The next topic for discussion in the naemsp dialog will be Prehospital
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Prehospital Emergency Care. 14(4):439-47, 2010 Oct-Dec.
prehospital analgesic in children. Emergency Medicine Australasia 2006;18(4):404-10.
in adults using inhaled methoxyflurane. Emergency Medicine Australasia 2007;19(6):509-14.
methoxyflurane analgesia in the emergency department and prehospital setting. [Review] [57 refs] ovidsp.tx.ovid.com.ezproxy1.library.usyd.edu.au/sp-3.2.2b/ovid...> Emergency Medicine Australasia. 21(1):4-11, 2009 Feb.
Paul Simpson Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute Ambulance Service of New South Wales
Hi
CNRD
Hôpital Armand Trousseau 26, av Arnold Netter
75571 Paris Cédex 12 Tel : +33 144735426
Secrétariat: +33 144735421 On Sep 22, 2:26 pm, galinski m > Nitrous oxide / oxygene 50/50 is a good and simple way for analgesia in prehospital setting. Its efficiency was proven in many studies but never in this situation and only for moderate pain. We do not know its efficiency for sever pain in association with morphine, for example.
> Question: Who know the prevalence of pain during the mobilisation of a trauma patient in spite of analgesia? I mean that some spoke about fentanyl for the mobilisation of patient but there is probably not a pain relief in all patients. So How many patients are still painful in spite of analgesia with a narcotic, for example? Is there reference about that? That is going to depend on a lot of things. Some people are more responsive to opioids than others. The type of pain also matters. The
dose will have a significant effect. I remember reading that the range of effective doses is very large. Comparing the effective dose at the
lowest end with the highest end, for opioid naive patients,k the high end is ten times higher than the low end. this study does nothing to
contradict that. Unfortunately, I do not remember the source of that range.
severe acute pain used a 50% decrease in the pain level as an indication of adequate pain management.
A 67% failure rate! least in America, ordered doses of 2 mg morphine, or even 5 mg morphine, few patients are even approaching 0.1 mg/kg morphine. For an
80 kg patient (176 pounds), 2 mg is one quarter of this dose, that the authors found to be inadequate. 5 mg is just a bit more than half of
the inadequate dose. Other studies have had similar results. http://roguemedic.com/2010/05/intravenous-morphine-at-0-1-mgkg-is-not... Intravenous morphine at 0.1 mg/kg is not effective for controlling
severe acute pain in the majority of patients. Ann Emerg Med. 2005 Oct;46(4):362-7. PMID: 16187470 [PubMed - indexed for MEDLINE]
morphine protocol used in his hospital without problems is at - http://blog.emcrit.org/podcasts/gentile-pain/
The follow-up post explaining the routine use of diphenhydramine is at http://blog.emcrit.org/blogpost/comments-on-pain-protocol/
effects prevent titration from continuing to the point of adequate relief of pain, or the patient experiences adequate relief of pain.
Titration should not have any maximum dose. What would be the point? With 0.1 mg/kg as a starting dose, rather than a total dose, the
pathetic 67% failure rate would be much, much lower. http://roguemedic.com/ Tim,
have most of them now indexed and upload onto the resource page for
this topic (http://groups.google.com/group/naemsp-dialog/web/topic-4--- prehospital-pain-management). Here is what's available for download as
PDFs so far: - Alonso-Serra H, Wesley K: NAEMSP Position Paper - Prehospital Pain
Management. Prehosp Emerg Care 2003; 7:482-488. - Bijur PE, Kenny MK. Gallagher EJ: Intravenous Morphine at 0.1 mg/kg
Is Not Effective for Controlling Severe Acute Pain In the Majority of Patients. Ann Emerg Med 2005; 46:362-367.
- Braude D, Richards M: Appeal for Fentanyl Prehospital Use (Letter to the Editor). Prehosp Emerg Care 2004; 8:441-442.
- Galinski M, et al: Out-of-hospital emergency medicine in pediatric patients: prevalence and management of pain. 2010 Am J Emerg Med
(article in press). - Galinski M, Ruscev M, Gonzalez G, et al: Prevalence and Management
of Acute Pain in Prehos[pital Emergency Medicine. Prehosp Emerg Care 2010;14:334–339.
- Kanowitz A, Dunn TM, Kanowitz EM, et al: Safety and Effectiveness of Fentanyl Administration for Prehospital Pain Management. Prehosp Emerg
Med 2006; 1-7. - Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Bendall JC:
Effectiveness of Morphone, Fentanyl, and Methoxyflurance in the Prehospital Setting. Prehosp Emerg Med 2010;14:439–447.
- Rupp T, Delaney KA: Inadequate Analgesia in Emergency Medicine. Ann Emerg Med 2004;43:494-503.
- Shavit I, Hirshman E: Management of Children Undergoing Painful Procedures in the Emergency Department by Non-Anesthesiologists.
Israel Med Assn J 2004; 6:350-355. - Svenson JE, Abernathy MK: Ketamine for prehospital use: new look at
an old drug. Am J Emerg Med (2007) 25, 977–980. - Veysman BD: Truth Hurts. Acad Emerg Med 2009.
collection for the reference of those interested in reading more about this topic, please send them to me at mic.gunder...@gmail.com.
Mic Gunderson Editor / Moderator, NAEMSP Dialog;
President, IPS On Sep 20, 6:56 pm, "Koehler, Danita N Dr CIV USA MEDCOM MEDDAC-AK" > TWO articles are worth review: > 1. CDC MMWR report (59:32 1026) "The number of poisoning deaths from
> opiates (1997=4000 deaths 2007=14,500 deaths)" > 2. CDC MMWR report (59 (30);957 Death Rates for the three leading
> causes of Injury Death" in which deaths from MVA and firearms has > dropped but death from drugs is on exponential rise.
Here is a link for the first report - http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a6.htm?s_cid=mm5932a6_w
There is no suggestion that EMS administration of opioids contributed to even one of these deaths.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5930a6.htm?s_cid=mm5930a6_w opioids contributed to a single opioid death. administration of opioids by EMS? Or are you just pointing out that the abuse of opioids has increased among the general public? http://roguemedic.com/ Query: Can methox be used in conjunction with opioid analgesics? For example, let's say that the methox doesn't quite do the job. Can you
add in some fentanyl? Any problems with that? Could you use lower doses of fentanyl if you paired it with methox?
(Gene Gandy, Tucson, AZ) Hi Jason Bendall here from the Ambulance Research Institute in Sydney. In our recent publication (Prehospital Emergency Care 2010;14;439-447)
there was no compelling evidence that combinations were more effective than morphine alone. Our service has used methoxy, morphine and IN
fentanyl alone or in combination for some time. Based on our results we encourage our paramedics to use morphine as first line for
moderate / severe pain as it appears the most effective option. That being said, methoxy is an effective agent in its own right. In answer
to your question though, there is no issue with giving methoxy and if inadequate giving an opioid. I am of the view however that if
possible, give morphine initially as it is associated with much higher odds of effective analgesia.
MBBS MM(ClinEpi) PhD FACAP Jason:
In your study, did you notice a problem with histamine release or Charles S. Krin, DO, retired FP, ED and EMS physician Hi Charles, to be honest we only looked at records from a database so did not look at this issue specifically case by case (almost 13,000 patients given morphine). Our Jurisdiction has however used morphine for over 30 years and are unaware of any significant issues. Our jurisdiction gives thousands of patients morphine annually. Over my 15 years with ASNSW it has not cropped up that often. In saying that I have had some patients with localised erythema post administration of morphine. Regards Dr Jason Bendall Jason:
variation. Anecdotally, I saw significant histamine symptoms in almost 15% of the patients that I treated during my career. A small percentage, like my ex wife, had a severe, anaphylactoid type reaction. including swelling of the face and tongue, generalized wheal and flare, and occasionally wheezing. Then again, in that same patient population (Louisiana, 1988-2005), it was not unusual to have significant problems with sphincter of Oddi 'squeeze' due to morphine, resulting in an increase in gall bladder symptoms.
Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author.
May I add in this: In patients with renal insufficiency or chronic renal failure Stage II or III, morphine carries some cautions. While at one time it was thought that morphine levels accumulated in patients with renal insufficiency, now it has been shown that it's metabolite, Morphine-6-glucuronide (M6G), if I understand it correctly, is the agent that accumulates in renal-impaired patients. That metabolite, if I understand correctly, has significant mu receptor blocking powers and can also depress respiratory depression. Therefore, I am told that MS should be administered with caution to patients in renal failure, OR, the doses should be reduced significantly. There seem to be a plethora of studies out there, all of which will pop up with a Google for "morphine metabolites." Not being a pharmacist nor a chemist, I run the risk of misunderstanding what I'm reading sometimes, but my reading seems to tell me that fentenyl or alfentanyl are the analgesics of choice for patients with renal insufficiency. Fentanyl seems to have neither the histamine release problems nor the metabolite build-up problems of morphine. Can anyone comment on this? Is there any significant risk in choosing one over the other in prehospital care given generally short scene to hospital transport times? GG Gene Gandy, JD, LP, NREMT-P EMS Educator Tucson, AZ
Dr. K,
Would fentanyl produce the same problems with the S of O? GG Gene Gandy, JD, LP, NREMT-P EMS Educator Tucson, AZ
Gene: to the best of my (off the cuff) knowledge, that problem is specific to morphine, and is probably related to the known problems with histamine release and morphine. ck Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author All,
I think we are rapidly arriving at two main threads here. First, how do we get people to use medications for patients with pain? And second, what are the optimal agents and treatment regimens. I wish I had an answer to the first, and hope to learn from others. For the second, I believe we need a medication that can be titrated rapidly to reasonable analgesic effect, and fentanyl, 1 mcg/kg, followed by 0.5 mcg/kg repeated in 5 minute intervals seems to be the best narcotic option. Michael ps: One other thought: in accordance with recommendations for safe documentation practices, can we please refer to morphine as "morphine" and not MS? It's an old trap we all fall into from time to time. Michael W. Dailey, MD FACEP Director of Prehospital Care and Education Associate Professor of Emergency Medicine Albany Medical Center 518/ 262-3773
Here in the US I suggest that we in prehospital care now tend to find that fentanyl is better at achieving effective analgesia in the short run than morphine, and so many EMS services now carry both morphine and fentanyl. Fentanyl is used for skeletal injury pain and visceral pain, and MS for cardiac pain, CHF, and so forth, although there are discussions going on about whether or not morphine has any real advantages other than length of effect. I like fentanyl because I can give it to a hip fracture patient a couple of minutes after I arrive, and in 5 minutes, she'll be pain free enough for me to be able to move her without subjecting her to excruciating pain. MS would take three times as long. So I'm wondering what the thinking is in Australia about morphine vs. fentanyl? Also, here, some services are now carrying hydromorphone (Dilaudid). Any thoughts about that? It's of great interest to me how we come to different conclusions about choice of drugs depending where in the world we are. A appreciate your response and your thoughts. Gene Gandy We should also mention that fentanyl can be given intransasally, which is great for the pediatric population. A quick spray can relieve pain without the discomfort of an IV. A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting * * *
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