Morphine vs. toradol, kidney stones.

[NYMedic828]

So what have you guys found works better with the assumption of kidney stones?

Does toradol being anti-inflammatory outweigh the greater pain suppression of opiates?

Does the lowering of BP via morphine reduce the pain at all?



I've never given either for kidney stones, was just a thought that came to mind.

 

[Doczilla]

I've given toradol, fentanyl, and morphine for kidney stones. I have to say that toradol seems to provide the longest lasting, more specific relief.

Toradol dilates the ureter while supressing the intense inflammatory response associated with renal calculi. this assists in passing as well as preventing that spasmotic, colicky pain that comes with it. Combined with an alpha blocker, its even better.

Also, in general, 30mg of I.V toradol is equivalent to 10mg of morphine from an analgesia standoint.

Lastly, the constipation that eventually comes with serial doses of opiates only makes the colicky pain worse if they haven't passed it.

 

[DrankTheKoolaid]

Toradol in combination with Reglan works magic renal stones

 

[NYMedic828]

Also, in general, 30mg of I.V toradol is equivalent to 10mg of morphine from an analgesia standpoint.

That's really interesting, I didn't think toradol was quite that strong.

So, not to get off topic but say I have an extremity fracture, giving 30Mg toradol IV will actually be stronger than 5mg of morphine?

I imagine the difference in the above case is the more rapid onset of relief with morphine.


Another side note, any contraindications to giving morphine in conjunction with toradol? (epocrates says none, just thought id ask)

 

[Doczilla]

There's no absolute interactions. Remember that most PO opiate preperations come with NSAIDS, if you count APAP. (Some do. )

The only thing is , traditional NSAIDS (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.

 

[DrankTheKoolaid]

It seems alot of people, not just forum readers underestimate the power of NSAIDS. If you get a chance read Soto Omoigui ( Author of the Anesthesia Handbook) Law of Pain which states all pain is caused by imflammation, which would explain why NSIADS and other AI drugs work so well.

 

[Doczilla]

I agree. Alot of people don't realize that the APAP in Percocet, vicodin, and others is what controls somatic pain. The opiates just slow pain signals through GABA and opiate receptors.

 

[mycrofft]

So what have you guys found works better with the assumption of kidney stones?

Does toradol being anti-inflammatory outweigh the greater pain suppression of opiates?

Does the lowering of BP via morphine reduce the pain at all?



I've never given either for kidney stones, was just a thought that came to mind.

Why would reduction of BP help pain, other than maybe migraine?

We used Toradol for torso pain (renal, cholecystitis) and found to work very well. Some patients also experienced some sedation, just as rare ibuprofen users report.

 

[NYMedic828]

Why would reduction of BP help pain, other than maybe migraine?

We used Toradol for torso pain (renal, cholecystitis) and found to work very well. Some patients also experienced some sedation, just as rare ibuprofen users report.

Wasn't sure whether or not pressure exerted by higher BP would put any more force behind the calculi or not. Guess that's a no.

 

[NYMedic828]

There's no absolute interactions. Remember that most PO opiate preperations come with NSAIDS, if you count APAP. (Some do. )

The only thing is , traditional NSAIDS (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.

So would you say that for a fracture, immediate treatment opiates are preferred as for something more muscular in nature, toradol may be better?

 

[Doczilla]

Yeah that's why most places will give you a 7 day course of opiates then switch you to NSAIDS. Sprains are a different story, but differentiating between fractures and sprains as difficult If you don't know where to look.

Anyone here use the ottowa ankle rules?

 

[Dwindlin]

The only thing is , traditional NSAIDS (not APAP) are discouraged for the first dew days of fractures because they supress osteoclastosis and osteoblastosis. This is what breaks down/rebuilds new bone.

Controversial. Evidence isn't great either way.

www.ncbi.nlm.nih.gov/pubmed/20552333
www.ncbi.nlm.nih.gov/pubmed/19240368

 

[mycrofft]

Don't know about osteoblasts and clasts, but NSAIDS taken right after the fx could aggravate bleeding, no?

 

[truetiger]

Why not both? My partner had a call last week in which he used 50mg of toradol with 50mcg of fentanyl to treat severe pain from panreatitis.

 

[Veneficus]

It looks to me reading this thread that there is a begining of a cultural bias here.

In EMS and in medicine in general in conservative countries, there is an almost cyclic aversion to the use of stronger pain medications.

The idea that pain is caused by inflammation is not ground breaking or revealing. The kininogen system is interconnected with inflammation and clotting, you cannot get through 5 chapters of any reputable pathophys texts without having that pounded into you.

I like to use a combination of opioid and NSAID for most pain outside of renal.

I like to explain it to patients as "a shot and a beer."

The opioid for breakthrough pain control, and the nsaid for maintenence. It seems to work very well.

 

[the_negro_puppy]

We don't carry NSAIDs other than Aspirin which can only be used for suspected mycardial isachaemia/AMI.

Morphine is our only option, alos possible methoxyflurane.

We are rolling out fentanyl, with IN first for children then slowly allows IV use for ACPs/

 

[truetiger]

Why has fentanyl been slow to catch on?

 

[the_negro_puppy]

Why has fentanyl been slow to catch on?

Not too sure. Other services in AUs already use it.

Our current indication is intranasal for paeds:

1.5 mcg/kg repeated once at 1mcg/kg after 10 mins. Total max 100mcg/kg


Our ICPs can give it to adults: 25-50mcg repeated at up to 50mcg every 5 mins, no max dose. The plan is to roll this capability down to use once our service has been using the drug for a while.

We have only just got Zofran as well. 4mg for adults, iv/im and 0.1 mg/kg for paeds 3 years and older.

 

[NYMedic828]

Why has fentanyl been slow to catch on?

Here in NYC, we have morphine and fentanyl.

It is VERYYYYY rare that someone goes back to the station to replace a vial of fentanyl. We have had 8 spare vials for about 7 months now.

Its actually pretty rare for morphine too. And thats on standing orders for isolated extremity injuries.

Personally, im a fan of pain control. Why should a legitimate patient be in pain if they don't have to be. The problem is, my partners in NYC are not.

Where I volly it doesn't matter, I'm in charge 99% of the time there is no one above an AEMT with me.

Pain management is just taboo it seems on an NYC ambulance. I don't know if it comes from laziness or poor education.

We carry zofran, morphine, fentanyl. We could be doing a lot of help to some of those constant abdominal pains we get.

 

[OzAmbo]

Why has fentanyl been slow to catch on?

Supply v demand issue here

Demand outstripped supply so much that services haev put off its ontroduction as the uice wasn't available to be used.

Id almost place bets that once more manufacturing capacity comes online that we may ditch morph completely for fentanyl and hopefully ketamine