# Dilaudid



## 18G (Apr 21, 2010)

Just curious if any systems are using dilaudid on their units. It seems to be the drug of choice here in the ED.


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## rhan101277 (Apr 21, 2010)

No, not here.


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## Melclin (Apr 21, 2010)

I'm always interested as to why all these different analgesics seem to be popular in EDs in the states. Whats wrong with morphine?


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## TransportJockey (Apr 21, 2010)

I've never worked in a service that carried them. In NM medics were allowed to use any narcotic but most services only authorized Fentanyl and Morphine. And to be honest with those two I would be perfectly happy


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## Dominion (Apr 21, 2010)

There is a service locally that carries Morphine, Dilaudid, and Fentanyl.  Just in case I guess.


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## 18G (Apr 21, 2010)

I think EMS services should carry two different analgesics. We only carry morphine which is okay however, if the patient has an allergy to it they are out of luck for pain management which I don't think is right. 

I wish we carried Fentenyl as well but we don't.... just good 'ol MS with a pretty conservative protocol.... 2mg every ten minutes to a total dose of 10mg. I think Dilauded is a pretty good drug and have given it many a times. It is much less likely to cause nausea in comparison to MS and has a relatively short duration of action.


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## Smash (Apr 21, 2010)

I think ems should carry as many options for pain relief as possible. That said, I don't know how much added benefit there would be from a third opioid agent if morphine and fentanyl are carried. I'd go for ketamine or a hypnotic instead. 

2mg every 10 minutes to a maximum of 10mg?  Is that set in stone or can it be varied?  That is not a conservative regimen, that's non-existant!


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## Veneficus (Apr 22, 2010)

Smash said:


> I think ems should carry as many options for pain relief as possible. That said, I don't know how much added benefit there would be from a third opioid agent if morphine and fentanyl are carried. I'd go for ketamine or a hypnotic instead.



can I come and work for you guys? 



Smash said:


> 2mg every 10 minutes to a maximum of 10mg?  Is that set in stone or can it be varied?  That is not a conservative regimen, that's non-existant!



that is unfortunately a very common protocol requiring online medical directon to deviate. Might as well do nothing right?


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## 8jimi8 (Apr 22, 2010)

18G said:


> I think EMS services should carry two different analgesics. We only carry morphine which is okay however, if the patient has an allergy to it they are out of luck for pain management which I don't think is right.
> 
> I wish we carried Fentenyl as well but we don't.... just good 'ol MS with a pretty conservative protocol.... 2mg every ten minutes to a total dose of 10mg. I think Dilauded is a pretty good drug and have given it many a times. It is much less likely to cause nausea in comparison to MS and has a relatively short duration of action.



in comparison to what?  Dilaudid lasts longer than morphine, and much more powerful.


......Nonproprietary (Trade) Name	 IM or SC Dose	 ORAL Dose
Morphine sulfate	 ..........................10 mg ..........  40-60 mg
Hydromorphone HCl (DILAUDID)......... 1.3-2 mg	 .....6.5-7.5 mg
Oxymorphone HCl (Numorphan)..........	 1-1.1 mg.....	 6.6 mg
Levorphanol tartrate (Levo-Dromoran)	 2-2.3 mg	 .....4 mg
Meperidine, pethidine HCl (Demerol)....	 75-100 mg.....	 300-400 mg
Methadone HCl (Dolophine).............	 10 mg..........	 10-20 mg
* Dosages, and ranges of dosages represented, are a compilation of estimated equipotent dosages from published references comparing opioid analgesics in cancer and severe pain.


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## MrBrown (Apr 22, 2010)

We carried it for a brief period in the late eighties while some hospital services carried nubain or foratol.

That however, was before my time.


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## ceej (Apr 26, 2010)

We carry Dilaudid for IV/IM. It's my go-to analgesic if I'm not worried about B/P issues.

I find it especially effective for kidney stone pain.

Morphine is always a good choice, too.

My beef with Fentanyl is my protocol allows 150mcg q 10 min up to 450mcg before I have to call. I find that not many patients can get adequate control until the ~600mcg range. Dilaudid on the other hand, I almost always have success at 1mg and rarely if ever give another 1mg before the hospital.


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## 8jimi8 (Apr 26, 2010)

ceej said:


> We carry Dilaudid for IV/IM. It's my go-to analgesic if I'm not worried about B/P issues.



And you aren't worried about blood pressure with morphine...?


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## ceej (Apr 26, 2010)

8jimi8 said:


> And you aren't worried about blood pressure with morphine...?



I think you misunderstood the quantification of my statement. I'm not going to give someone 2mg of MS with a blood pressure of 80/P


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## 8jimi8 (Apr 26, 2010)

while we're on the subject...

how much does 1 mg or morphine drops someone's blood pressure?

Is there a reliable estimation?  I know everyone is different, but you have those ranges  e.g. 1 unit of novolog will drop someones BG an approximate 40 points.  1 unit of PRBCs will cause the HGB to rise by 2 etc...


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## 8jimi8 (Apr 26, 2010)

ceej said:


> I think you misunderstood the quantification of my statement. I'm not going to give someone 2mg of MS with a blood pressure of 80/P



Anecdotally

we had a lady c/o 10/10 crushing, radiating chest pain.  BP was 85/60 on LUE.

Pt would go to sleep when you left the room... with a smile on her face... (yah in 10/10 crushing, radiating chest pain)

Ecg was unchanged, CE's were run in the last 24 hours (-) x3 over 18hrs.  Stat CE's were (-).

Md and CRT RN were on the floor and I was told to give the morphine anyway.

Pressure didn't drop a bit. (i think i gave her 4)  pain went down to a 9.

lol

i think 0-10 for us meant 9-10 for her.  So many patients are healthcare savvy now.  Especially our population who get "crushing, radiating chest pain" when its too cold to sleep on the street.

They know that all you have to say is I have pain 10/10 and you'll get the feelgood juice... or a couple of 10/325s.


Oh the county... I love workin at the county!


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## alphatrauma (Apr 28, 2010)

8jimi8 said:


> while we're on the subject...
> 
> how much does 1 mg or morphine drops someone's blood pressure?
> 
> Is there a reliable estimation?  *I know everyone is different*, but you have those ranges  e.g. 1 unit of novolog will drop someones BG an approximate 40 points.  1 unit of PRBCs will cause the HGB to rise by 2 etc...



That's an interesting question you put forth. I would think that due to variances in physiology from person to person, there is just too much at play to make such an estimate.


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## ah2388 (May 3, 2010)

one of the services ive rode with carries dilaudid, ms, and fentanyl.

Ive only seen dilaudid used in the ED with great success for all types of pain.  With that being said, Ive also found fentanyl given weight based (1-3mcg/kg) to be a very effective analgesic as well


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## rhan101277 (May 3, 2010)

8jimi8 said:


> Anecdotally
> 
> we had a lady c/o 10/10 crushing, radiating chest pain.  BP was 85/60 on LUE.
> 
> ...



lol 10/325's


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## MoonachieFirstAid&Rescue (May 3, 2010)

In NJ BLS doesnt carry anything.


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## exodus (May 3, 2010)

MoonachieFirstAid&Rescue said:


> In NJ BLS doesnt carry anything.



BLS doesn't carry anything anywhere, hence the ALS discussion forum?


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## BLSBoy (May 5, 2010)

MoonachieFirstAid&Rescue said:


> In NJ BLS doesnt carry anything.



In NJ I can't even give it without asking permission. 
Why even put this in?<_<


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## medicRob (May 8, 2010)

We have morphine and dilaudid on our rigs. Many services around here discourage carrying multiple narcotics of this caliber unless absolutely necessary given the rise in thefts as of late.


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## RALS504 (May 16, 2010)

One of the EMS services in my systems lets EMT-Is give Dilaudid or Morphine. It is a very progressive service, thier capability is definately MICU.


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## 18G (Jul 8, 2011)

Had a morbidly obese (500lb) patient last night with a femur fx. ED was giving 1mg of Dilauded IV without much effect on patients pain. Pt. stated the 1mg barely decreased the pain and was rating 8/10 on my assessment with evidence of pain response. Pt. appeared very uncomfortable. 

ED doc wanted to give transfer orders of Dilauded 1mg q2hrs PRN. It wasn't making any sense to me to keep doing the same thing over and expecting a different result so I asked the nurse to see about having it changed to 2mg q1hr PRN of which the doc did. Transfer was a little over 2hrs. 

So about 15mins into the transfer after I get everything situated patient is still having 8/10 pain that is being exacerbated by the dynamics of the ambulance transport so I give the 2mg Dilauded slow IVP as ordered. Within 10mins pain is slightly reduced, pt. getting sleepy but alert and oriented, hard to hold eyes open.... I'm thinking okay patient had long night, the narc is making her want to sleep. 10-15mins later... highly somnolent, decreased orientation, desaturating, decreased B/P, slight perioral cyanosis developing = NOT GOOD.

I don't want to hit her hard with Narcan so I decided to give 0.2mg Narcan IV... nothing. 5mins later another 0.2 which results in full reversal. Patient is back to baseline mental status and level 9 pain.... ok.. this sucks!

So I call MedComm and explain the case to the doc (who is very cool during the consult) to see what direction she wanted me to go for pain management. Orders are given for 50mcg fentanyl q20-30mins PRN. Patient get's 100mcg over 90mins which brings pain to a level 7 and is tolerable with no adverse effects.    

POINTS FOR DISCUSSION:

- I was really surprised that 2mg of Dilauded in a 500lb patient would have the profound and negative effect that it did on this patient. Especially considering that 1mg was barely even scratching the surface.  

- Anyone else have any cases like with involving Dilauded?

- I am a strong advocate for pain management for my patients and feel I did the right thing. 

- Any other input is appreciated !


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## TransportJockey (Jul 8, 2011)

Oh hey, update... My ILS truck in NM only carries MS and Fent. I am allowed to give Dilaudid, if we carried it. But we don't anymore


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## slb862 (Jul 9, 2011)

We use Fent and morphine.  A little Versed at times. 

I usually give Morphine 1st, then follow it with Fent., then some Versed if needed.

Dilaudid works great for some things. In the ED they use quite a bit of it.  I also have noticed it is certain physicians drug of choice.


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## MediMike (Jul 11, 2011)

We carry Dil in some of our more rural rigs, like someone above mentioned apparently it holds some magic capability to handle kidney stone px.  Good friend of mine was holding on to a 3.4mm stone that just wasn't moving, 200mcg Fent didn't touch it, 1mg Dil wiped it away!


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## jjesusfreak01 (Jul 17, 2011)

MediMike said:


> We carry Dil in some of our more rural rigs, like someone above mentioned apparently it holds some magic capability to handle kidney stone px.  Good friend of mine was holding on to a 3.4mm stone that just wasn't moving, 200mcg Fent didn't touch it, 1mg Dil wiped it away!



Do y'all carry Toradol on your rigs? I'm told it works wonders for kidney stone pain...most of the time. I would probably use it first line before moving to narcs, if possible.


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## shfd739 (Jul 17, 2011)

jjesusfreak01 said:


> Do y'all carry Toradol on your rigs? I'm told it works wonders for kidney stone pain...most of the time. I would probably use it first line before moving to narcs, if possible.



Just from what I've seen Toradol is hit or miss for kidney stones. It's never worked for my wife's or some coworkers stones...but I've seen patients that it's worked great for. It looks like to an extent around here dilaudid is taking the place of morphine as the ERs pain drug of choice. 


Sent from my electronic overbearing life controller


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