fentanyl info

[knxemt1983]

I've read all the posts I could find on the advantages / diadvantages of fentany vs. morphine. I have been asked to research the option of adding fentanyl to our pain management protocols, and am having trouble finding research documentation to submit to our medical director. Does anyone have any links to some research or articles? This is the first time our MD has charged me to do something so I wanna be sure and do it right. thanks for any help you can give me.

 

[Melclin]

-Rickard C. O'Meara P. McGrail M. Garner D. McLean A. Le Lievre P. A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. American Journal of Emergency Medicine. 2007;25(8):911-7

-Galinski M. Dolveck F. Borron SW. Tual L. Van Laer V. Lardeur JY. Lapostolle -F. Adnet F. A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. American Journal of Emergency Medicine. 2005; 23(2):114-9

-Kanowitz A. Dunn TM. Kanowitz EM. Dunn WW. Vanbuskirk K. Safety and effectiveness of fentanyl administration for prehospital pain management. Prehospital Emergency Care.2006;10(1):1-7

-Thomas SH. Fentanyl in the prehospital setting.American Journal of Emergency Medicine. 2007;25(7):842-3

-Jaslow D. Klimke A. Cunnius P. Neubert D. Prehospital pharmacology: fentanyl. EMS magazine. 2007;36(8):105-9

And for arguments specifically for:

-Braude D. Richards M. Appeal for fentanyl prehospital use. Prehospital Emergency Care. 2004;8(4):441-2.


IN fentanyl is used here by our basic level providers. Its a good way of giving less well trained providers another pain relief option if you're wary of the IV route.

I have a special relationship with my universities journal database search engine, so I can do some more looking around if you need more stuff or specific stuff. If you don't have journal access, I can download those articles and email them to you if needs be

 

[Akulahawk]

One specific advantage of Fentanyl over Morphine is that you don't get a histamine release with Fentanyl like you do with Morphine... and therefore, you don't get the decrease in blood pressure. Of course you could give benadryl prior to giving morphine... but that only stops the effect of the histamine as opposed to not having it released in the first place.

Search for Fentanyl histamine in your favorite search engine... and you'll see results about that aspect of this. Flight programs I'm familiar with use it and seem happy with it.

 

[medic417]

Add it but do not let them take morphine away. Sorry no links right now.

 

[Akulahawk]

Add it but do not let them take morphine away. Sorry no links right now.

This would be my preference too...

 

[knxemt1983]

Add it but do not let them take morphine away. Sorry no links right now.

I totally agree, morphine has its place. it seems to me that carrying both would give us an expanded ability to control pain, especially with the shorter half-life of fentanyl.

 

[knxemt1983]

-Rickard C. O'Meara P. McGrail M. Garner D. McLean A. Le Lievre P. A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. American Journal of Emergency Medicine. 2007;25(8):911-7

-Galinski M. Dolveck F. Borron SW. Tual L. Van Laer V. Lardeur JY. Lapostolle -F. Adnet F. A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. American Journal of Emergency Medicine. 2005; 23(2):114-9

-Kanowitz A. Dunn TM. Kanowitz EM. Dunn WW. Vanbuskirk K. Safety and effectiveness of fentanyl administration for prehospital pain management. Prehospital Emergency Care.2006;10(1):1-7

-Thomas SH. Fentanyl in the prehospital setting.American Journal of Emergency Medicine. 2007;25(7):842-3

-Jaslow D. Klimke A. Cunnius P. Neubert D. Prehospital pharmacology: fentanyl. EMS magazine. 2007;36(8):105-9

And for arguments specifically for:

-Braude D. Richards M. Appeal for fentanyl prehospital use. Prehospital Emergency Care. 2004;8(4):441-2.


IN fentanyl is used here by our basic level providers. Its a good way of giving less well trained providers another pain relief option if you're wary of the IV route.

I have a special relationship with my universities journal database search engine, so I can do some more looking around if you need more stuff or specific stuff. If you don't have journal access, I can download those articles and email them to you if needs be

I should have access to them through my school, but it's not working. maybe because i took a semester off before starting nursing school. I'l shoot you a pm with my email. thanks a bunch

 

[Hellsbells]

another good resource is google scholar

 

[Melclin]

I totally agree, morphine has its place. it seems to me that carrying both would give us an expanded ability to control pain, especially with the shorter half-life of fentanyl.

And an excellent way of treating people who have a specific allergy.

Analgesia in general is not handled well in US EMS it would seem. We have an inhalant for fast and more mild pain relief, Methoxyflurane; IV/IM morphine and IN/IV fentanyl.

On the chopper they also carry an IV NSAID: Dynastat, and pethidine.

 

[downunderwunda]

Analgesia in general is not handled well in US EMS it would seem. We have an inhalant for fast and more mild pain relief, Methoxyflurane; IV/IM morphine and IN/IV fentanyl

Methoxyflurane is not considered a frontline analgesia any more, it is way too nephrotoxic. The concerns for Nephrotoxicity are not for the patients, but for officers administering this drug routinely, much as there are now questions being asked of NO, or Entonox with birth rates highly elevated of female siblings.

Morphine will always be the standard other drugs are compared to, however as a natural opiate, it has inherent problems of side effects. It is also long acting, which has both advantages & disadvantages.

With a half life of around 1 hour, Fentanyl is perfect for prehospital analgesia & silences the doctors who moan that they cant examine a patient for too many hours after morphine administration. It is also excellent for kids as it crosses the mucosa & can be given Intra Nasal, rather than via IMI or IV.

 

[Smash]

With a half life of around 1 hour, Fentanyl is perfect for prehospital analgesia & silences the doctors who moan that they cant examine a patient for too many hours after morphine administration. It is also excellent for kids as it crosses the mucosa & can be given Intra Nasal, rather than via IMI or IV.

Any doctor who thinks that adequate prehospital analgesia leads to difficulties in assessing patients needs to get some nasty kidneystones and be treated (undertreated) by paramedics.

Hopefully that will drag them into this century and stop them whinging based entirely on recieved wisdom with no basis in science.

 

[Melclin]

The concerns for Nephrotoxicity are not for the patients, but for officers administering this drug routinely

Enjoynz tells me that they have been using charcoal filters for the exhaled methoxyflurane over the ditch, for that very reason.

I've been told by that the concern for provider health regarding penthrane is largely a beat up. It makes sense that it could become a problem though. Methoxyflurane toxicity is dose-time dependant and inorganic fluoride is very fat soluble. Do you know of any published evidence showing that it causes problems for providers. Still it seems like you could easily modify the kinds of environment you administer the drug in i.e. opening a window.

In any case I think I'd prefer to use IN fentanyl anyway. I'm glad the powers that be finally approved it for use by ALS roadies and not just MICA.

Any doctor who thinks that adequate prehospital analgesia leads to difficulties in assessing patients needs to get some nasty kidneystones and be treated (undertreated) by paramedics.

Hopefully that will drag them into this century and stop them whinging based entirely on recieved wisdom with no basis in science.

+1


In the UK, diamorphine, better know by its street name, Heroin, is commonly used in EDs. Imagine how much we'd get rolled for our drugs if we started carrying heroin and the undesirable masses caught wind of it.

 

[Ridryder911]

Ironic JEMS has a specific article on Morphine vs. Fentanyl based upon Australia
http://www.google.com/search?q=Jems...ie=UTF-8&oe=UTF-8&sourceid=ie7&rlz=1I7GGIH_en

Personally, I highly recommend Fentanyl in the prehospital arena much more than Morphine Sulfate. The newer research indicating AMI that are having > bifascicular blocks can have at least a 60% increase of mortality when administered Morphine Sulfate. The release of histamine and the lowering of blood pressure in patients of trauma and those that need analgesics without those s/e.

I quite aware of the s/e of "stone chest syndrome" with the administration of Fentanyl but if administered properly and appropriate dosage one should not have those consequences.

There is another JEMS article I could not locate describing Fentanyl as the safest and most used analgesic used in prehospital care in the U.S.

R/r 911

 

[Melclin]

Ironic JEMS has a specific article on Morphine vs. Fentanyl based upon Australia
R/r 911

That article was based the Rikard et al trial done, in part, here in Melbourne. Its the first in the list of articles I posted. The methodology was a bit soft. I'd be interested to know why they didn't blind the study in any way, and why they included pts who had penthrane as well without adjusting the results.

 

[Akulahawk]

Ironic JEMS has a specific article on Morphine vs. Fentanyl based upon Australia
http://www.google.com/search?q=Jems...ie=UTF-8&oe=UTF-8&sourceid=ie7&rlz=1I7GGIH_en

Personally, I highly recommend Fentanyl in the prehospital arena much more than Morphine Sulfate. The newer research indicating AMI that are having > bifascicular blocks can have at least a 60% increase of mortality when administered Morphine Sulfate. The release of histamine and the lowering of blood pressure in patients of trauma and those that need analgesics without those s/e.

I quite aware of the s/e of "stone chest syndrome" with the administration of Fentanyl but if administered properly and appropriate dosage one should not have those consequences.

There is another JEMS article I could not locate describing Fentanyl as the safest and most used analgesic used in prehospital care in the U.S.

R/r 911

I've heard of providers administering 50 mg diphenhydramine prior to morphine sulphate administration precisely because of the histamine problem. Also, carefully titrated analgesia won't impede evaluation, and may actually make it easier to properly evaluate a patient. When you do it that way, you're not trying to obliterate the pain, you're trying to make it tolerable. Doing that doesn't erase the Sx of where the pain is and where it radiates and may actually help in better localizing the pain.

The liklihood of this happening anytime soon in Sacramento County... slim & none. I suspect Slim just died...

 

[downunderwunda]

Any doctor who thinks that adequate prehospital analgesia leads to difficulties in assessing patients needs to get some nasty kidneystones and be treated (undertreated) by paramedics.

Hopefully that will drag them into this century and stop them whinging based entirely on recieved wisdom with no basis in science.

Smash, have you ever had Renal Colic?

Synthetic Opiates work far better than morphine on them. If i must get more specific, I was refering to trauma patients.

Put simply, it is an attitude that some doctors that is propogated by moronic medics who overuse morphine. Why? BECAUSE THEY CAN. I have 3 different analgesics available to me. Protocols state that morphine is the preferred analgesic for adults. Does this mean I use it every time? No way. I choose the most appropriate analgesic for the patient.

I've been told by that the concern for provider health regarding penthrane is largely a beat up.

Then why have they stopped using it in theatre?

I will search for some research on the subject & see how I go on toxicity to officers. I know one was commissioned by the union, but when they started to put results forward that were adverse, the service withdrew support for the study.

Still it seems like you could easily modify the kinds of environment you administer the drug in i.e. opening a window.

You have seen a merc havent you? the rear windows are fixed. The design makes it very difficult to drive, especially on the hwy (I am rural based so most driving is at speed) with the window open.

 

[Melclin]

Then why have they stopped using it in theatre?
...
You have seen a merc havent you? the rear windows are fixed. The design makes it very difficult to drive, especially on the hwy (I am rural based so most driving is at speed) with the window open.

Well the dosages/exposure time are much higher when used in theatre as an anesthetic.

Yes I know the rear windows are fixed :glare:. I didn't specifically consider the difficulty with driving at high speeds with the window down, no, but you know what I mean. Modify the way you give it. Put the air conditioning on, only give it on scene etc.

 

[downunderwunda]

To be honest, I have tried, as have most, all you have suggested. Now, I rarely use it.

Experience tells you that an inhalation analgesic, that requires the person to be continually breathing it in to have its effect, & the removal causes pain, means that it is very hard to get a proper history from the patient. It is also difficult to get them to comply when they have little belief that it will work.

I know it works. The main exception is a person with renal colic. It works like a dream. Better than any opiate. Yes, I also speak from experience unfortunatly there!!!!

 

[Smash]

Smash, have you ever had Renal Colic?

Synthetic Opiates work far better than morphine on them. If i must get more specific, I was refering to trauma patients.

Put simply, it is an attitude that some doctors that is propogated by moronic medics who overuse morphine. Why? BECAUSE THEY CAN. I have 3 different analgesics available to me. Protocols state that morphine is the preferred analgesic for adults. Does this mean I use it every time? No way. I choose the most appropriate analgesic for the patient.

I'm not sure what your point is. I was referring to the attitutudes of Doctors who think that the presence of pain improves their ability to diagnose problems when in fact the opposite is true.

Are you suggesting that morphine should not be used for pain relief? Or that patients with traumatic pain should not be treated?

You may have 3 options for pain relief (and I have more), but not all services are created equal. If a paramedic is only authorized to carry morphine are you suggesting that they should not use it? I don't undertand in this context what the 'overuse' of morphine means.