Interesting paramedic intercept

[medic32]

Hello everyone,

I had an interesting intercept the other morning and thought I would run this by everyone.
Around 0430 I was awoke by my duty captain and sent out to meet a neighboring ambulance for a paramedic intercept. When I got the report over the radio, they had told me I had a 47 year old male pt who had recent back surgery and was experiencing 10/10 back pn radiating into his legs. When I got into the ambulance I found a conscious alert male in obvious discomfort and distress. The EMT on board had told me the pt had had a spinal endoscopy with lysis of adhesions aprox 10 days ago, also about 5 days ago the patient was leaking spinal fluid and returned to the hospital for a blood patch. He stated that he had been managing his pain well with medication until this morning. So with IV, O2 and monitor in place, BP 138/68, HR 96, RR 16 non labored O2 saturation 100% on 2 L of oxygen. So enroute I did my best to manage his pain usuing fentanyl. We had an aprox 20-25 min transport time. Here in NH we have standing orders for 150mcg of fentanyl. So over the whole duration of the call he received 150 mcg's of fentanyl with little relief. Upon arrival we transferred the pt to the hospital staff. Also keep in mind he was flying to Cleavland OH for these procedures and flew home soon after both. Later on we returned to the hospital with another pt so I did a quick follow up. Our pt has a Pneumocephalus from his procedure, aka (air on/in the brain) PS I dont mean to insult anyones intellegence. The nurse on duty told us since we had left he had received another 60 mg's of morphine with little relief. Also he had no vital sign changes with us, however when we returned he was hypertensive due to ICP. With me he was conscious alert and oriented just complaining of the pain. So in closing, I'm looking for thoughts on treatment in the field. Has anyone encoutered this before, or heard or seen this procedure?

[CombatMedic]

I think that youy did everything tha tyou were supposed to. You followed your protocols and trerated the patient as he presented.

My question it, what happened to you mobile ICP monitor and Cat Scan. (That is supposed to be funny, although I am not much of a comedian) You did what you could and were supposed to.

Just keep doing what you can.

[scotttt]

Other than give more Fentanyl, what else is there to do? If he was in obvious pain and not tolerating it after 150mcg, I'd have no issue with give some more fentanyl. Someone in true severe pain will be able to tolerate quite a bit of opioids.

[medic32]

Other than give more Fentanyl, what else is there to do? If he was in obvious pain and not tolerating it after 150mcg, I'd have no issue with give some more fentanyl. Someone in true severe pain will be able to tolerate quite a bit of opioids.

I couldn't agree with you more, however I was a little hesitant with giving more due to our last run review( I also would have liked to given a little more). At the last review our medical director is telling us and the ED to be extremely careful with fentanyl. I have used fantanyl numerous times with varying results. However apparently on an ED pt they were using fentanyl and the pt experienced a respiratory arrest(this pt was not brought in by EMS by the way) some time ago. So since the ED mishap I guess we're all paying for it in one way or another. If you don't mind me asking scott how much fenatanyl have used used on one pt for pn management. I had a 23 y/o who worked at a tree service who fell 40 ft, multiple thoracic an lumbar fractures and leg fx, I used 200mcg's with him before I started getting anywhere with managing his pain. The reason I ask is since this pt in the ED there is kind of a scare for some medics here in using it. I like fentanyl but it's also fairly new here, and I also agree with you that folks in severe pn manage healthy doses fairly well.

[GaHazMedic]

I couldn't agree with you more, however I was a little hesitant with giving more due to our last run review( I also would have liked to given a little more). At the last review our medical director is telling us and the ED to be extremely careful with fentanyl. I have used fantanyl numerous times with varying results. However apparently on an ED pt they were using fentanyl and the pt experienced a respiratory arrest(this pt was not brought in by EMS by the way) some time ago. So since the ED mishap I guess we're all paying for it in one way or another. If you don't mind me asking scott how much fenatanyl have used used on one pt for pn management. I had a 23 y/o who worked at a tree service who fell 40 ft, multiple thoracic an lumbar fractures and leg fx, I used 200mcg's with him before I started getting anywhere with managing his pain. The reason I ask is since this pt in the ED there is kind of a scare for some medics here in using it. I like fentanyl but it's also fairly new here, and I also agree with you that folks in severe pn manage healthy doses fairly well.

Dosing for Fentanyl is 1-2mcg/kg q 30min prn. A lot of people get nervous using it because it is 150 times more potent than morphine and can be dangerous if not monitored.

[medic pathetic]

Fentanly is more potent, but aren't the side effects less severe than morphine? And it doesn't last as long as morphine, right?

[GaHazMedic]

Fentanly is more potent, but aren't the side effects less severe than morphine? And it doesn't last as long as morphine, right?

A dose of 100 mcgm (0.1 mg) (2.0 ml) is approximately equivalent in analgesic activity to 10 mg of morphine or 75 mg of meperidine. Alterations in respiratory rate and alveolar ventilation, associated with narcotic analgesics, may last longer than the analgesic effect. The pharmacokinetics of SUBLIMAZE can be described as a three-compartment model, with a distribution time of 1.7 minutes, redistribution of 13 minutes and a terminal eliminatistribution of 13 minutes and a terminal elimination half life of 219 minutes. The usual duration of action of the analgesic effect is 30 to 60 minutes after a single intravenous dose of up to 100 mcgm (0.1 mg) (2.0 ml). Following intramuscular administration, the onset of action is from seven to eight minutes, and the duration of action is one to two hours. The side effects are about the same, with the risk of respiratory depression being much higher. The following observation has been reported concerning altered respiratory response to CO2 stimulation following administration. DIMINISHED SENSITIVITY TO CO2 STIMULATION MAY PERSIST LONGER THAN DEPRESSION OF RESPIRATORY RATE. (Altered sensitivity to CO2 stimulation has been demonstrated for up to four hours following a single dose).

[scotttt]

Although fentanyl is ~100 times stronger than morphine, we typically give a dose about 100 times smaller. Respiratory depression is always a possibility despite whatever opioid you choose. However, if a patient is in enough pain, there will be sufficient stimulation from various physiologic mechanisms to counteract the respiratory depressant effect of opioids to keep them breathing and awake (tolerance). It's once you surpass the tolerance threshold then respiratory depression may set in.

In interesting aside: For cardiac anesthesia, a patient typically recieves 30mcg/kg as an induction dose and a total cumulative dose of up to 100mcg/kg. Impressive, if you ask me.

[GaHazMedic]

Although fentanyl is ~100 times stronger than morphine, we typically give a dose about 100 times smaller. Respiratory depression is always a possibility despite whatever opioid you choose. However, if a patient is in enough pain, there will be sufficient stimulation from various physiologic mechanisms to counteract the respiratory depressant effect of opioids to keep them breathing and awake (tolerance). It's once you surpass the tolerance threshold then respiratory depression may set in.

In interesting aside: For cardiac anesthesia, a patient typically recieves 30mcg/kg as an induction dose and a total cumulative dose of up to 100mcg/kg. Impressive, if you ask me.

That is not true with Fentanyl. Even at low doses, it affects the body's ability to sense CO2 levels. This has occurred after just one dose and is possible even after the pain relief has ended.

[Lord_Balsac]

Never heard of it.

I would have just sucked the air out his brain via the portable suction. (If it was charged)

[strwblue]

WOW I am old...they didn't give IV pain killer back in the day...(Except Morphine for CP and even that was very spairingly. Hmmm so much has changed.

And No offense but when did back pain (even a 10/10 become a Paramedic call) I guess when they start OK kick *** pain killers on the truck. Right On.