Pain medication and when not to give it

[ParamedicStudent]

We haven't really gone over pain management in class yet, but I was wondering yes you give morphine for pain, but when do you Not use it? I know it'll drop you BP so you can't give it to someone who's hypotensive,

So in theory, if someone is in extreme pain, but is hypotensive and/or showing contraindications of morphine, you'll just let them suffer great pain (while providing care)

 

[STXmedic]

Fentanyl is not as vasoactive as morphine, so fentanyl would be a good option in the borderline hypotensive patient. In fact, fentanyl tends to get used far more often than morphine. Ketamine is another excellent option for pain management, and may even raise their BP a bit, but ketamine isn't all that prevalent in the prehospital arena yet.

In short, if you're patient is in pain, treat it. If their BP is so low that you're worried about bottoming it out, they've probably got other problems that need addressing first anyway. Generally, above 80 systolic I'll have no problem giving fentanyl (though I may start at a lower dose and titrate up).

 

[SpecialK]

There is no practical reason for a patient to be left in intolerable pain.

Many options exist: entonox, methoxyflurane, paracetamol, ibuprofen, tramadol, codeine, oromorph, morphine, fentanyl, hydromorphone, ketamine, nerve blocks, and more. I guess it all depends on where you work.

The historic teaching was "you can't give morphine to somebody with low blood pressure" or "anything more than a touch of morphine will make people stop breathing" and to be frank, that is just wrong. If the patient is a bit on the hypotensive side give them some fluid and small increments of morphine (better yet use fentanyl or ketamine if it is appropriate) and as for the "stopping breathing", rubbish, technically possible, but it is also technically possible for me to fly if I flap my arms hard enough!

 

[STXmedic]

Many options exist: entonox, methoxyflurane, paracetamol, ibuprofen, tramadol, codeine, oromorph, morphine, fentanyl, hydromorphone, ketamine, nerve blocks, and more. I guess it all depends on where you work.

The majority of posters here are from the US, and most of those just aren't options. Almost everywhere has morphine. Many have fentanyl. A couple systems have ketamine. And you'll very occasionally see something like dilaudid or toradol. Most systems can't even give OTC NSAIDs for pain.

Everything else you posted I agree with, as reflected in my first post.

 

[TransportJockey]

You still see dilaudid from time to time too. I miss,having more options. (Used to have demerol, dilaudid, morphine, fent, ketamine, and toradol for my pain mgmt options)

 

[harold1981]

Morphine would be contraindicated in case of COPD, liver failure or in combination with alcohol. We don't use it anymore as a prehospital analgesic drug. The only protocol in which morphine appears is for severe CHF. Ocassionally we would give it via the subcutaneous route to terminally ill patients who are dying after consulting the GP. For pain management we have fentanyl, ketanest and paracetamol (IV, oral tablets or suppositories). Last year they took the entonox out.

 

[Chewy20]

Morphine would be contraindicated in case of COPD, liver failure or in combination with alcohol. We don't use it anymore as a prehospital analgesic drug. The only protocol in which morphine appears is for severe CHF. Ocassionally we would give it via the subcutaneous route to terminally ill patients who are dying after consulting the GP. For pain management we have fentanyl, ketanest and paracetamol (IV, oral tablets or suppositories). Last year they took the entonox out.

Just curious, why morphine in severe CHF? The nitro not working for you? Are you hoping the morphine will drop their BP enough? Any other positive effects?

 

[Carlos Danger]

So in theory, if someone is in extreme pain, but is hypotensive and/or showing contraindications of morphine, you'll just let them suffer great pain (while providing care)

That's a pretty uncommon scenario. A small or moderate dose of morphine is unlikely to have a significantly negative affect on hemodynamics, except in really brittle patients.

That said, it certainly is possible that someday you come across a situation where you have to choose between analgesia OR a blood pressure. The priority then is clear.

Fentanyl is, all around, a far better drug than morphine for the prehospital environment.

 

[harold1981]

We give it as a preload and afterload reducting agent, after NTG. But it also reduces the anxiety and stress associated with the acute respiratory failure. We are taught to first do the oxygen and NTG. Next bring in the IV and supply lasix. If that doesn't give sufficient effect, put on the CPAP. And if that isn't enough give morphine. The NTG will be ongoing untill reaching the ED.

 

[STXmedic]

We give it as a preload and afterload reducting agent, after NTG. But it also reduces the anxiety and stress associated with the acute respiratory failure. We are taught to first do the oxygen and NTG. Next bring in the IV and supply lasix. If that doesn't give sufficient effect, put on the CPAP. And if that isn't enough give morphine. The NTG will be ongoing untill reaching the ED.

That's interesting. CPAP and NTG are pretty much the staple treatments down here. A CHF exacerbation here will get an initial double dose (800mcg) of NTG, with the CPAP applied pretty much right away. Then an IV with an NTG infusion titrated to effect. We don't even carry lasix anymore, and morphine isn't in the protocols for CHF either. NTG and CPAP alone tend to provide excellent relief for these patients.

 

[harold1981]

We might go the same way in the future. Do you give the NTG infusion over a 60cc syringe pump?

 

[STXmedic]

We use the infusomat space large volume/in line pumps.

 

[SpecialK]

Morphine would be contraindicated in case of COPD, liver failure or in combination with alcohol. We don't use it anymore as a prehospital analgesic drug. The only protocol in which morphine appears is for severe CHF. Ocassionally we would give it via the subcutaneous route to terminally ill patients who are dying after consulting the GP. For pain management we have fentanyl, ketanest and paracetamol (IV, oral tablets or suppositories). Last year they took the entonox out.

I've never heard of morphing being contraindicated in COPD. Why do you say that?

What did you replace entonox with? Methoxyflurane?

Rectal paracetamol jeez, count me out.

 

[Chewy20]

We give it as a preload and afterload reducting agent, after NTG. But it also reduces the anxiety and stress associated with the acute respiratory failure. We are taught to first do the oxygen and NTG. Next bring in the IV and supply lasix. If that doesn't give sufficient effect, put on the CPAP. And if that isn't enough give morphine. The NTG will be ongoing untill reaching the ED.

Hmm interesting. Seems like a lot of wasted time before getting to CPAP. What's the thought process the medical director has on that?

Also just saw you work in another country. Explains some of it.

 

[harold1981]

I've never heard of morphing being contraindicated in COPD. Why do you say that?

What did you replace entonox with? Methoxyflurane?

Rectal paracetamol jeez, count me out.

It's listed as a contraindication in our protocols. I am not sure why. Maybe someone else can help.
Entonox was often used as a first step drug in combination with IV paracetamol, often with unsufficient results. Many of loved it , especially when repositioning luxations. We tend to use fentanyl more agressively now, via the intranasal route and in larger dosages.

We use paracetamol suppositories of 120mg or 240mg for our pediatric patients. We also carry 500mg and 1000mg. It works fine.

 

[SpecialK]

I would hate to not have inhalational analgesia, I seriously do not think I could work without it. The idea of not having it is unthinkable!

Entonox is easy to administer, has very few side effects and only a small number of contraindications (for which you can use methoxyflurane) and works really well, either alone or in combination with paracetamol, ibuprofen or tramadol.

It is great stuff. Shame you do not have it anymore. I'd much rather give somebody who needs pain relief a bit of entonox if that'll do that job rather than intranasal fentanyl. Intranasal fentanyl is good but really I think only for situations where you cannot obtain intravenous access.

 

[harold1981]

Hmm interesting. Seems like a lot of wasted time before getting to CPAP. What's the thought process the medical director has on that?
Also just saw you work in another country. Explains some of it.

Our medical directors don't dictate the protocols. They are formulated at a national level, after a broad consensus, in which different specialist groups are involved. Based on research, therapies are adapted where needed. Indeed...choices may differ between the USA and other countries. Sometimes you are a step ahead, sometimes we are. Our CHF patients generally also arrive at the ED in good shape. Who is doing better? I don't think it's easy to say.

 

[harold1981]

I would hate to not have inhalational analgesia, I seriously do not think I could work without it. The idea of not having it is unthinkable!

Entonox is easy to administer, has very few side effects and only a small number of contraindications (for which you can use methoxyflurane) and works really well, either alone or in combination with paracetamol, ibuprofen or tramadol.

It is great stuff. Shame you do not have it anymore. I'd much rather give somebody who needs pain relief a bit of entonox if that'll do that job rather than intranasal fentanyl. Intranasal fentanyl is good but really I think only for situations where you cannot obtain intravenous access.

I personally seldom give fentanyl intranasally, as most patients will get an IV anyway, and have the fentanyl in combi with IV paracetamol and sometimes ondansetron as well. However in pediatric patients the intranasal route it is my prefered route, as it is with midazolam for the status epilepticus patients.