IM Morphine

[Shishkabob]

So we have IM Morphine in our protocols for pain management. I'm still trying to find a time when I would do IM Morphine as opposed to IV.


When would you do IM Morphine (keep in mind I do primarily IFT)



One such case that I debated it was the other day. I was returning a patient back to her NH after she was checked out at the ER for a fall 2 hours earlier. She had a deformity of 2" of her right leg near her hip. IV was DCed at hospital. Pain of 6/10 resting, 10/10 movement.

Would IM Morphine have been an idea? I opted against it was we werent going to a hospital, but to a NH where she probably wouldnt have been checked on often and where they didn't have Narcan just in case.


I guess I'll talk to one of my supervisors on Monday about its usage.

 

[usafmedic45]

I'm still trying to find a time when I would do IM Morphine as opposed to IV.

WWII combat medicine reenacting?

 

[redcrossemt]

When you couldn't obtain IV access???

 

[8jimi8]

i wouldn't give it im without a iv access. Too much to go wrong with interventions being delayed by no iv access

 

[got_shoes]

I would say it would be used in IFT hospice pt's for comfort care, MCI's where you don't have time to start a IV line. or in pt's are quads, most of the time they don't have good IV access, or in Pt's who are amputees. only a things i can think of.

 

[redcrossemt]

i wouldn't give it im without a iv access. Too much to go wrong with interventions being delayed by no iv access

I would prefer not to; the truth is, however, that we can't obtain IV access in every patient who deserves pain relief. Our standing orders state to attempt 3 PIVs and if we still are unsuccessful to go to IM.

What complications are you worried about? Respiratory depression? Hypotension? You can always give nalaxone IM as well...

That being said, I am lucky to have fentanyl which I regard as a little safer than morphine in so far as it is shorter acting and has less histamine response. I've heard it also hurts less IM. Not sure why we don't have IN yet, but I hope it's coming soon.

 

[medicRob]

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For the purposes of EMS and Emergency Medicine in general, IV administration of morphine is ideal in that it has quick onset and is a more reliable route of administration. However, there are some advantages to the intramuscular administration of morphine in that the slower absorption lessens the risks of respiratory depression, nausea, and other bad ju ju. Moreover, IM does have its advantages in the hospital setting in that the medication has a longer duration and is required to be administered less frequently (q 3-4h).

In most situations in EMS, the patient requiring morphine will be in such condition that immediate onset of the medication is required. Also, if I am giving my patient morphine in the first place, I am going to want an established IV just in case of the "What ifs". It all depends on situation.

 

[Level1pedstech]

You might try the emergency nursing forum over at all nurses.com. They are very helpful over there and Im sure you would get a solid answer to your question. Just a suggestion.

 

[the_negro_puppy]

I think the obvious answer is you give IM when IV access cannot be easily obtained.

In my experience, I have given IM to an 8 year old with a distal humerous fracture that was yelling with the pain, but was not cooperative with methoxyflurane, and would not hold still or allow partner to attempt IV access.

Other case was an obese man with severe lower back pain, writihing in pain, poor lighting in house and had really poor veins. Gave him IM as well.

 

[MrBrown]

I think the obvious answer is you give IM when IV access cannot be easily obtained.

I think you are right mate, we can give it IM if we do not have IV access; not that I have done it but still

When fentanyl replaces morf here I immagine we will get it via IN as well

 

[Melclin]

Surely the bigger question is why your lady was being discharged from hospital with 6-10 pain scores minus any plan for pain relief.

What was the issue with her hip?

Poor pain management really annoys me.

EDIT: just to add a bit more we have an option for IM Morphine, 10mg with the option for a 15 minute follow up dose of 5 mg for people >60kg. <60kg including kids get 0.1mg/kg with consult with a more experienced paramedic for a follow up dose. I've never seen it used seeing as though we also carry an inhalant analgesic and IN fentanyl.

 

[Veneficus]

In the hospital we sometimes DC patients and gie them an IM morphine w/ epi injection.

The epi slows the absorbtion making the morphine last longer to achieve "breakthrough" of pain, followed up by pain control with oral NSAIDS. (usually ibuprofin)

In an IFT setting it could help the morphine last long enough for a doc to come and see the pt. the next day and decide how to further control pain.

In poor populations it also removes the need to have them fill a PO script for 1 or 2 pills.

 

[Melclin]

In the hospital we sometimes DC patients and gie them an IM morphine w/ epi injection.

The epi slows the absorbtion making the morphine last longer to achieve "breakthrough" of pain, followed up by pain control with oral NSAIDS. (usually ibuprofin)

In an IFT setting it could help the morphine last long enough for a doc to come and see the pt. the next day and decide how to further control pain.

In poor populations it also removes the need to have them fill a PO script for 1 or 2 pills.

Interesting...how much of each?

 

[got_shoes]

Vene, how much epi? and wouldn't the concentration be different then what most EMS units carry? like 1:20,000? or have I misunderstood? how does epi slow the reaction? I was thinking that epi would speed up absorption. feeling a bit ignorant on this subject and I can't seem to find anything about this.

 

[Veneficus]

Interesting...how much of each?

The epi we usually use is 1:100,000 in H2O. The amount based on how long of a relative delay. Most common I have seen is 1ml of 1:100,000 +4-10 mg morphine, IM for non postoperative pain control.

I am aware that 1:50,000 and 1:200,000 epi concentrations can be used but I have not seen it personally.

Followed up with the common 2400-3200 mg ibuprofin/24 hours. (in other words 800mg 3 or 4 times in 24 hours)

Epi acts as a local vasoconstrictor which delays the absorbtion of the morphine, similar to lidocaine with Epi.

a good article on outpatient coctail post op.
http://www.medscape.com/viewarticle/500446

As an aside, 1:100,000 epi soaked dressings work really well for bleeding control, but standard disclaimer applies, don't act on your own, get permission from med control or have it written in to scope of practice.

 

[1badassEMT-I]

We got fentanyl and morephine and I am not pushing niether without IV access there is to much to go wrong for sure!

 

[Veneficus]

We got fentanyl and morephine and I am not pushing niether without IV access there is to much to go wrong for sure!

???

No offense, but this looks like trolling to me.

 

[1badassEMT-I]

???

No offense, but this looks like trolling to me.

What do you mean TROLLING! because I voice a opinion on what I would or would not do....is TROLLING......GET REAL!

 

[MrBrown]

Can you give IN fentanyl?

 

[JPINFV]

Everyone once in a while I see the docs over on the EM forum at SDN discussing fentanyl lollipops. Does anyone know if any EMS systems use them?