Morphine Administration

[MrBrown]

One of the most important aspects of prehopital medicine is the sufficent relief of pain. Pain is nasty, it has negative physiologic and psychologic effects and is just plain uncomfortable.

We take an agressive approach to analgesia with a wide selection of analgesics (paracetamol, methoxyflurane, morphine +/- midaz, ketamine) as well as traditional non-medication based modalities eg splinting, positioning.

Nobody should be witheld pain medication for fear of "masking symptoms" or "they are a druggie" or because "pain never killed anybody".

If you are in pain, you should get something for it. End of story.

 

[Smash]

To be honest, I'm too new here to know how often it's used, usalfyre will be of better assistance there, but yes I would presume it would be in an attempt to give ungodly amounts of narcotics as, atleast in my county, we're 45min-1hr+ away from anything that resembles a hospital.

It's a hell of a step to take. Not saying that it is bad, good or indifferent, merely that it is a big step. Personally I would probably prefer to have something like ketamine in my bag of tricks for a start, but then if you have long transports and something like major burns, it is probably the humane thing to do anyway.

 

[Shishkabob]

On our ground trucks we only carry Fentanyl for analgesia and Ativan / Versed for sedation (Not including Etomidate and Roc for RSI). Our flight crew, though, gets Morphine and Ketamine as well.

Plus if it ends up being a burn, chances are the chopper was auto-launched, and they'll get a tube and a hop on over to Parkland.



But it's an option, and I like having the ability to have options.

 

[Dave 52-4]

Then explain how it means something different.
QUOTE]

The main thrust of my point (as I do not argue) is that we must refrain from treating the protocol and not the patient. Pain is a consequence of injury, it is a natural responce. Any primate if taught and rewarded well can follow an algorithm. We have to think, we have to assess.

Do I treat pain daily , sure I do, but I am not grandiose with my manner to think I can act as a cure all.

You want to treat a belly pain with a fist full of Morphine, Fent, whatever so beit, but, the second you bottom a pressure secondary to narcotics and infarct a patient because "that is what the protocol states", treated a subjective complaint without a full and methodical assessment - Fine. I have never made that mistake yet, from the talent I see here in the written form I doubt many others have either. Is it renal colic, or is it referred pain from a minuscule leak in the descending aorta secondary to HTN...If your that good let me know when your next lecture is, I will be in the front row.

Renal Colic? Really? I mean really? You ciphered that in the back of your truck in the first five minutes?

I know many services that have had RSI taken away because of a low ETT placement rates and lack of a true prehospital assessment, where I work we still have it, because we assess, because we do not look at things like pain control as a right versus a definitive diagnoses.

To those who say 2 mg's of MS04 wont hurt are are living a misnomer, 2mg of Morphine in the face of a true fracture is symbolism over substance, in other words - useless...

If, after an objective assessment pain is a true possibility, it should be treated, and treated in an aggressive manner...Other wise this is bunk really.

JMO, many have others.

 

[usalsfyre]

The main thrust of my point (as I do not argue) is that we must refrain from treating the protocol and not the patient.

Absoloutely

Do I treat pain daily , sure I do, but I am not grandiose with my manner to think I can act as a cure all.

Has nothing to do with being a cure all. It has to do with relieving a patient's suffering and being humane.

You want to treat a belly pain with a fist full of Morphine, Fent, whatever so beit, but, the second you bottom a pressure secondary to narcotics and infarct a patient because "that is what the protocol states", treated a subjective complaint without a full and methodical assessment - Fine. I have never made that mistake yet, from the talent I see here in the written form I doubt many others have either.

Fent is VERY hemodynamicly stable, so much so it is the cardiac anesthia agent of choice. Very seriously doubt you'll "bottom them out and infarct them" unless you just completely miss the signs of massive, massive shock.

Is it renal colic, or is it referred pain from a minuscule leak in the descending aorta secondary to HTN...If your that good let me know when your next lecture is, I will be in the front row.

Renal Colic? Really? I mean really? You ciphered that in the back of your truck in the first five minutes? .

I chose renal colic/renal stones because it is one of the easier diagnosis to make of physical exam alone. Ask an ED doc if the REALLY need imaging to do it.

I know many services that have had RSI taken away because of a low ETT placement rates and lack of a true prehospital assessment, where I work we still have it, because we assess, because we do not look at things like pain control as a right versus a definitive diagnoses.

My service has very agressive RSI protocols, does ALOT of RSIs, has first pass succes rates in th 98% range last time I checked and views pain management as an approprite treatment of patient symptoms.

To those who say 2 mg's of MS04 wont hurt are are living a misnomer, 2mg of Morphine in the face of a true fracture is symbolism over substance, in other words - useless...

Agreed

If, after an objective assessment pain is a true possibility, it should be treated, and treated in an aggressive manner...Other wise this is bunk really.

JMO, many have others.

My point is pain management should be ruled out rather than ruled in. I don't need to find a reason to treat pain, I need to find a darn good reason I SHOULDN'T treat it. Anything else is quite frankly cruel. We need to get over our misgivings about pain management, and do what we should have been focusing on all along, relieving suffering.

 

[usalsfyre]

How does med control feel about RSI for pain relief only? Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.

Absoloutely why we have it in the protocol, I haven't personally heard of it being done though.

 

[Dave 52-4]

My point is pain management should be ruled out rather than ruled in. I don't need to find a reason to treat pain, I need to find a darn good reason I SHOULDN'T treat it. Anything else is quite frankly cruel. We need to get over our misgivings about pain management, and do what we should have been focusing on all along, relieving suffering.

Nice points and I totally agree, I think we are the same path here as we rule "things in or out" through an agressive assessment.

Merry Christmas!

Be Well.

 

[usafmedic45]

What other non-opitates are there?

Ketamine.

How does med control feel about RSI for pain relief only? Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.

Once again, ketamine.

Honestly, it's one of my favorite drugs for anyone in severe pain: it's got neuroprotective effects, it causes bronchodilation, you don't lose your drive to breath or your protective airway reflexes and the patient is comfortable and cooperative.

I know many services that have had RSI taken away because of a low ETT placement rates

That's when you stop looking at ETI and "airway control" being the same thing and manage the airway however it needs to be managed. If you need to drop a Combitube, do it. Once they are down and have an airway secured by whatever means work, there's no reason to complain about "failed intubation". This is one of my biggest pet peeves and one of the things I talk about in my conference presentations.

 

[Smash]

Once again, ketamine.

Honestly, it's one of my favorite drugs for anyone in severe pain: it's got neuroprotective effects, it causes bronchodilation, you don't lose your drive to breath or your protective airway reflexes and the patient is comfortable and cooperative.

Yeah, I know, I was surprised at the use of RSI rather than ketamine

Personally I would probably prefer to have something like ketamine in my bag of tricks

I understand the rationale, but ketamine is just such a useful and safe drug I don't understand why everyone doesn't have it.

 

[usalsfyre]

But, but, people get high on ketamine...

I agree, and wish we had ketamine at both analgesic and induction doses. However some of our ED docs seem uncomfortable with using it in the ED, much less on the trucks, citing concerns over emergence, misuse, security, diversion ect. I think alot of the push back is due to the area (we are rural Bible belt) and worries over the public finding out we gave little Johnny and acid trip after he suffered 3rd degree burns (although who wouldn't want an acid trip after that?).RSI is an incredibly invasive answer to the problem. Give it a little time, maybe when ketamine is more safely established in the US (I know they've been using it for years overseas) and maybe we'll see it.

 

[Veneficus]

But, but, people get high on ketamine...

I agree, and wish we had ketamine at both analgesic and induction doses. However some of our ED docs seem uncomfortable with using it in the ED, much less on the trucks, citing concerns over emergence, misuse, security, diversion ect. I think alot of the push back is due to the area (we are rural Bible belt) and worries over the public finding out we gave little Johnny and acid trip after he suffered 3rd degree burns (although who wouldn't want an acid trip after that?).RSI is an incredibly invasive answer to the problem. Give it a little time, maybe when ketamine is more safely established in the US (I know they've been using it for years overseas) and maybe we'll see it.

First and foremost, good to see you back. Happy Holiday.

But I wouldn't expect too much in the way of "advancement" in pain management, especially with ketamine in the US for the adult populations. (it is used mostly in peds)

The first problem is a new physician is likely to use what the old physician taught her. Which largely excludes ketamine.

Another major problem is some states, like my home, are trying to find a way to hold doctors responsible for patients who get addicted to prescription drugs. So pain management outside of the specialty isn't likely to be taking great leaps forward.

Finally, bible belt or not, US medicine can only be described as "adverse" to treating pain. There are still senior surgeons who like the idea of leaving a patient in pain to see if abd pain worsens instead of a serial ultrasound or CT scan. There are still other providers on a grand scale who think controlling pain will somehow mask something life threatening. Let's not forget the punitive medicine crowd who decides patients don't deserve or shouldn't be in that much pain.

Top it all off with an unhealthy dose of unfounded fear among a majority of providers who feel that proper pain management will result in death and all other kinds of worse than death scenarios.

Example, EMS with 2mg per dose max 10mg of morphine.

Indicated dose for analgesia, 0.15 mg/kg

a 70kg pt should recieve an initial dose of 10.5mg I think we both know that will never happen.

Even with newer things like fent, which has less "side effects" the doses are often limited to 50-100ug.

How about benzo/opioid synergy, 2-4mg morphine and 2-4mg versed, to treat nociceptive and psychological pain and in as little as 4-8mg total, you can all but absolve pain in most adults. Best of all the versed has very potentent amnestic effects, which really helps with kids, even in doses much smaller than conscious sedation.

But you won't even see EDs in the US using or even considering it. Even in patient populationss who have more psych aspect to their pain than nociceptive.

RSI for pain control? For irretractable pain in the most extreme of circumstances perhaps. But I can't really see it as an alternative just because the fent didn't work.

 

[MrBrown]

Seriously people ketamine FTW .... its the most awesome thing since we got nubain and foratol in the early 1990s

 

[johnrsemt]

I have given a patient 100mcg Fentanyl * 2 6 min apart, when starting B/P was 66/20 due to partial amputation of hand with severe bleeding. Called for orders for 50 mcg, Doc yelled at me on phone and told me to give 100mcg.
pain went away and B/P went up to almost 100/60.

 

[ClarkKent]

I think many who withhold pain medicine are just lazy and do not want to fill out the paperwork.

I know that I am only and EMT-B (and not working as one), but for pushing MS, is there really that much more paper work todo? Is it just one more check mark you have to make on the PCR, or is there a whole book that you have to fill out just because someone need help with pain management? Just asking

 

[usalsfyre]

I know that I am only and EMT-B (and not working as one), but for pushing MS, is there really that much more paper work todo? Is it just one more check mark you have to make on the PCR, or is there a whole book that you have to fill out just because someone need help with pain management? Just asking

There's some doccumentation realted to administering a controlled substance, and the doccumentation guidlines are usually a bit stricter as far as what goes in the PCR.

 

[Smash]

Another major problem is some states, like my home, are trying to find a way to hold doctors responsible for patients who get addicted to prescription drugs.

What? No, what? But... no.... what? Serious? But that is just... what? Who could possibly think that that could.... what? Sorry, I just can't comprehend such a thing at all.

My god, what a pathetic state of affairs.

 

[vquintessence]

What? No, what? But... no.... what? Serious? But that is just... what? Who could possibly think that that could.... what? Sorry, I just can't comprehend such a thing at all.

My god, what a pathetic state of affairs.

But not at all shocking, given that drug dependency has become a disease that makes the afflicted eligible for SS, gov't housing and transportation assistance.

NOBODY takes personal responsibility anymore (in US at least..). It's always the fault of the deepest pockets.

It's McDonalds fault that my kid is fat.
It's my elderly neighbors fault I slipped on ice on their sidewalk property at 03:00 during a snowstorm.
It's the dog owners fault that I got bit while burglarizing their home while they're away.

 

[MrBrown]

You my friend are correct; there is no personal responsibility anymore.

 

[socalmedic]

...for pushing MS, is there really that much more paper work todo?...

yes, about 2 pages. they are short pages, but you do have to call the supervisor to get a refill. which means you actually have to finish your paperwork right after the call. I personally have no problem doing this, i do not consider the call complete until the paperwork is done. I do not know of any medics who would withhold pain management due to the paperwork, but i am sure they are out there.

 

[socalmedic]

nobody takes personal responsibility anymore (in us at least..). It's always the fault of the deepest pockets.

It's mcdonalds fault that my kid is fat.
It's my elderly neighbors fault i slipped on ice on their sidewalk property at 03:00 during a snowstorm.
It's the dog owners fault that i got bit while burglarizing their home while they're away.

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