How many services use Fentanyl instead of Morphine for Cardiac Chest Pain?

Fentanyl or Morphine for Cardiac Chest Pain?

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johnrsemt

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Had a conversation today with coworker.
When I was at my old service/s (10 plus years ago) we were switching from Morphine to Fentanyl for Cardiac. Here everyone still thinks Morphine is the end all for Cardiac.
It doesn't help that we are having problems getting Morphine; and Fentanyl is fully stocked.

Thoughts? Comments?
 
There are many studies that show negative outcomes when morphine is given compared to fentanyl in cardiac patients.

We don't even carry morphine anymore, and I can't even think of a reason why you would.
 
We made the switch to fentanyl back around 2014
 
The literature shows that fentanyl is just as effective as morphine for cardiac chest pain.

Since you have less histamine response from fentanyl I would certainly prefer it as it it has a more predictable clinical effect. Some of the more old school clinicians will advocate that morphine decreases BP, improves coronary perfusion, decreases afterload, et cetera; these have a varying amounts of truth to them (from none to some). I would far prefer to control hemodynamics with predictable vasoactive medications that to rely on a variable side effect of a drug.

I generally prefer fentanyl over morphine in the prehospital environment. Since the patient will have at least a 1:1 ALS provider there isn't a reason that the patient cannot be redosed, so I don't view the shorter duration as a detriment. Fentanyl typically has a safer/larger therapeutic index and less adverse reactions than other narcotics, especially morphine.

Our HEMS/CCT and specialty teams carry fentanyl, morphine, and dilaudid but fentanyl is used far more than morphine or dilaudid.
 
We carry both. We fly a lot of cardiac patients and i have never given Morphine and do not plan on it. I prefer Fentanyl for the reasons already mentioned.
 
We carry both but the morphine is only if we run out of fentanyl and we cant restock
 
I've never used anything other than Fentanyl. I'm lucky if I even get that far down the list to give it at all.
 
I use morphine in two instances; cases in which the patient says "morphine worked great for this in the past" and "the morphine will soon expire." That said, it's fentanyl in ACS for me just because there's less of a side effect profile.
 
ODEMSA region, VA:
We use Fentanyl. Morphine hasn't been available to us for several years.
That said - morphine is the back up if the hospital restocking the drug box is out of Fentanyl.
(similar with Versed and Valium, we carry Versed and Valium is the back up if supply is out)
 
Out of interest what are the dosing administering protocols with fentanyl compared to morphine

We use morphine initial loading dose 4mg iv and 2mg increments titrated to effect (BP permitting)
max 16mg
 
0.1mcg/kg, 100mcg per dose max, max total of 200mcg.

We give a lot of benzos with our pain meds, so we use less narcotics. Versed 0.1mg/kg up to 2.5mg for potentiation of analgesia and anxiolysis.

philslat said:
Out of interest what are the dosing administering protocols with fentanyl compared to morphine

We use morphine initial loading dose 4mg iv and 2mg increments titrated to effect (BP permitting)
max 16mg
Click to expand...
 
NPO said:
0.1mcg/kg, 100mcg per dose max, max total of 200mcg.

We give a lot of benzos with our pain meds, so we use less narcotics. Versed 0.1mg/kg up to 2.5mg for potentiation of analgesia and anxiolysis.
Click to expand...

just wondering how do you titrate to effect,particularly in cardiac chest pain , with those fentanyl doses
 
For chest pain: treat until they have no pain, or you have physiologic changes that would prohibit further treatment (ie hypotension). Don't neglect your nitro for pain relief though.

For traumatic injuries: I can usually get them to fall asleep, and I find that to be a good goal. Especially in kids.

For atraumatic, noncardiac pain: I ask them what their pain is, and what would be tolerable, then work with them to maintain a tolerable pain level.

I also let my patients direct their pain management. I tell them to ask for pain meds when they need it. I find this results on fewer doses being given, but the patient's feel more comfortable when they do ask.
 
NPO said:
For chest pain: treat until they have no pain, or you have physiologic changes that would prohibit further treatment (ie hypotension).

For traumatic injuries: I can usually get them to fall asleep, and I find that to be a good goal. Especially in kids.

For atraumatic, noncardiac pain: I ask them what their pain is, and what would be tolerable, then work with them to maintain a tolerable pain level.

I also let my patients direct their pain management. I tell them to ask for pain meds when they need it. I find this results on fewer doses being given, but the patient's feel more comfortable when they do ask.
Click to expand...
are we talking in an adult just 2 dose administrations with the fentanyl
ie 100mcg x 2 to a max total of 200mcg
 
That is my protocol, yes. We can go over if we call medical control, but we can augment the opiates with benzos with standing orders, and that goes a long way. 100mcg fentanyl + 2mg versed it's a good combo.
philslat said:
are we talking in an adult just 2 dose administrations with the fentanyl
ie 100mcg x 2 to a max total of 200mcg
Click to expand...
 
philslat said:
Out of interest what are the dosing administering protocols with fentanyl compared to morphine

We use morphine initial loading dose 4mg iv and 2mg increments titrated to effect (BP permitting)
max 16mg
Click to expand...

My protocol for fentanyl, regardless of complaint, is 1mcg/kg, to a max of 150mcg, one time, then OLMC.

In practical application, if you’re a normotensive, adequately breathing, adult sized human, I’m going to give you a hundred as a hand shake, fifty more if that doesn’t get us to a good place, and since I’ve opened the second vial, if you need it I figure you paid for it, have another fifty. Beyond that, I’m calling the boss. I know my med control docs very well and I know where the line is when I can’t say “hey, I did this, sign here” is(in context, about 200 of fent), and when I’m going to get push back.

For cardiac chest pain, I don’t have to leave town as my primary resource hospital is a STEMI center, so you get a hundred and by the time you need more or I have time to give you more, we’re backing in. For trauma, I have a forty minute drive, burns can be twice that. I usually call for orders immediately if I think I’m going to need them. A few weeks ago, I gave a patient 250mch in a little less than an hour, with orders, and everybody was happy.
 
NPO said:
That is my protocol, yes. We can go over if we call medical control, but we can augment the opiates with benzos with standing orders, and that goes a long way. 100mcg fentanyl + 2mg versed it's a good combo.
Click to expand...
We've just got fentanyl with the very same dosing limits plus the restriction that we cannot give both iv morphine and iv fentanyl to the same patient it has to be one or the other. We've been told that the fentanyl is stronger but at those doses it may wear off quicker than morphine so we should take transport time into account when choosing which drug to administer

My own issue with the fentanyl is with just the 2 doses that you can administer how do you titrate to effect particularly in cardiac chest pain the way you can with the 2mg iv morphine increments

We don't have standing orders to administer benzos in pain management
 
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