you allow people to suffer.



+1000000000


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## BigBad (Jul 29, 2012)

we carry both.    i work in a rural area with long tranports and lots of trauma due to ski resorts.   our protocol max dose 30mg morphine and 300mcg fent.   This can all be put on one pt if warrented...and add benzos if muscle spasms.   Rarely do I mix the two, but in some pts one works better than the other.  We prefer fent for chest pain and shorter transports.   I consider 100mcg if fent = to 4mg of morphine.   Yes fent is stronger....but thats why its in mcgs.    I use morphine in longer transports and its easier to maintain the theraputic window with.   its all relative to your populations needs...


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## Merck (Jul 29, 2012)

Well put, BigBad.  Drugs are the same whether an ABX or narcotic - pick the right one at the right time for the right patient.  We speak of onset and duration and argue the difference between them.  The name of this post concerns me in the same way that one titled 'Imapenem, why even carry penicillin' would.

We just use whatever we need at the time.  Sure there can be a little histamine release and slight drop in BP with MS but I've used it successfully for years on both cardiac and non-cardiac patients.  While it may not be as potent things are still generally dosed accordingly and MS provides a longer duration.

As for the whole 'do we treat pain and how much' question I have long heard things like "I leave them with at least 3/10 pain so that the doctor takes it seriously".  What a load of garbage.  Treat your patient to make them comfortable and eliminate suffering and record and report it appropriately.  If the doctor/RN doesn't believe you then they're idiots.


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## Shishkabob (Jul 29, 2012)

Because some people report sensitivity to Fentanyl, and some people report better results with morphine.


And burns.


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## Doczilla (Aug 1, 2012)

Consider the potential harm of administering nitro in a complete occlusion of a CA. What will the reflex tachycardia do to the ischemic zone when there's no blood flow? 

Morphine provides the theoretical benefit of beta blockers in that you can blunt that reflex tachycardia from nitro administration as well as contributing to afterload reduction.


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## WTEngel (Aug 12, 2012)

I like to have morphine as an option. I agree that the argument shouldn't necessarily be that one is always superior to the other. Certainly a case can be made that in certain patients with certain presentations one would be superior, but blanket statements just don't do it for me.

I will also throw into the mix that fentanyl does have a rare incidence of causing chest wall rigidity. There has been some research that points to the rate of administration being the cause, although I have seen it pushed over 3 minutes and cause rigidity. 

In the cases I have seen where this was encountered, sedation, paralysis, and intubation was ultimately required to ventilate the patient. I have only seen it in peds.

Just food for thought...


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## Shishkabob (Aug 12, 2012)

WTEngel said:


> I will also throw into the mix that fentanyl does have a rare incidence of causing chest wall rigidity. There has been some research that points to the rate of administration being the cause, although I have seen it pushed over 3 minutes and cause rigidity.
> 
> In the cases I have seen where this was encountered, sedation, paralysis, and intubation was ultimately required to ventilate the patient. I have only seen it in peds.



I don't know if I told ya WTEngel, but I had one such patient, a 17yo with an arm fx.  


You want to have the crap scared out of you as a provider?  Have a ped with chest wall rigidity from the Fentanyl you gave... Narcan doesn't do anything to help.


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## OzAmbo (Aug 12, 2012)

NYMedic828 said:


> Here in NYC as I've stated in the past we
> But anyway, what's the purpose of even having morphine when fentanyl doesn't cause as many adverse reactions?


There are documented adverse reaction when fentanyl is used in the same patient management episode as IV amiodarone.

Although morph is still our first line drug, it will sooner or later become the second line (in fact, it probably would be already of fentanyl production could keep up with use)

Morph will still be in our arsenal as there are those who have profound respiratoy depression with fentanyl that they dont get with morph. We also have a need for an opiate for post intubation sedation, RSI and analgesia in patients who are being managed for cardiac chest pai who are also getting aiodarone for their tachy arrhythmias.

I guess the other thing too is that in the management of such a common condition, i think it would be short sighted to only have 1 drug available

Sorry if already posted by someone slese.....


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## WTEngel (Aug 14, 2012)

Linuss said:


> I don't know if I told ya WTEngel, but I had one such patient, a 17yo with an arm fx.
> 
> 
> You want to have the crap scared out of you as a provider?  Have a ped with chest wall rigidity from the Fentanyl you gave... Narcan doesn't do anything to help.



I didn't know that happened to you.

I don't know the mechanism by which the rigidity develops, but I do know it will put some hair on your chest the first time it happens to you and you aren't prepared.

This is one of the worst "can't ventilate, can't oxygenate" scenarios I have ever been in.


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## Doczilla (Aug 15, 2012)

Sounds like a sh*t sandwich. Another example of why ketamine underutilized: money in kids. Even sub-anesthetic doses provide profound anesthetia. 

Ive used it all the way up to extremely urgent chest tubes when i didn't have time for an intercostal block, with excellent results. 

One kid in particular came back a few weeks later to get the staples in his sternum checked out, didn't recall anything from the procedure. I put that as a win in my book.


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## Akulahawk (Aug 15, 2012)

One way to see morphine being used, is to include a small dose of Benadryl prior to administration. The Benadryl is used primarily in its role as a histamine blocker, as morphine is known to trigger some histamine release. That, of course, may be what is causing the drop in blood pressure following morphine administration. Personally, I would like to see fentanyl and other pain medications available for use in the prehospital setting. I would also like to see several different sedatives and anti-nauseous being available in the prehospital setting, because  one medication may not work very well, for a specific patient.

As we all know, some medications work well in some patients, and do not work at all in others. One thing I do like about fentanyl is that some patients do well with it and can get adequate relief from pain with it at a relatively low dose when compared to morphine. Of course, we do have to watch out for the chest rigidity problem.


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## ccrook (Aug 19, 2012)

*Just a couple of thoughts*

The way I see it there are a couple of reasons to carry both.  First, with morphine, the peripheral pooling/ decreased pre-load effect that is detrimental in trauma is very handy in the treatment of CHF, second, Fentanyl has a much faster onset of action than morphine for trauma ie. femur/hip fractures where you may be pre-medicating prior to movement and need to work quickly.  Finally, the onset of action for Fentanyl is very desirable for drug seekers so I typically reserve it for patients that I can visualize their problem ie. trauma  and leave morphine for medical conditions.  Besides its nice to have options.


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## medicsb (Aug 20, 2012)

Linuss said:


> I don't know if I told ya WTEngel, but I had one such patient, a 17yo with an arm fx.
> 
> 
> You want to have the crap scared out of you as a provider?  Have a ped with chest wall rigidity from the Fentanyl you gave... Narcan doesn't do anything to help.



Aaaand what was the dose you gave?


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## Hockey (Aug 21, 2012)

Anjel1030 said:


> We carry morphine for cardiac chest pain.
> 
> Not pain management, that is what fentanyl is for.



Wat?

Where did you get this info from?!  Protocol says either one.  

5-17


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## Anjel (Aug 22, 2012)

Hockey said:


> Wat?
> 
> Where did you get this info from?!  Protocol says either one.
> 
> 5-17



I talked with dr. Gardner at MoH. She is our med director. She said we have the option for both, but morphine is for chest pain, and fentanyl for pain. Unless the pt is allergic to fentanyl then they get morphine. 

But fentanyl is preferred.


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## Handsome Robb (Aug 22, 2012)

Not to nitpick but how about vasodilatory effects reducing afterload, workload and MvO2?


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## Anjel (Aug 22, 2012)

NVRob said:


> Not to nitpick but how about vasodilatory effects reducing afterload, workload and MvO2?



In regards to? Who was that question aimed for?


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## NYMedic828 (Sep 2, 2012)

Why do people have it in their head that different drugs of the same class aren't ultimately equal in strength assuming the dose is equivalent.

For example most people I talk to seem to believe that the reason we don't give people fentanyl over morphine is because it's too strong and they don't need that much pain relief most times... Do they not get that we are giving 10mg morphine as an equal to 100mcg of fentanyl? (roughly)


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