Fentanyl; Why even carry Morphine?

[Christopher]

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.

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.

 

[Christopher]

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...

 

[18G]

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.

 

[Veneficus]

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.

 

[the_negro_puppy]

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

 

[Jon]

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.

 

[18G]

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.

 

[medic417]

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.

 

[18G]

you have caused harm when you allow people to suffer.

+1000000000

 

[BigBad]

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...

 

[Merck]

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.

 

[Shishkabob]

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


And burns.

 

[Doczilla]

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.

 

[WTEngel]

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...

 

[Shishkabob]

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.

 

[OzAmbo]

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.....

 

[WTEngel]

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.

 

[Doczilla]

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.

 

[Akulahawk]

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.

 

[ccrook]

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.