Snapshot on who is giving morphine for patients with a STEMI who has no chest pains?

cheers

Mike

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Not me.
Hi dr-exmedic, is that because protocol does not allow you to or because those who write the protocols do not understand the advantage?

On our side of the pond, I have not seen that the administration of morphine has been added to the "best practices" recommendations of any group for the STEMI patient without chest pain.

 

My .02 cents

 

Morphine should never be given to patients without chest pain. Morphine is often thought to reduce preload by many paramedics and physicians alike. It does do this, but only because it induces a histamine release, the histamine is what lowers your preload, not the morphine itself. So imagine that you are basically inducing a mild allergic reaction on your patient who is having an MI, not the best plan. We tolerate this side effect because it is good at reducing their pain, and therefore reducing their anxiety and hopefully reducing myocardial oxygen demand that way. But if they are pain free, morphine will only complicate the problem. This is why fentanyl will work just fine for MI's as well, it reduces pain and does not release histamine. If you want to lower BP use your 3 nitro's, consider a nitro drip, and look into giving ACE inhibitors or beta blockers (especially in Anterior MI's). Also stay away from morphine and nitro in the right sided / posterior MI, not worth the risk.

According to my medical director, no conclusive study has ever been done that shows morphine to be a vasodilator (as it's been portrayed to be).  Also, morphine has a high incidence of nausea without an anti-emetic being given first.  Nausea causes anxiety, anxiety causes tachycardia and mild hypertension, which causes increased cardiac output (and by extension, greater stress on the heart, something we don't want).  Morphine is quickly falling out of favor for STEMI use, but if you use it, I would highly recommend giving an anti-emetic first (my preference is Zofran).  I agree with Jason Bowman that you're better off using nitro (either sublingual or drip), ACE inhibitors, or beta blockers.  In my area of Wisconsin, if the patient is not experiencing pain, you don't give a pain reliever.  For pain relief, fentanyl tends to be a better option due to less side effects and comparable pain relief.
Mike Bjarköy said:
Hi dr-exmedic, is that because protocol does not allow you to or because those who write the protocols do not understand the advantage?

It's because there is no advantage, as I'm no longer bound by protocols--or much of anything; just got issued an unrestricted medical license. :)

My service uses Fentanyl, and I've had better luck with that than morphine.  It is included in the STEMI protocol and does not specify whether or not the patient has chest pain.  I would not give it, but I guess you would be allowed to by protocol.

thanks dr-exmedic. didn't know if the dr. in your tag was a medical one or non medical. didn't wish to undermine you at all. I know you probably didn't take it that way but just thought I would mention it.

cheers

Mike

dr-exmedic said:

Mike Bjarköy said:
Hi dr-exmedic, is that because protocol does not allow you to or because those who write the protocols do not understand the advantage?

It's because there is no advantage, as I'm no longer bound by protocols--or much of anything; just got issued an unrestricted medical license. :)

Thanks for the insight all, I thought I was missing something here but obviously not. 

 

One of the contracts I have is with an NHS ambulance service in the UK which have stated recently...

Morphine

Appropriate analgesia is vital, as pain activates the sympathetic nervous system, increasing the

cardiac workload and therefore myocardial oxygen demand. JRCALC 2006 therefore includes ‘pain

associated with suspected myocardial infarction’ as an indication for the administration of

morphine. A clear rationale must be documented in the procedural exclusions section of the PCR

for any suspected or confirmed MI where morphine is not administered.

Given the benefits of morphine in reducing cardiac pre-load and the overall workload of the heart,

the Trust also fully supports the administration of 2.5mg morphine in cases of suspected or

confirmed myocardial infarction where pain is not experienced (eg silent MI). Administration in the

absence of pain, should continue to follow the JRCALC contra-indications and cautions for

morphine.

 

So I may do a bit of digging around in the journals before replying to this recent release by my service - for armed is a good position to be in. I couldn't possibly comment on the knowledge base of those who have released this but am confident the above is not the best treatment option - as you have rightly pointed out.

cheers

Mike

 

Mike, it could be to do with the CQC's KPI's, an attempt to boost figures, and demonstrate clear exclusions on the PCR. Making sure every STEMI patient can be counted in the right box. 

 

The number of patients with pre-hospital clinical diagnosis of STEMI recorded as having been administered analgesia (morphine and/or entonox).

The number of patients with pre-hospital clinical diagnosis of STEMI, excluding those who refuse either or both drugs, and those with a contraindication to either or both drug and those not in pain.

 

I guess it could be argued that the service is trying to deliver a catch all, where a pain score is not implemented properly by the crew or misunderstood by the patient. So a small dose of 2.5mg covers this and allows for analgesia to be given to STEMI patients. 

OFFS - so mistreat patients as long as we hit the targets. I despair.
Neil White said:

I guess it could be argued that the service is trying to deliver a catch all, where a pain score is not implemented properly by the crew or misunderstood by the patient. So a small dose of 2.5mg covers this and allows for analgesia to be given to STEMI patients. 

That seems quite likely; more likely is that they've misread (or not read) the evidence. Note the statement "Given the benefits of morphine in reducing cardiac pre-load and the overall workload of the heart". Which, as already pointed out, has never been proven.

 

Makes me start thinking though--should we perhaps give it in dyspneic pts with suspected MI? I would think reducing dyspnea is just as important as reducing pain, and for exactly the same reasons: activation of the sympathetic system. Morphine is as good for reducing dyspnea as it is for pain, and we all know of dyspnea as an "anginal equivalent."

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