Morphine for facial/airway burns.

[Carlos Danger]

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.

7-8 mcg/kg? Is that a typo?

I agree that fentanyl is a better drug for prehospital use. Faster onset, more stable hemodynamic profile, more consistent dose-dependent effects, more titratable. Just better all the way around.

An excellent combo in burn patients is 100mcg of fent, 12-25mg of promethazine, and 1-2mg of versed. This gives an excellent synergistic effect and in an average sized patient you'll almost always get decent analgesia and anxiolysis for a 20-30 minutes or so.

As for the OP's question, it is the histamine release they are afraid of. At least that's the rationale that I've heard before.

 

[Melclin]

and the patient is negative for normal pain med contraindications.

What do you and/or your system consider to be "normal pain med contraindications"? I can't think of anything in particular that would be 'normal'.

 

[Veneficus]

What do you and/or your system consider to be "normal pain med contraindications"? I can't think of anything in particular that would be 'normal'.

If I had to guess, profound hypotension.

However, most often easily remedied with fluid infusion.

 

[Handsome Robb]

You know the rule, BLS before ALS.

Dumb rule.

That's like "treat the patient not the monitor".

Do what's in your best interest for your patient.

A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now. Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS". Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra.

Facial burns =/= airway burns, despite what your EMT/Paramedic text tells you. Also, soot/burns in the nares doesn't always indicate airway involvement requiring intubation either.

6-7 mcg/kg of fent sounds like a lot, but honestly on the one and only burn patient I've had I wish I could have gotten up that high for my max dosing. 300 didn't touch the poor fella. That's getting up into the dosing where you'd need to be worried about intercostal rigidity though. I know it can happen with smaller doses as well but it's generally associated with high dose, rapid IVP. That plus circumferential burns to the torso would make for a fantastically fun patient to attempt to ventilate in the prehospital field, especially with a BLS airway...

I agree with better options for an induction agent than fentanyl but I can't really speak further on that seeing as we don't RSI. Never have done it, tubed plenty of dead people, a few near-dead ones, but never sedated, paralyzed and intubated a live one outside of OR rotations during school. I will say ketamine is potentially wandering its way into our pain/sedation management protocol in the near future. Doubt we will ever have diprivan as an option but who knows.

 

[Veneficus]

A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now. Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS". Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra.

You forgot: "If they live at all, and with what level of deficit" even if they do make it out of the hospital after a prolonged stay.

(just trying to help)

 

[KellyBracket]

Just gave 25 of morphine to someone with facial burns last night.

Haven't heard officially, but I think I passed.

 

[Veneficus]

Just gave 25 of morphine to someone with facial burns last night.

Haven't heard officially, but I think I passed.

I don't think it counts if you do it after you already passed.

 

[Carlos Danger]

Dumb rule.

A burn patient with airway involvement doesn't need any sort of BLS airway shenanigans, they need a definitive airway placed and they need it now.

It's not a dumb rule at all.

BLS maneuvers are not "shenanigans". BLS procedures are indicated far more often than ALS procedures. And BLS procedures are always the rescue when ALS procedures fail. I remember seeing a study a while back that said that ALS procedures positively impacted patient outcomes something like 2% or 3% of the time, and most of those were cases of severe pediatric asthma, where early epi, magnesium, and continuous nebs can be truly life-saving. That's pretty much inline with my experience, I'd say.

"BLS before ALS" doesn't mean that you forgo ALS procedures where they are indicated. It means that you don't expose the patient to a risky ALS procedure when BLS maneuvers work just fine, and you don't rush an ALS procedure because you are too impatient to do BLS.

In the realm of airway management, BLS before ALS means that you never paralyze someone that you don't think you can mask ventilate. It also means that when you start having trouble intubating, the very first thing you should do is revert to "BLS" BVM ventilation.

Paramedics kill patients all the time by not adhering to this rule. And it is honestly one of the main reasons why many higher-level clinicians think poorly of paramedics.

Have fun explaining to the physician why you had to do a surgical cricothyrotomy on your patient that you could have easily RSI'd a few minutes prior to having to break out the scalpel because you wanted to try "BLS before ALS". Now that patient not only has to be weaned off the vent, but also off the trach that you just guaranteed they're going to get. Someone's going to be spending a lot longer in the hospital and rehab facilities than the probably needed to had a definitive airway been placed when it was indicated rather than trying to follow some silly EMS education mantra.

Huh?

Why would a patient who was cric'd rather than ETI'd need to spend "a lot longer" in the hospital and rehab facility?

You do realize that any patient who requires intubation for airway burns is pretty much guaranteed to end up trached anyway?

Facial burns =/= airway burns, despite what your EMT/Paramedic text tells you.

I think your approach is backwards, quite frankly.

First of all, it is not true that just because someone's face is burned, their airway is going to close off in a few minutes. Airway burns are actually quite rare, even in severe facial burns.

There may be risks in waiting, but there is also risks involved in prehospital RSI. I do not think prehospital RSI should be done "electively".....it should only be done when a truly pressing need for intubation exists.

I think if the likelihood of airway burns seems high (close proximity to flame in enclosed spaces, steam burns, hoarseness), then early intubation is probably indicated.

But if none of those indicators exists, then the likelihood of airway burns is small and the risk of RSI probably significantly outweighs the risk of waiting.

In the worst-case scenario, a cric is a perfectly appropriate option and should have zero impact on their long-term clinical course.

6-7 mcg/kg of fent sounds like a lot, but honestly on the one and only burn patient I've had I wish I could have gotten up that high for my max dosing. 300 didn't touch the poor fella. That's getting up into the dosing where you'd need to be worried about intercostal rigidity though.

Adding a small dose of a benzo (1-2 mg of versed is best, if you have it) will significantly potentiate fentanyl and make these patients a lot more comfortable. Promethazine or droperidol are helpful as well, if you have them.

Intercostal rigidity is, frankly, not really worth worrying about. It is very rare, and usually not life-threatening when it does happen. If it does compromise ventilation, titrated doses of nalaxone are usually effective at reversing it. I would never withhold fentanyl for fear of rigidity.

And 6-7 mcg/kg of fent IS a lot, not matter how you look at it. I'm not saying a dose that high is never required, but it is a lot of drug, especially in a heavier patient.

I agree with better options for an induction agent than fentanyl but I can't really speak further on that seeing as we don't RSI. Never have done it

I will say ketamine is potentially wandering its way into our pain/sedation management protocol in the near future.

Doubt we will ever have diprivan as an option but who knows.

Fentanyl is not an induction agent. It can be used as an adjunct but the only time I've ever heard of it used as the primary agent is in neonates. It is rarely if ever used alone in adults.

Ketamine is a good drug. Hopefully it continues to gain in popularity in EMS.

I doubt you'll ever see propofol either. It is not appropriate for prehospital use, IMO. Without a lot of experience with it, it's just too easy to bottom out BP, and that can be devastating in TBI patients, which is that vast majority of RSI's done prehospital. I just don't see a need for that risk when there are other induction agents that have much safer hemodynamic profiles (etomidate, ketamine). ED docs aren't even allowed to use propofol for induction in many facilities.

 

[Veneficus]

Adding a small dose of a benzo (1-2 mg of versed is best, if you have it) will significantly potentiate fentanyl and make these patients a lot more comfortable. Promethazine or droperidol are helpful as well, if you have them.

In my experience, 1-2mg of versed is too low of a dose, even when trying to synergize opioids.

I have also used a midazolam/fent/promethazine cocktail, and even then you are looking at 5+ of versed and 25-50mg of promethazine (IV) in addition to whatever opioid gets you significant reduction.

And 6-7 mcg/kg of fent IS a lot, not matter how you look at it. I'm not saying a dose that high is never required, but it is a lot of drug, especially in a heavier patient..

I am not sure fent isthe best choice for burns anyway, comparitively to morphine, it is short acting.

Ketamine is a good drug. Hopefully it continues to gain in popularity in EMS.

Since it is argubly the best for a hemodynamically unstable patient, i am not really sure what the resistance to it is.

I doubt you'll ever see propofol either. It is not appropriate for prehospital use, IMO. Without a lot of experience with it, it's just too easy to bottom out BP, and that can be devastating in TBI patients, which is that vast majority of RSI's done prehospital. I just don't see a need for that risk when there are other induction agents that have much safer hemodynamic profiles (etomidate, ketamine). ED docs aren't even allowed to use propofol for induction in many facilities.

I am always interested when people claim tha etomidate is better for hemodynamic profiles. The "safety" seems exaggerated compared to what it is.

Ketamine is still the only agent that is considered hemodynamically safe in anesthesia.

In any event, slow titration, along with increased fluid as needed, I think is still a reasonable strategy no matter what agent you are using.

The fact that facilities restrict ED docs does not sound like a reflection of their ability to use it. It sounds more political to me. It is even difficult to argue for safety, because not giving a medication is always "safer" than using one. That doesn't lessen the indication or usefulness though.

P.S. I have not heard of a rash of paramedic assisted death as of late either. The "paramedics kill people all the time" assertation is a little over the top.

 

[Carlos Danger]

In my experience, 1-2mg of versed is too low of a dose, even when trying to synergize opioids.

I have also used a midazolam/fent/promethazine cocktail, and even then you are looking at 5+ of versed and 25-50mg of promethazine (IV) in addition to whatever opioid gets you significant reduction.

5mg isn't a bad dose either for most patients, but that's about the most I would use if I'm just trying to potentiate fentanyl. It's generally considered that opiate potentiation in a patient with a lot of pain who you want to keep spontaneously breathing requires a very small dose of versed. If they are still in pain after that, then they need more opiate, not more benzo.

I am not sure fent isthe best choice for burns anyway, comparitively to morphine, it is short acting.

Fent is much better IMO because of it's rapid onset and more predictable effects. It is much more lipid soluble than morphine, so it crosses the BBB quicker and more reliably. IV fent reaches peak effect in 5-10 min, compared to 25-30 min for IV morphine. Also, it doesn't cause histamine release, which can negatively effect hemodynamics and also contribute to more uneven absorption into the CNS. It's shorter duration of action (30-45 min compared to 3 hours for morphine) contributes to it's safety profile.

It's just easier to titrate and safer to give larger doses of than morphine.

Since it [ketamine] is argubly the best for a hemodynamically unstable patient, i am not really sure what the resistance to it is.

I think the resistance is primarily due to many ED docs just not being familiar with it. Even though it's been around since the 60's, my understanding is that it basically wasn't used at all for several decades. It has gained in popularity recently, but it's effectively a brand new drug for familiarity purposes. And I think to many docs it's kind of looked as being "one of those weird anesthesia drugs".

Ketamine does have some drawbacks compared to etomidate. It increases ICP, which is bad considering that most prehospital RSI's are done on TBI patients. It also reduces coronary blood flow and increases Mv02, so it's not safe to use in someone with severe CAD.

I am always interested when people claim tha etomidate is better for hemodynamic profiles. The "safety" seems exaggerated compared to what it is.

Ketamine is still the only agent that is considered hemodynamically safe in anesthesia.

Have you ever done inductions with propofol? Why do you think ketamine is hemodynamically safer that etomidate?

Ketamine generally isn't really used much as an induction agent in anesthesia. It can be, but when it is used that way, it's usually for a specific reason, such as being used in conjunction with propofol for a total IV anesthesia technique. Or for it's analgesic properties in a patient who you don't want to give a lot of opiates to.

You can probably argue that on a non-cardiac patient, ketamine and etomidate are equally safe. But etomidate is definitely more hemodynamically stable than either propofol or ketamine, which makes it the best drug to use in a patient population that can include both TBI patients with ICP concerns, and hypotensive trauma patients.

Ketamine causes a centrally-mediated SNS stimulation that causes increases in BP and HR, whereas propofol decreases both BP and HR.

Etomidate, on the other hand, neither decreases nor increases BP or HR.

This is from Clinical Anesthesia by Barash:
"Consequently, etomidate is considered to be the induction agent of choice for poor-risk patients with cardiorespiratory compromise as well as in those situations in which maintenance of normal blood pressure is crucial (e.g. cerebrovascular disease)".

This from Miller's Anesthesia:
The minimal effect of etomidate on cardiovascular function sets it apart from other rapid-onset anesthetics. An induction dose of 0.3 mg/kg of etomidate given to cardiac patients for noncardiac surgery results in almost no change in heart rate, MAP, mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, stroke volume, cardiac index, and pulmonary and systemic vascular resistance. A large dose of etomidate, 0.45 mg/kg (which is 50% larger than a normal induction dose), also produces minimal changes in cardiovascular variables.

In any event, slow titration, along with increased fluid as needed, I think is still a reasonable strategy no matter what agent you are using.

The thing is, we shouldn't be slowly titrating anything in an RSI. RSI needs to be a simple, rapid procedure where the meds are given quickly and have little effect on hemodynamics.

Also, if you have a patient with increased ICP due to a TBI and you drop their BP significantly, you just increased their likelihood of mortality by 50%. Ditto if their SBP is already is already in the 70's and you drop it into the 40's because you pushed the prop a little fast.

The fact that facilities restrict ED docs does not sound like a reflection of their ability to use it. It sounds more political to me. It is even difficult to argue for safety, because not giving a medication is always "safer" than using one. That doesn't lessen the indication or usefulness though.

But it's not a case of it being "safer to not give a medication", because there are other drugs which work just as well for RSI, and are safer and easier to use.

Propofol takes practice to learn to use safely. It's not rocket science, but until you've done lots of inductions with it on healthy people, you just aren't going to be good at using it. And until you are good at using it on healthy patients, you certainly have no business using it on really sick people who are much more susceptible to the negative effects that it can produce.

There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?

 

[Veneficus]

5mg isn't a bad dose either for most patients, but that's about the most I would use if I'm just trying to potentiate fentanyl. It's generally considered that opiate potentiation in a patient with a lot of pain who you want to keep spontaneously breathing requires a very small dose of versed. If they are still in pain after that, then they need more opiate, not more benzo.

I have not used it to try and potentiate fent, mostly in conscious sedation (probably boardering on TIVA in some instances) and post op pain management where the goal was to try and keep the patient sedated.

Fent is much better IMO because of it's rapid onset and more predictable effects. It is much more lipid soluble than morphine, so it crosses the BBB quicker and more reliably. IV fent reaches peak effect in 5-10 min, compared to 25-30 min for IV morphine. Also, it doesn't cause histamine release, which can negatively effect hemodynamics and also contribute to more uneven absorption into the CNS. It's shorter duration of action (30-45 min compared to 3 hours for morphine) contributes to it's safety profile.

I probably give preference to morphine because I am very familiar with it. I find it very predictable. I also like it more because of its longer effect.

It's just easier to titrate and safer to give larger doses of than morphine.

What would you consider a large dose?

I think the resistance is primarily due to many ED docs just not being familiar with it. Even though it's been around since the 60's, my understanding is that it basically wasn't used at all for several decades. It has gained in popularity recently, but it's effectively a brand new drug for familiarity purposes. And I think to many docs it's kind of looked as being "one of those weird anesthesia drugs"..

That is interesting.

Ketamine does have some drawbacks compared to etomidate. It increases ICP, which is bad considering that most prehospital RSI's are done on TBI patients.

To my understanding this was demonstrated to be transient and that ketamine may be more beneficial in the long term.

1.Have you ever done inductions with propofol? 2.Why do you think ketamine is hemodynamically safer that etomidate?

1. In theatre
2. No small part becase I was taught that way. There has been a lot of publicity on how safe etomidate is, but many providers I know have had negative outcomes with it and strongly caution against thinking it is a "safe drug."

Peds anesthesia here uses ketamine a lot and I have neither seen nor heard of any adverse reaction.

I think the CAD caution you mentioned earlier is not really suited to the trauma and emergency population as a whole. Obviously a gereatric patient might be differnet.

Ketamine generally isn't really used much as an induction agent in anesthesia. It can be, but when it is used that way, it's usually for a specific reason, such as being used in conjunction with propofol for a total IV anesthesia technique. Or for it's analgesic properties in a patient who you don't want to give a lot of opiates to.

A very agreeable statement.

You can probably argue that on a non-cardiac patient, ketamine and etomidate are equally safe. But etomidate is definitely more hemodynamically stable than either propofol or ketamine, which makes it the best drug to use in a patient population that can include both TBI patients with ICP concerns, and hypotensive trauma patients.

That is my argument. Along with the above mentioned ICP data with ketamine.

This is from Clinical Anesthesia by Barash:
"Consequently, etomidate is considered to be the induction agent of choice for poor-risk patients with cardiorespiratory compromise as well as in those situations in which maintenance of normal blood pressure is crucial (e.g. cerebrovascular disease)".

This from Miller's Anesthesia:
The minimal effect of etomidate on cardiovascular function sets it apart from other rapid-onset anesthetics. An induction dose of 0.3 mg/kg of etomidate given to cardiac patients for noncardiac surgery results in almost no change in heart rate, MAP, mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, stroke volume, cardiac index, and pulmonary and systemic vascular resistance. A large dose of etomidate, 0.45 mg/kg (which is 50% larger than a normal induction dose), also produces minimal changes in cardiovascular variables.

That is not the only entry in Miller's about etomidate, in the 7th edition there are entries that also issue the same cautions of etomidate that I raised.

Also, if you have a patient with increased ICP due to a TBI and you drop their BP significantly, you just increased their likelihood of mortality by 50%. Ditto if their SBP is already is already in the 70's and you drop it into the 40's because you pushed the prop a little fast.

I agree, but I would argue it comes down to familiarity, I have never been witness to neurosurg anesthesia in 2 hospitals use anything but propofol and fent.

But it's not a case of it being "safer to not give a medication", because there are other drugs which work just as well for RSI, and are safer and easier to use..

I see your point, but I argue that the drug you are familiar with is the safer and easier to use.

There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?

Despite my distaste for emergency medicine, I think they are capable people at what they do and can be taught to use any tool safely and efficently. Most of the patients I have seen them RSI in the sates are not hemodynamically unstable. The few that I have seen here in Europe, it is done by anesthesia anyway, and usually the decision on what is used is individual. I have seen anesthesia use propofol to RSI an unstable trauma (who was taken right to theatre from the ED) and without ill effect.

I have noticed a very wide variety in anesthesia practice around the world.

 

[Dwindlin]

There's a reason why anesthesia is it's own specialty. CRNA's and MDA's don't use prop for RSI if the patient is unstable, so why would a paramedic or ED doc?

Yes they do. Also, most hate being called "MDA's", they are Anesthesiologists.

 

[VFlutter]

Yes they do. Also, most hate being called "MDA's", they are Anesthesiologists.

Agree on both points especially the last, many consider it degrading or disrespectful.

 

[Dwindlin]

That is not the only entry in Miller's about etomidate, in the 7th edition there are entries that also issue the same cautions of etomidate that I raised.

In his defense that is straight out of the 7th edition. Etomidate is pretty darn hemodynamically stable, about the only group of people it isn't stable in is severe valvular disease.

Having said that, it's not what I would choose first for RSI/sedation.

 

[Carlos Danger]

I have not used it to try and potentiate fent, mostly in conscious sedation (probably boardering on TIVA in some instances) and post op pain management where the goal was to try and keep the patient sedated.

I used to work as a flight nurse for a program that was contracted with a burn center to transport their accepted patients to them. These were usually very fresh injuries and the transports often involved several hours outside of the hospital, so I learned a lot about early burn management and I got pretty good at keeping them comfortable.

One of the most interesting things I learned was how to use small doses of benzos to potentiate opiates. If you are already giving decent amounts of opiates, it doesn't take much midazolam to really make the patient a lot more comfortable. Anti-emetics help as well.

If the patient was ventilated, I would usually use a fentanyl infusion along with the versed or propofol infusion. If the patient was not ventilated, I would give a few mg of versed and an antiemetic up front, then boluses of fentanyl every 20 minutes or so.

If the patient had already received an adequate dose of a long acting opiate (hydromorphone or morphine), then I would use morphine if they required further analgesia. Which they always did, because a dose of analgesia that is adequate to keep a patient comfortable in a hospital bed is often not adequate to keep them comfortable during transport.

I probably give preference to morphine because I am very familiar with it. I find it very predictable. I also like it more because of its longer effect.

What would you consider a large dose?

I agree that familiarity is a lot of it.

For prehospital transports that are usually around 30 minutes or less, typical doses of fentanyl might be 200 or 300 mcg in divided doses.

As you know, the equivalent dose of morphine is roughly 20-30 mg.

In my experience, 200-300mcg of fentanyl is more reliable and has less side effects than 20-30 of morphine, plus a faster onset. But again, it probably comes down mostly to what you are most familiar with.

I think the CAD caution you mentioned earlier is not really suited to the trauma and emergency population as a whole. Obviously a gereatric patient might be differnet.

If I were the medical director of an EMS agency, my paramedics would have ketamine available. Though for RSI, I would rather they use etomidate in most cases, especially in cases of increased ICP or in cardiac patients.

Despite my distaste for emergency medicine, I think they are capable people at what they do and can be taught to use any tool safely and efficently. Most of the patients I have seen them RSI in the sates are not hemodynamically unstable. The few that I have seen here in Europe, it is done by anesthesia anyway, and usually the decision on what is used is individual. I have seen anesthesia use propofol to RSI an unstable trauma (who was taken right to theatre from the ED) and without ill effect.

I don't doubt that most ED MD's can learn to safely use propofol, and I'm not personally against it. But at the same time, I just don't see a need when there are other meds available that don't take experience to learn to use. I don't think most ED docs get much experience using propofol during their training, and it does take some practice to learn to use it safely.

 

[Carlos Danger]

Yes they do. Also, most hate being called "MDA's", they are Anesthesiologists.

Oh well. I don't particularly like being called an "ambulance driver", but I know that no disrespect is meant, so I don't take any.

Funny, you never hear gastroenterologists complain about being called "GI docs" or orthopedic surgeons complain about being called "orthopods", or emergency medicine physicians complain about being called "ER docs".

"Anesthesiologist" doesn't exactly roll of the tongue....or the keyboard.

 

[Dwindlin]

Oh well. I don't particularly like being called an "ambulance driver", but I know that no disrespect is meant, so I don't take any.

Funny, you never hear gastroenterologists complain about being called "GI docs" or orthopedic surgeons complain about being called "orthopods", or emergency medicine physicians complain about being called "ER docs".

"Anesthesiologist" doesn't exactly roll of the tongue....or the keyboard.

But it is disrespectful, whether that is the intent or not.

Yes, actually there are many physicians out there who dislike being referred to by those nicknames. How often do people outside of your social/professional circles hear you say you don't like being called "ambulance driver"? My guess is not too many, same thing applies to doctors.

 

[Jeremy89]

Anyway, enough semantics about titles and names...

With regards to the OP's question- I haven't seen anyone bring up Narcan. Most agencies I know of are required to carry it if the have the capability to give narcs. Of course, that's going with the whole 'dosage causing sedation' theory. Sure, I understand if you begin to lose their airway it'll reverse the opioid effect, but that won't do anything for the histamine release. But if that's really the major concern of these MD's, why couldn't they add Benadryl to the protocol, with morphine for burns? I dunno, just a thought..

 

[Carlos Danger]

But it is disrespectful, whether that is the intent or not.

Yes, actually there are many physicians out there who dislike being referred to by those nicknames. How often do people outside of your social/professional circles hear you say you don't like being called "ambulance driver"? My guess is not too many, same thing applies to doctors.

Hmm. Interesting stuff.

 

[Veneficus]

Anyway, enough semantics about titles and names...

With regards to the OP's question- I haven't seen anyone bring up Narcan. Most agencies I know of are required to carry it if the have the capability to give narcs. Of course, that's going with the whole 'dosage causing sedation' theory. Sure, I understand if you begin to lose their airway it'll reverse the opioid effect, but that won't do anything for the histamine release. But if that's really the major concern of these MD's, why couldn't they add Benadryl to the protocol, with morphine for burns? I dunno, just a thought..

I would offer against thinking of using narcan as a solution to sedation and depression in patients with severe pain.

Using the example of another wound, but equally applicable in burns, in order to control pain, you must control both nociceptive and neurologic pain (remembered pain) which is pain anticipated. The fundamental reason for adding sedation to opioid management.

Acute reversal of both anesthesia and the lesser form, analgesia, increases both pain and awareness of pain, even if the person is not concious. This is easily learned and demonstrated with both clinical signs and vital sign changes during anesthesia in surgery, and equally applicable to prehospital analgesia.

Basically your patient is depressed, unable to communicate with you, but can still be in considerable pain.

If a surgeon cut you open and then immediately anesthesia was reversed, it would hurt like hell. For the duration of the reversal, no pain management would be adequete.

Why would you do that to somebody?

(one of the reasons I like morphine over fent is because it more gradually loses effect over time)

I would also point out that people can be in such pain that analgesia itself is no longer effective. In that case, depressing their respiratory drive and taking control of their respirations may be the only way to allow enough dosage for pain management.

Severe pain creates pathology. So in the critically ill, reducing pathology needs to be a goal. Prehospital may not have definitive treatment of underlying pathology but it does possess treatment to mitigate deletorious effects of pain. Even when that means anesthesia from large dose opioids or the now antiquated sedation facilitated intubation.

Specifically addressing the anaphylactoid reaction of various opioids, the question becomes, why would you want to? Part of the physiologic response of anesthesia is to reduction of cardiac output and BP. Decrease in these vital signs is a sign effectiveness.

Managing this response is the other side of the coin of providing pain relief.

Now it may be said that in prehospital, anesthesia is not done, only analgesia. But I do not think that fits the definition or the reality.

Anesthesia is making sure the patient cannot feel pain, does not react to pain, and does not remember pain.

While it is not as profound as general anesthesia, the goal of analgesia is the same. Which really makes the semantics of it how much treatment is required, not the type of treatment provided.

Afterall, if you had a ped who fractured a bone, moderate sedation is an indicated treatment prior to ortho consult.

Wouldn't your goal be to make sure the child did not feel the pain or react to it? Do we not add benzos for their amnestic effect so the child does not remember or anticipate pain? (Do you remember anticipating the hurt of going to the doctor when you were younger because of your experience getting an injection for vaccination or other uncomfortable treatment of dx? Didyou want to go back to the doctor? Did you anticipate pain from the procedures?)

I should at least mention that the mechanism of histamine release caused by opioids such as morphine is slighly different than that of an allergic reaction at the molecular level. It is also dose dependant unlike a "standard" allergy attack.

Diphenhydramine is a first generation H1 blocker. Just like promethazine. The former is less sedative than the later, but still so. Adding benadryl may reduce vasodilation, but it will also deepen sedation. Epi would work directly against sedation, which would negate analgesia and require even higher doses.

One of my anesthesia mentors likes to be as simple as possible and use as few agents as possible on any given patient. Consequently he uses propofol almost exclusively and adjusts the dose and fluid therapy to his liking.

I am more fond of cocktails because of the philosophy of managig both types of pain while limiting the amount of agent used. That is the reason behind neuromuscular blockers. Otherwise, we could just use high-dose opioids for induction and anesthesia. Some services opposed to giving their medics neuromuscular blocks, still have high dose benzo admin to knock the patient down to the point of intubation. Which I think is foolish because it does the same thing in a less optimal and less safe way.

But for all of this, you really do not want to start playing mad scientist and mixing anymore chemicals than is required in the critically ill. It is a giant balancing game, and everything you add has to be balanced. The more you have to balance, the less likely you will succeed.

Depressing a patient in severe pain is not a fail, it may be what you need.