Zofran and ACS

[vquintessence]

When you all out there bust into the narcs regarding ACS, what is the general consensus on preventively administering Zofran "to stay ahead of the game"? I mean, N/V can be a manifestation of ACS in and of itself... but now we've throw analgesics into the situation? Anyways, aside from the answer "every situation is unique", can anybody give a general yes or no opinion on the matter? I know, I know, this is medicine and there are never "yes" or "no" answers... but for selfish and debating purposes, could we try it.

Personally I'm extremely sensitive to analgesics; even low doses PO will make me nauseous... I've opted for pain, simply to avoid the nausea. That said, it's safe to say I'm biased toward a more pro-active prevention of N/V, especially when analgesics enter the game.

Typically the decision will boil down to: if there's NKA and no serious hepatic compromise... the pt gets it. Recently my thinking has been audited, and I'm curious about any positions for or against. This is no attempt to vent or cry about the audit, I'd just would like to walk away wiser to differing opinions.
Thanks as always!

 

[marineman]

When I was doing clinicals in the ER it was standard that any patient that was getting analgesics would get 4mg Zofran first.

On the street it's medics choice, in our protocols it's listed as a special note "consider Zofran prior to morphine" as a reminder that it's an option but not required. I usually will give it but it really does come down to patient presentation and if there are more pressing things that I need to get done the Zofran takes a back seat unless patient already has N&V.

 

[medic417]

If you eliminate the stress of N&V you lesson demand on heart lessoning the damage that is occurring. So yes use Zofran or other to help N&V.

 

[OklaEMT]

I will usually ask the patient if they get nauseated easily or have had N/V with other pain medications.... if there is a 'yes' then you definitely get Zofran. Otherwise, I'm afraid I have to go with 'depends on the situation' B)

 

[Shishkabob]

If you have Phenergan, obviously use that first so that you don't potentiate the morphine too much.


I, myself, would give Zofran or phenergan proactively, as feeling N/V is never fun.

 

[Ridryder911]

Actually, newer studies are revealing Phenergan does not potentiate as much as once was thought. As well, Zofran is a great anti-emetic as long as they are not currently nauseated. In other words great for prophylactic use. The reason is used with great use in Chemotherapy patients (why it was developed).

Personally, I have seen Zofran work very few times, after the patient had became nauseated or have vomited in comparison to other anti emetics.

R/r 911

 

[triemal04]

If you eliminate the stress of N&V you lesson demand on heart lessoning the damage that is occurring. So yes use Zofran or other to help N&V.

Kind of like using analgesics other than morphine for cardiac chest pain. I don't see how this could be a problem, especially if you are using morphine to manage their pain. There is a good, valid reason to give it so...vquintessence, did you actually get in trouble over this, or just called on to defend your thinking?

 

[ResTech]

If I understand correctly, anti-emetics aren't a "one size fits all". Depending on the cause of the nausea and which neurotransmitters are involved will likely determine how well a particular patient responds to a given anti-emetic. This is largely due to anti-emetics targeting and inhibiting the binding of the different neurotransmitters at different receptor sites which turns off the "nausea & vomiting" signal to the CTZ and vomiting center in the brain.

Nausea from motion responds well to anti-emetics that block histamine and acetylcholine. Chemotherapy patients respond better with anti-emetics that block serotonin such as Zofran.

One doc in the hospital I do clinicals always order Droperidol for nausea while the other docs mostly order either Zofran or phenergan... mostly Zofran.

Phenergan has dropped out of favor in many hospitals and pre-hospital given the high profile cases of its damaging effects with extravasation. It is highly vesicant and can be very damaging if not administered properly.

 

[Smash]

Only about 5% of patients receiving IV morphine will develop nausea from the morphine.

If they have nausea, I treat it. I don't prophylactically give more drugs unless I have a reasonable expectation that they will develop nausea.

 

[OklaEMT]

Actually, newer studies are revealing Phenergan does not potentiate as much as once was thought. As well, Zofran is a great anti-emetic as long as they are not currently nauseated. In other words great for prophylactic use. The reason is used with great use in Chemotherapy patients (why it was developed).

Personally, I have seen Zofran work very few times, after the patient had became nauseated or have vomited in comparison to other anti emetics.

R/r 911

I will definitely second that..... once they start vomiting, it is hard to catch up with Zofran. Unfortunately, that is the only anti-emetic that we carry (unless you count Benadryl). Which I will say, I worked at a service once that only used Benadryl, they didn't carry any other anti-emetics. It works surprisingly well.

 

[Melclin]

Metaclopramide and Prochlorperazine are our options. I've honestly never heard of Zofran except on this forum. Not to hijack the thread but does anyone mind mentioning how it compares to the two I mentioned in terms of efficacy and availability to you guys?

 

[carpentw]

Metaclopramide and Prochlorperazine are our options. I've honestly never heard of Zofran except on this forum. Not to hijack the thread but does anyone mind mentioning how it compares to the two I mentioned in terms of efficacy and availability to you guys?

Well, metoclopramide, otherwise known as Reglan here in the states acts on a different part of the body than Zofran does. Zofran blocks serotonin receptors in the medulla oblongada. Reglan is a gastroprokinetic agent which is a fancy way of saying it works in the gut. I don't know much about Prochlorperazine other than its a phenothiazine so it probably functions much like promethazine in that its a histamine antagonist. In short each drug does the same thing (more or less), but functions in a different part of the body.. My service currently uses only Zofran or phenergan (promethazine) as ant-emetics. Like others have said, typically Zofran works alright if the patient isn't already actively vomiting.

I have heard rumors the FDA black boxed reglan here, but haven't really followed up on it to much. Something to do with the development of tardive dyskinesia.. Don't know much more about it.

 

[Smash]

Reglan (metoclopramide) accelerates peristalsis. However this is a secondary action to it's primary anti-emetic action which is related to the modulation of dopamine in the vomiting center of the brain.

This is why there is a risk of developing tardive dyskinesia when it is used for a long time. However this is not really a concern for the use of it in single IV doses in emergent situations

 

[medic_texas]

As a paramedic, I rarely used an anti-emetic when I gave a narcotic.

As a nurse, almost always do I give one with the other.

Reglan for nausea - I can see the reasoning behind it but there are better drugs out there for nausea IMO.

 

[Melclin]

Reglan for nausea - I can see the reasoning behind it but there are better drugs out there for nausea IMO.

It's funny how different places have very different emphasis on different drugs. Metoclopramide is a first line treatment for nausea in prehospital practice and in EDs every where here. (As an aside I read somewhere that wellbutrin is something like the 2nd most highly prescribed anti-depressant in the US and its not used here except for the occasional prescription for smokers trying to quit).

I have heard rumors the FDA black boxed reglan here

Yeah you yanks have banned a whole pile of drugs that we like ^_^ Methoxyflurane is the biggest one I can think of. First line analgesic used all over Australia many hundreds of times every day - banned in the US....and phenergan is OTC, great when you need a good nights sleep.

 

[medic_texas]

I wish phenergan was OTC here..

Benadryl is a good anti-emetic also, someone mentioned that and very few know about it really. Good job

 

[vquintessence]

Only about 5% of patients receiving IV morphine will develop nausea from the morphine.

Where does the 5% figure come from? I don't drastically disagree with you about there being a "high frequency" of morphine IV induced N/V, I just can't find a study which cites a hard & fast %. Personal experiences/bias has me believing that the following factors create a good recipe for an upset tummy:
-Opioid administration (IV being the lesser evil, but still present)
-Ambulance ride, pt facing rear position and little to no cabin ventilation
-N/V manifestation from CP
-Stressful/anxious situation
-Environmental factors in ambulance

http://www.nauseaandvomiting.co.uk/NAVRES001-4-opioid.htm

Granted the above journal/whatever focused much of its findings related to cancer pts and post-op. Their highest figure of "significant" induced N/V can easily be discarded because it references Cesearian sections, where the morphine is likely given intrathecal (spinal).

http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102212623.html

This study was interesting in that it involved a healthy control group; only wish that more than ~40 people were included.

emedicine addressed the topic somewhat thoroughly, but in the end I was unable to find any specific studies regarding opioid induced nausea related specifically to IV and dose. :sad:

If they have nausea, I treat it. I don't prophylactically give more drugs unless I have a reasonable expectation that they will develop nausea.

Amen, but reasonable expectation is very subjective, no?

There is a good, valid reason to give it so...vquintessence, did you actually get in trouble over this, or just called on to defend your thinking?

No trouble, just had to defend rationale. All civil, everyone walked away with some beneficial gain.

 

[wyoskibum]

Only about 5% of patients receiving IV morphine will develop nausea from the morphine.

If you push the IV morphine too fast, you could potentially cause nausea as well.

I don't prophylactically give more drugs unless I have a reasonable expectation that they will develop nausea.

I do make an exception on my patients that are immobolized.

 

[Akulahawk]

Benadryl does work. It also can minimize any BP drop that you might see with morphine administration. Morphine can cause a histamine release... guess what Benadryl blocks the effects of... If you get nauseated whenever you have a good histamine release, Benadryl will work as an anti-nauseant... Interesting stuff.

 

[ResTech]

If you push the IV morphine too fast, you could potentially cause nausea as well.

I know Demerol can cause severe nausea and projectile vomiting if pushed fast as well. Other substances can act in this manner... as the body detects a rapid increase in a foreign substance it activates nausea and vomiting to help prevent any additional absorption if the source would be coming from the stomach... an evolutionary process.

Akulahawk, I agree so much with ya on the Benadryl... I think Benadryl is a great medication and very useful... treats allergic reactions, EPS, nausea, and works well for sleep.