Question about narcotics and allergies

[mycrofft]

Follow your protocols. But words I never want to hear (but have) are:

"Well, we can go ahead, we have epi and benadryl on hand".
That's up there with "I can throw my kid brother off the roof, I have a traction splint in the car".

 

[SoCal]

"Well, we can go ahead, we have epi and benadryl on hand".
That's up there with "I can throw my kid brother off the roof, I have a traction splint in the car".

I disagree completely, this is taking the situation and rationalizing it. This is thinking ahead, and ultimately Epi did the right thing, however you do have many tools in your box.

 

[Sasha]

I disagree completely, this is taking the situation and rationalizing it

There is no guarantee that epi will stop the reaction. You would be putting the patient in a potentially life ending situation with no promise that you can reverse the effects.

 

[SoCal]

There is no guarantee that epi will stop the reaction. You would be putting the patient in a potentially life ending situation with no promise that you can reverse the effects.

I agree with you, and like i said Epi did the correct thing, however, thinking about what all you have to use in that "in case" scenario will keep you on your toes...

 

[daedalus]

From what i have seen epi post in my time here, she is a thoughtful and concise paramedic. I think she cares about her profession and patients. I would trust her with my family gladly over some the the sorry excuses out here in socal. I think she has done the right thing, and there is no need to lecture her about the importance of pain control. It seems to me that Epi would if possible always lean on the side of controlling pain.

 

[Smash]

I can't imagine that anyone would actually think that having epinephrine and benadryl on hand would actually justify giving a contra-indicated treatment and re-reading the original post I do not think that this is how it was meant. It seems to me that she was considering possible outcomes, what the worst case scenario would be and how she would manage it if she elected to give the fentanyl.

I have not really read any of Epi-do's previous posts being new to this board, and I disagree with Epi's decision not to give the pain relief as there is no reason for the patient to have a reaction to fentanyl because they have had a reaction to morphine in the past (they may have a reaction to fentanyl, but this would be entirely coincidental)

However, that said it is obvious that this was done with the best interests of the patient in mind given the situation and understanding of the pharmacology, and she was clearly acting as an advocate for the patient and seeking to ensure no further harm came.

Further to this, the fact that she is asking opinions of other providers from all over the world suggests that she is a self-reflective practitioner seeking to improve her performance and this is exactly the type of person we need in EMS.

 

[SoCal]

I can't imagine that anyone would actually think that having epinephrine and benadryl on hand would actually justify giving a contra-indicated treatment and re-reading the original post I do not think that this is how it was meant. It seems to me that she was considering possible outcomes, what the worst case scenario would be and how she would manage it if she elected to give the fentanyl.

I have not really read any of Epi-do's previous posts being new to this board, and I disagree with Epi's decision not to give the pain relief as there is no reason for the patient to have a reaction to fentanyl because they have had a reaction to morphine in the past (they may have a reaction to fentanyl, but this would be entirely coincidental)

However, that said it is obvious that this was done with the best interests of the patient in mind given the situation and understanding of the pharmacology, and she was clearly acting as an advocate for the patient and seeking to ensure no further harm came.

Further to this, the fact that she is asking opinions of other providers from all over the world suggests that she is a self-reflective practitioner seeking to improve her performance and this is exactly the type of person we need in EMS.

Thanks for posting that, that is exactly what I was trying to say.

 

[mycrofft]

EPi-do's post was great. I would never suspect her of the "we got epi/benadryl" bit .

I have no inkling nor do I imply that Ms Epi would do something like that.

But my generic statement stands. I have heard parameds, nurses, and even MD's say that and sometimes act on it.

Witholding a pain medication because you honestly suspect a likelihood of anaphylaxis is ethical, thougthful and legal. It is right. Intentionally administering what amounts to a poison (high likelihood of anaphylactoid reaction in a particular pt) because you have the putative antitdote on hand is not only ethically unsound, but illegal and a felony to boot. "House MD" not withstanding, it is wrong.

 

[rescue99]

In certain situations where reversal of S/S of an allergic reaction is necessary, you bet hospitals do. I can say for absolute fact it's done Mycrofft. It's been done to me on at least 3 separate occasions. I get benadryl and zantac as a precaution anytime I'm given any anesthetic for example and before any contrast.

In the case of the poster of this thread, she did exactly what she should have done. In a more life threatening situation advice is but a radio call away. That's what Med Control is for! We have advice right at our finger tips, always.

 

[medic417]

In a more life threatening situation advice is but a radio call away. That's what Med Control is for! We have advice right at our finger tips, always.

Wow that must be nice. Here you are in communication dead zone much of the time. Even Satellite phone is not reliable.

 

[rescue99]

Bummer....and this system would remain BLS until the communications issues could be resolved if communications were that poor. If education requirements don't step up to the plate then restrictions have to be in place.

There are some very, very rural areas where communication is risky or impossible but, for the most part this should not happen. Portables, 900's, dispatch, land line and a cell. If none of these work and ya don't have the knowledge, skills or ability to make some decisions......revert back to basic. Do what you know.

 

[redcrossemt]

If none of these work and ya don't have the knowledge, skills or ability to make some decisions......revert back to basic. Do what you know.

Shouldn't you have the knowledge, skills, and ability to make decisions regarding every drug and procedure you are trained and equipped to perform?

I am in a system where, thank heavens, we can give narcotics pre-radio. However, dopamine is post-radio for us. Does that mean that if I can't contact med control, I shouldn't give dopamine?

The answer is absolutely not. In the case of radio communications failure, we are trusted to continue on in the protocols. If you are a paramedic, you can not rely upon medical control - you must have the knowledge and skills to perform at the ALS level.

 

[rescue99]

by "ability" I am referring to not being able to for whatever reason...protocol or otherwise.

 

[Ditchmedic]

Questions about narcs and allergies

If they hurt, fix it. If you are not sure, call Med control, that's what they are there for.

 

[Melclin]

Fentanyl is commonly recommended and used where pts have a morphine allergy. A true allergy to morphine is rare and anaphylaxis is rarer still. Most people with "allergies" have some kind of sensitivity issues or have actually suffered from the histamine release caused by opiates (which can causes varrying degrees of similar, but not as severe, reactions to anaphylaxis), but of course you have to play it on the safe side if they say they have a morphine allergy. Our service carries fentanyl for just such a purpose (also RSI for the big boys, and a general alternative to morphine at the digression of the medic).

As smash says, being as it is that it's an entirely different substance to Morphine, I can't see what reason you would have to think that a morphine allergy would be a problem when administering fentanyl.

Other than an actual anaphylactic response (as far as I can tell, its debatable whether or not true morphine allergies exist in the same sense as grass or peanut), it is possible to have something called and anaphylactoid (I think) response which is not IgE mediated and does not involve the anaphylactic cascade. It can, however, appear very similar though it is not nearly as serious. It is caused by the release of histamine which is caused by the presence of the opioid. Different opioids have different abilities to liberate histamine. Fentanyl, like other synthetic opioids, have a very low ability to release histamine. As such, fentanyl is far less likely to cause any kind of allergic response.

If you are taking on the responsibility of administering a drug, I feel you should know what it's doing to the pt, to the best of your ability (fentanyl is not well understood). This is a great, brief little article that explains it all pretty well:http://depts.washington.edu/druginfo/DTT/2006_Vol35_Files/V35N4.pdf