Fentanyl and Rigid Chest

[Thepardoner]

So here in the state of NY, we have nice options for pain management. Fentanyl, Morphine, and Ketamine.

Right now, we can give 50mcg+50mcg on standing orders. They are increasing the total dosage to 200mcg of fentanly.

My question to those out there using fentanyl, if for some reason your patient does develop rigid chest, which is RARE, but can happen if administered too quickly and irrelevant to the amount pushed, what do you have to counter that? Spoke to a bunch of people in the hospital that said narcan is not a 100% in terms of reversing the rigid chest. Everyone I spoke to said the best option is a short acting paralytic.

Does everyone who administers fentanyl have paralytics in their formulary?

Has anyone treated a patient that developed a rigid chest?

Thanks!

 

[NomadicMedic]

Good discussion about it here: https://emtlife.com/threads/fentanyl-and-chest-wall-rigidity.20791/

Anecdotaly, I've used lots of Fentanyl and never had it happen to me. And I have no paralytic agents at my service.

 

[StCEMT]

Nope and nope. Haven't given it very much though, I don't need to break out narcs that often.

 

[CANMAN]

Give tons of Fentanyl out both in the aircraft and trauma bays in the adult patient population and have never had it happen in that patient population. We carry Succs, Roc, and Vec.

Peds/Neo is more the patient population I have heard of cases, and seen 1, which was a <5kg neonate.

 

[EpiEMS]

Fascinating complication! The evidence that I've been able to find, though, doesn't seem to really explore the epidemiology of the complication. Anybody have anything?

 

[hometownmedic5]

You could probably float a small canoe with the volume of fent I've given and never seen it. Honestly, this is the first time I've even heard of it. After reading about it briefly, aside from narcan I carry nothing to fix this.

 

[VFlutter]

Maybe @E tank can comment but I think it is slightly more commonly seen with the dosages used for narcotic only inductions in cardiac anesthesia, I.e 50-100mcg/kg. However given that these patients are usually paralyzed immediately after it probably isn't a big issue.

 

[E tank]

Ditto all of the above.

Having given it by the ounce bolus, I've never dealt with that. What I have dealt with is upper airway obstruction with great difficultly mask ventilating. This is probably what gets confused for a rigid chest more often than not. The obese, no neck large tongue types are especially at risk for that sort of event.

 

[VentMonkey]

Yeah, I agree with everyone thus far. I get it perhaps being a relative contraindication (see: keep it in the back of your mind) with certain patient populations such as the emphysemic, or the patient with remarkable burns to their torso who is fully conscious without immediate airway compromise.

Either patient listed above, and noted to be in need of pain control, I really can't think of any reasons to withhold Fentanyl because of some study done on "x" patient population in the name of science, or more likely to get their name put into some pubmed article, and perhaps add to their credibility.

Clearly, I am no physician, but I am filing this not-so-common sounding complication in the "I'll keep it in mind" category, but again, carrying Narcan, and basic to advanced airway adjuncts does carry their appropriation.

Again, knowing what to take with a grain of salt vs. what's trending, showing promise, or has been proven to be worth mentioning in the EBM/ cutting-edge medicine realms are two different things.

Also, I can't think of any narcotics I carry that don't pose this sort of inherent risk in the above patients. I'll expect the worse, prep, and take my chances.

 

[Handsome Robb]

50 mcg + 50 mcg?

Might as well give them an ice pack...

We routinely give people 100-200 mcg per dose.


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