Morphine for facial/airway burns.

[NYMedic828]

So a friend of mine had his medic state skills test today.

He failed trauma because he gave morphine to a burn patient with facial burns.

Our protocol in NYC allows standing order morphine for burns (up to 5mg) with a bolded note "Morphine shall not be given in the presence of burns to the face or airway."

So he failed because he gave morphine, mind you his proctor was egging him on with "hes screaming in pain what are you gonna do?"


So why is it contraindicated? Is it histamine/swelling related? If it is, wouldnt fentanyl be the logical move?

 

[the_negro_puppy]

I would like to know the answer too, airway burns is a precaution for morphine for us in our protocols.

 

[Nattens]

Believe it is due to Morphine's action on the CNS causing Respiratory depression therefore a loss of airway control in the patient with respiratory burns. The loss of airway control being one of the reasons why it makes a good sedative agent for maintenance of inbutation.

 

[NYMedic828]

Believe it is due to Morphine's action on the CNS causing Respiratory depression therefore a loss of airway control in the patient with respiratory burns. The loss of airway control being one of the reasons why it makes a good sedative agent for maintenance of inbutation.

All do respect I don't think that is it.

The respiratory depression from 5mg of morphine in the majority of patients is non-existent.

Sedative doses of morphine far exceed 5mg and a patient would be unconscious before hypoventilation fully set in.




If I had to take a guess, I imagine the reason is not to enhance the release of histamine aiding in further inflammation but im not quite sure it works this way in the case of morphine binding to histamine.

 

[Nattens]

All do respect I don't think that is it.

The respiratory depression from 5mg of morphine in the majority of patients is non-existent.

Sedative doses of morphine far exceed 5mg and a patient would be unconscious before hypoventilation fully set in.

Fair enough, my guess was a wild stab, there is a reason why my training sidebar has "Student" in it.

You do mention a "majority" of patients, would it be possible that the guideline is trying to cater to the minority that may have a altered conscious/respiratory depression reaction from a dose as low as 2.5mg-5mg? Or maybe if airway burns are already causing respiratory depression due to the swelling the resp depression effect from morphine could tip them over the edge?

 

[Smash]

Burns - - > oedema-- > airway compromise. Morphine - - > histamine release - - > worse swelling? I

I have no idea but either way it's absolute bull****, and 5mg of morphine for burns is homoeopathic...

Sorry for brevity on phone late for work.

 

[Rykielz]

If it's written in the protocol you need to know it. As for the reasoning... I have no clue and it does sound kinda lame.

 

[Veneficus]

I agree with Smash, it sounds like paranoia over anaphylactoid reaction.

5mg of morphine to a severe burn isn't going to do S**t.

I have given upwards of 90mg (yes that is 9 0 ) to severe burn patients over the course of 20-30 minutes and it barely does anything.

A specific group of mediciations, PCN and morphine being among them can cause anaphylactoid reaction, it is similar but a different mechanism, and is not as likely to become life threatening.

It is also why so many people report allergies to these meds.

I am really starting to think NYC should get rid of all that ALS equipment they never use and just drive around with leeches and hot pokers.

 

[Smash]

NYC ALS equipment:

 

[abckidsmom]

Burns - - > oedema-- > airway compromise. Morphine - - > histamine release - - > worse swelling? I

I have no idea but either way it's absolute bull****, and 5mg of morphine for burns is homoeopathic...

Sorry for brevity on phone late for work.

Homeopathic! Ha!

I have 20 MG morphine, and 200 mcg fentanyl. Severe burns get a helicopter just because I barely have the meds I need to wait 15 minutes for them to get there.

It's so sweet to see something like this happen in testing. Gives me hope that EMS is on the way. Yessir.

I would advise my friend to gather documentation and challenge that, especially since its written into the protocol.

 

[usalsfyre]

Not to mention the majority of facial burns don't equal airway burns....

The fact that the proctor was essentially pushing him to fail in a testing situation is indicative of how broken the system is.

 

[Clare]

IV morphine is great stuff, but there are some things it just doesn't quite make the grade on, burns are one of them, ketamine is much better provided you can get it within a reasonable time frame.

5 mg of morphine is probably a little low for somebody who has significant burns, burns are often excruciatingly painful. 1 mcg/kg of fentanyl is probably a better option.

I have only seen a couple of patients with very significant burns and I have to say they are not for me. I can handle most anything except burns, they give me the absolute creeps.

 

[Thricenotrice]

Not to mention the majority of facial burns don't equal airway burns....

The fact that the proctor was essentially pushing him to fail in a testing situation is indicative of how broken the system is.

Taking a stab at the OPs question;
I would be willing to guess that according to the people that write the guidelines and protocols, facial burns are close enough to airway burns, due to the possibility of inhaling the gases, and the close proximity to the airways. - to them.

As for the reasoning behind the reasons not to give it, I will second the histamine release, and the rare possibility of an anaphylactoid reaction

 

[KellyBracket]

Did the examiner perhaps think that morphine was not the right answer because intubation was supposed to be the next proper step?

In reality it's a silly point. Giving morphine while preparing for airway control is just fine. And yeah, 5 mg of morphine might as well be a 60x dilution...

 

[MSDeltaFlt]

Yeah, that scenario is so wrong on multiple levels. I have no idea how he could have failed the station.

 

[NYMedic828]

Did the examiner perhaps think that morphine was not the right answer because intubation was supposed to be the next proper step?

In reality it's a silly point. Giving morphine while preparing for airway control is just fine. And yeah, 5 mg of morphine might as well be a 60x dilution...

I believe it was facial burns and the patient is in severe pain, stating such. Don't think intubation came into question but I wasn't there.

Outside of improper protocol, I don't see whats wrong with treating the patients pain.

I also believe the body still experiences pain regardless of chemical sedation, especially at the doses we are permitted for benzos?

Yeah, that scenario is so wrong on multiple levels. I have no idea how he could have failed the station.

Because he gave a treatment that was contrary to protocol, regardless of the protocol being contrary to sound medical care.

It is certainly unfair that the tester egged him on about severe pain.

 

[MSDeltaFlt]

Morphine contrary to sound medical care on facial burns?!? I've worked in a burn center and I have never heard of such for any reason.

 

[NYMedic828]

Morphine contrary to sound medical care on facial burns?!? I've worked in a burn center and I have never heard of such for any reason.

I'm agreeing with you. I think you misread.

I am stating that the reason he failed was:

Gave a treatment contrary to the protocol.

The reason he shouldn't fail is

The protocol is contrary to standard medical practice.


He shouldn't fail for being right when the system is wrong.

 

[MSDeltaFlt]

Ah. Yes I did misread you.

 

[medictinysc]

According to http://www.ncbi.nlm.nih.gov/pubmed/6172999

High doses of morphine produced peripheral vasodilation and frequently significant hypotension. These effects are thought to be due, in part, to the release of histamine. One putative advantage of high-dose fentanyl anesthesia is its relatively small effect on peripheral vascular resistance. In a randomized study, the authors examined the possibility that the hemodynamic differences between morphine and fentanyl might be attributable to histamine release. Fifteen patients were studied prior to coronary artery bypass surgery. Subjects received in infusion of morphine (1 mg . kg-1, iv at 100 micrograms . kg-1 . min-1 [n = 8]) or fentanyl (50 micrograms . kg-1 at 5 micrograms . kg-1 . min-1 [n = 7]). Patients in the morphine group had an average 750 per cent peak increase in plasma histamine accompanied by a significant decrease in mean arterial pressure (-27 mmHg- and systemic vascular resistance (-520 dyne . s . cm-5). The greatest decrease in systemic vascular resistance occurred in those patients with the highest levels of plasma histamine (r = -0.81). Patients in the fentanyl group had no change in plasma histamine and no decrease in arterial pressure or systemic vascular resistance. Cardiac output and heart rate were comparable between the two groups. Differences in the release of histamine account for most, if not all, of the different effects of morphine and fentanyl on the peripheral vasculature.

does that sound like a small amount like 5mg morphine, or does it sound like a lot more?????? it is even given / min??????

if the med control is using a study like this to base his/her decision on "pain control" for burn victims, then maybe they might want to take away the shocks on our ambulances too..... the bounciness could put a pt to sleep therefore occluding the pt's airway>>>>> SARCASIM