Morphine for facial/airway burns.

[NYMedic828]

According to http://www.ncbi.nlm.nih.gov/pubmed/6172999

High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.

does that sound like a small amount like 5mg morphine, or does it sound like a lot more?????? it is even given / min??????

if the med control is using a study like this to base his/her decision on "pain control" for burn victims, then maybe they might want to take away the shocks on our ambulances too..... the bounciness could put a pt to sleep therefore occluding the pt's airway>>>>> SARCASIM

Honestly I don't think the problem stems from the medical directors being foolish. Our (well, my former) medical directors happen to be very respected doctors in the region but other EMS providers I cannot say the same for.

Had this been a real patient and during treatment the provider called the doc and said "I would like to request a discretionary order to administer morphine outside of protocol" he would look almost certainly be approved.

Unfortunately, the protocol is for standing order morphine and when your body of providers is vastly undereducated as they are in 90% of EMS systems, you can only allow so much leniency.

My purpose in making this thread was to essentially ensure that there wasn't some actual medical contraindication to morphine in this scenario that I never heard of.

The unfortunate factor in these situations is that now my friend will have it in his head, as a new provider, that a treatment he believed to be and was correct about is in fact wrong and should not be considered in the future in a real situation. Not a very good way to mold new paramedics into anything but a cookbook provider.

 

[usalsfyre]

Unfortunately, the protocol is for standing order morphine and when your body of providers is vastly undereducated as they are in 90% of EMS systems, you can only allow so much leniency.

Horse puckey.

It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up.

I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.

 

[NYMedic828]

Horse puckey.

It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up.

I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.

I've never been to a system outside of NYC/LI so my perception is purely based on my region.

But out here, the common thought process is that 10mg of morphine will put someone to sleep. Fentanyl is far too dangerous (100ug max) to give to just about anyone and analgesia administration isn't worth our time. (People don't grasp the concept of equivalent dosing)

I once suggested to call med control to give a blatantly snapped tib-fib fractured child (ped struck) IN fentanyl and my partner thought I was insane and going to kill the kid. So, the poor kid suffered the entire bumpy ride to the ER.

No one gives analgesia most of the time which means they never see it work and how little 5-10mg or 100mcg actually is so they keep this thought process in their head.

It actually boggles my mind that people think hypoventilation from opiates will set in BEFORE altered mentation and loss of consciousness. Like the patient is going to forget to breathe when they are awake...

This is what I deal with.

 

[Veneficus]

According to http://www.ncbi.nlm.nih.gov/pubmed/6172999

High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.

does that sound like a small amount like 5mg morphine, or does it sound like a lot more?????? it is even given / min??????

if the med control is using a study like this to base his/her decision on "pain control" for burn victims, then maybe they might want to take away the shocks on our ambulances too..... the bounciness could put a pt to sleep therefore occluding the pt's airway>>>>> SARCASIM

A study of 15 patients from 1982? Really?

 

[Veneficus]

Horse puckey.

It'd be one thing if this was an out there, off the wall procedure or med. However, the rest of the country seems to give that and far higher doses of opiate analgesics daily and we don't hear about body bags stacking up.

I'm the first to say Paramedics are undereducated, but the majority can't be trusted with morphine? I think you're judging based on skewed perceptions.

The paranoia about various medications is not limited to paramedics. I have met doctors and nurses who think if you give 2mg of morphine the patient is going to suddenly die.

I have heard more than one provider with a story of "I once had a patient..."

Various "safety" agencies latch on to this like it is the word of God, but I think it requires perspective.

Around the world, on average, 1:350,000 people undergoing general anesthesia die. So I think we can agree that GA, is probably the extreme side of pain/anxiety/awareness management.

There are probably millions (I have no idea the number) of doses of analgesia with opioids or antianxiety with benzos given daily around the world. We hear about "I once saw a patient..."

I have given thousands, perhaps 10s of thousands of doses of analgesia with and without benzos in my career. So what is the number needed to harm?

1:million?
1:5 million?
1:10 million?

So somebody somewhere (in this case NYC) thinks that it is reasonable to withold analgesia or prescribe an ineffective dose of it because 1:God knows how many of millions of people might have a bad reaction?

If we did that we wouuld never prescribe tylenol. It certanly wouldn't be OTC in every civilized country in the world.

Hell, we wouldn't do any procedure or prescription at all at those rates.

What would medicine be like if a surgeon had a bad outcome doing a procedure and his solution was to never do that procedure again?

Because it is no different from a doctor having a bad medication reaction and never prescribing that medication again.

I have no doubt, somebody some where at some point is going to have an adverse reaction. But it doesn't mean we stop treating everyone else because of it. That is bad medicine.

If we can send patients home on warfarin but cannot "trust" paramedics to give morphine, never mind we send patients home with their own morphine, then somebody's *** needs to lose their job.

Either the medical director (council) which is my first pick, because obviously their quality control responsibilities for those working under them are not being met, or the providers, because they are so incapable they should be driving a taxi not an ambulance.

No union should protect people who suck. Neither should management. That includes the medical director.

 

[Clare]

I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?

Yup, benzodiazepines do not provide any analgesia, the patient can be in significant pain and have all of the physiological insult that comes along with it yet still be sedated, hence why opiates are used in combination with midazolam, although it's no longer formally described within the CPG

 

[johnrsemt]

In my old area we could give Morphine up to 10mg, 5mg doses 5-10 minutes apart. It only put one person to sleep. In the ED only had one person stop breathing (allergic reaction) and we bagged her till the Benadryl kicked in.
Fentanyl we could give up to 200mcg: 100mch, 2nd and 3rd doses of 50mcg it worked great. I gave 100mcg to a patient with a pressure of 70/30 with HR of 150. Her blood pressure went up when her heart rate dropped to 80 when the pain went away.

Pain management is something (sometimes the only thing) that we can do pre hospital; I hate it when some medical directors won't let us do it.

Here we are supposed to start with 2mg Morphine titrated to pain to a max of 10mg; Fentanyl we start with 50mcg.

 

[HMartinho]

I think in nowadays there is a big "Hypochondriasis" about morphine and opioids. At least I see what happens in Portugal, where patients screaming in pain, receiving intravenous paracetamol/acetaminophen (1 g diluted in 10 ml saline, perfused within 15 to 30 minutes), instead of morphine, tramadol, fentanyl, and so on. Which, obviously, is a joke, and a true "insult" to the patient with severe pain.

 

[BigLouie2314]

Coming from a major east coast burn center...Morphine, Morphine, Morphine. And i laugh at anyone who says anything less than 15mg doses.

If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.

If the pt has facial and/or airway burns, first priority before any pain management should of course be intubation. RSI the pt, then worry about pain management. Burns are one of the most painful injuries a person can have. Good practice would be to use fentanyl during your RSI process (also be wary of thier blood pressure and the use of versed in these pt's. They also may be hyperkalemic or burns greater than 24hrs which would be a contraindication to the use of Succinylcholine in RSI. I go with Vecuronium as a standard.) and then once the pt is successfully intubated, give morphine.

As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)

One thing to remember with burns, and I learned this from our Burn ICU surgeons, is that burns are extremly painful and there never is enough pain management for them.

 

[Veneficus]

If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.

Why something short acting like fent?

As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)

What made you pick 15mg?

 

[usalsfyre]

Coming from a major east coast burn center...Morphine, Morphine, Morphine. And i laugh at anyone who says anything less than 15mg doses.

And if 10 seems to work? I agree, 15 is an odd number...

If the pt is not intubated yet, high dose fentanyl should be used. Anywhere form 7.0-8.0 mcg/kg of fentanyl should be considered.

It's interesting you choose a near anesthetic dose of fent for unintubated patients but for intubated patients you you mention a dose of morphine that didn't even raise my eyebrows.

If the pt has facial and/or airway burns, first priority before any pain management should of course be intubation.

The majority of patients with simple facial burns don't require intubation. In fact, very, very few do.

RSI the pt, then worry about pain management.

Unless of course your patient is so agitated from pain you literally can't do anything till pain management on board. My standard approach for major burns in the past has involved a good bit of fent IN right off the bat. Take care of one of there patients and you might see why.

Burns are one of the most painful injuries a person can have. Good practice would be to use fentanyl during your RSI process

Diprivan or ketamine would be a far better choice.

(also be wary of thier blood pressure and the use of versed in these pt's.

Why? The fluid shift in burns happens way later. That's why the Parkland formula is for 24 hours. Without concurrent trauma hypotension is not something I'd even think about...in fact they're probably going to be pretty hypertensive.

They also may be hyperkalemic or burns greater than 24hrs which would be a contraindication to the use of Succinylcholine in RSI. I go with Vecuronium as a standard.)

Why? While I like roccuronium a lot more than sux this isn't a situation I'd shy away from it. Again, the hyperkalemia issue comes along later. Do you understand the electrolyte shift and the hows/whys if it? And if their facial burns are >24hrs old, why the hades am I RSI'ing them? It's a pretty good bet the airway is not an issue at that point.

and then once the pt is successfully intubated, give morphine.

Or start a diprivan or fent/versed drip so they're knocked out enough they don't remember this ordeal.

As for morphine dosing, as long as the pt remains normo or hypertensive, I give 15mg IVP every 5-10 min. If the pt is not intubated and awake, I continue the dose until they are pain free, watching of course for resp. depression. If they are intubated, I continue until thier vital signs indicate they are in less pain (i.e. blood pressure, airway pressures, agitation, etc.)

Again, why 15mgs. Odd dosing. If your transporting a lot of burn patients why not push for Diluadid?

 

[mogleyisme]

This is going to sound dumb, but I don't think it was mentioned at all. Did he check BP before administration, haha.

In Florida, Orange County, we can give morphine to burn patients as long as it's indicated.

 

[usalsfyre]

In Florida, Orange County, we can give morphine to burn patients as long as it's indicated.

When the flaming fornication is it NOT indicated for burns?!?!?

Are you sure you didn't mean contraindicated (and the contraindications get pretty relative quite honestly)

 

[mogleyisme]

When the flaming fornication is it NOT indicated for burns?!?!?

Are you sure you didn't mean contraindicated (and the contraindications get pretty relative quite honestly)

Can't think of any reason why not

 

[Veneficus]

Again, why 15mgs. Odd dosing. If your transporting a lot of burn patients why not push for Diluadid?

I asked because I have seen morphine packaged in 15mg/1ml vials. They look like the regular vials only instead of an orange cap they have a lime green one. (Brighter than the versed caps.)

 

[Melclin]

I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?

And if 10 seems to work? I agree, 15 is an odd number...


It's interesting you choose a near anesthetic dose of fent for unintubated patients but for intubated patients you you mention a dose of morphine that didn't even raise my eyebrows.


The majority of patients with simple facial burns don't require intubation. In fact, very, very few do.

...

Diprivan or ketamine would be a far better choice.

Or start a diprivan or fent/versed drip so they're knocked out enough they don't remember this ordeal.

Interestingly, for airway burns our chopper dude/dudettes do what I believe is a essentially a propofol/fentanyl GA with subsequent propofol infusion for sedation with concurrent analgesia.

I was chatting to a chopper bloke about it once and he said its awefully embarassing when you give you opiate/benzo combo prior to paralysing and the pt is still sitting their looking at you, screaming. He was a big fan of propofol for that purpose.

 

[CarlHoma]

I attended a burn care program given by Dr. Daniel Lozano from Lehigh Valley Hospital in Allentown, PA a few weeks ago and he was against administering morphine because of the histamine release it is thought the cause. According to Dr. Lozano they do not administer morphine at all in their burn center. Instead I believe they use dilaudid with fentanyl for breakthrough pain.

With that said ... sounds like the registry proctor was a little full of himself. I do not believe that administering morphine to a trauma patient is a critical fail unless the proctor is considering it "Uses or orders a dangerous or inappropriate intervention" (nremt.org/nremt/downloads/P301%20NREMT.pdf[/). In that case the proctor may want to visit a proctologist for cranial impaction.

Just my humble opinion ... I could be wrong.
Carl

 

[jacob6493]

I believe it was facial burns and the patient is in severe pain, stating such. Don't think intubation came into question but I wasn't there.

Outside of improper protocol, I don't see whats wrong with treating the patients pain.

I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?



Because he gave a treatment that was contrary to protocol, regardless of the protocol being contrary to sound medical care.

It is certainly unfair that the tester egged him on about severe pain.

In response to treating patient's pain, here in PA we are free to go on burns anywhere with as long as airway has been managed, including possible early intubation, and the patient is negative for normal pain med contraindications. We have Fentanyl, MS and Nitrous.

As for the scenario some else may have mentioned this but I believe the airway/intubation could be a potential critique point. You know the rule, BLS before ALS.

 

[usalsfyre]

You know the rule, BLS before ALS.

You would do well to strike that phrase from your vocabulary.

 

[seamedic]

Just had a case on our boat where a crew member got splashed with caustic soda. 1st,2ed and 3rd burns to his face, rt side of his skull, just about all of his rt arm up to his armpit and back. When I talked with our Doc's about px control, they advised to give Vicodin. I could not believe it, but my pt said he did not need anything for px. One tough fishermen.