Fentanyl and chest wall rigidity

[18G]

I had a 28y/o w/ a spleen lac. who was losing a lot of blood the other day. We were transferring him from our local ED to the trauma center by ground since heli couldn't fly due to weather.

Pt. was in a lot of pain and I gave Fentanyl. I remembered this thread and pushed it (100mcg) over a full 1-2mins.... no problems with rigidity.

On a side note.... if a pt. gets no relief with 50mcg, why would a hospital keep giving 50mcg doses when it's clear it's not touching the patients pain? Nothing like expecting change by doing the same thing over and over.

 

[WTEngel]

Depends on the amount of time between dosages. 50 mcg every 20 minutes without relief is a bit ridiculous, but 50 mcg every 3-5 until relief is noted doesn't sound too out of line.

A lot of referrals I have been to seem to go one way or the other. They either are worried about too much pain medication, and the patient is coming unglued, or they go the complete opposite and the patient is breathing 5 times a minute with a pressure of "crap / crap" and a MAP of "please help me!" (this was quoted from one of my favorite nurses during an M&M meeting.)

 

[18G]

These 50mcg doses were 30mins to an hour or longer in between. I gave 100mcg just a few mins out and the trauma doc ordered another 50mcg soon as we got to the trauma bay. Pt. was showing a trend with lowering of the B/P so was cautious about giving pain med.

Pressure started at 120/70's and slowly dropped to SBP of 101 throughout the transport. MC advised to hold off on pain med until pressure improved with fluids... I wasn't thrilled about raising the pressure and wanted to maintain it right where it was with a close eye but did give fluid through a second line to achieve pressure of 114 at which time I gave pain med.

 

[Sandog]

On a side note.... if a pt. gets no relief with 50mcg, why would a hospital keep giving 50mcg doses when it's clear it's not touching the patients pain? Nothing like expecting change by doing the same thing over and over.

Isn't that the definition of insanity?

 

[helimedic39]

I'm sure everyone knows this about Fentanyl, but it is a BP neutral med. Yes there are times when the BP drops, but it's usually in conjunction with another med or underlying problem. I read in an earlier post about the use of Narcan. Yes this will reverse the issue. My recommendation though is low dose. I've seen too many times people pull out the prefill 2mg and give this. Not necessary as 0.4 will suffice. I also like to dilute any narc in with 8 or 9 cc of saline depending on how much of the med there is. I have found that this does not give patients that "punch" of the med and its just easier to control when pushing rather than 1 cc. Just my 2 cents.

 

[Sandog]

One must exercise caution when giving Narcan to counteract Fentanyl, Hypertensive patients can go south.

 

[usalsfyre]

Usually it's not the fentanyl that causes a B/P dump, it's the midazolam. As far as small reductions in B/P, it's related to reducing pain and it's associated effects. Reversing fent with narcan shouldn't cause ANY change in B/P, other than the fact they're now going to start hurting agiain.

 

[usalsfyre]

These 50mcg doses were 30mins to an hour or longer in between. I gave 100mcg just a few mins out and the trauma doc ordered another 50mcg soon as we got to the trauma bay. Pt. was showing a trend with lowering of the B/P so was cautious about giving pain med.

Pressure started at 120/70's and slowly dropped to SBP of 101 throughout the transport. MC advised to hold off on pain med until pressure improved with fluids... I wasn't thrilled about raising the pressure and wanted to maintain it right where it was with a close eye but did give fluid through a second line to achieve pressure of 114 at which time I gave pain med.

This is just idiotic, and a doc that's not familiar with fentanyl.

 

[usalsfyre]

...or they go the complete opposite and the patient is breathing 5 times a minute with a pressure of "crap / crap" and a MAP of "please help me!" (this was quoted from one of my favorite nurses during an M&M meeting.)

Seen some of this with morphine. Usually though, it's the first example you gave. "The recieving needs to be able to assess them" battlecry :glare:.

 

[jrm818]

Usually it's not the fentanyl that causes a B/P dump, it's the midazolam. As far as small reductions in B/P, it's related to reducing pain and it's associated effects. Reversing fent with narcan shouldn't cause ANY change in B/P, other than the fact they're now going to start hurting agiain.

There are some old (70's and 80's) case reports and very tiny studies that apparently (no full text online that old, so going on abstracts alone) demonstrated a linkage between narcan administration and development of acute hypertension in patients with a baseline level of chronic hypertension.

Unfortunately I can't find any more modern update on the issue. I wouldn't be surprised if most of the effect was due to unmasking of pain and reversal of opioid sympatholysis, however.

 

[Sam Adams]

opioid sympatholysis

that's a mouthfull!