Category: Cardiac Ischemia

Morphine in Cardiac Ischemia

Question #: 361


Good afternoon,

Just recently did an inferior MI pt with ST elevation in II, III and avf with reciprocal changes to V3 to V6. We did a 15 lead by putting v4 on the right side and it was negative. His pressure was systolic 160 . I gave the pt so e ASA but was confused if Nitro should of been given therefore I didn't give any. We were both PCP . Should Nitro be given if the 15 lead is negative? And fallow the stemi protocol?


As specified in the ALS PCS companion document, in the situation where nitro is contraindicated, pain is severe in nature (≥ 7/10) and safe morphine administration parameters are met, you can administer morphine right away without administering nitro. The 7/10 pain threshold was first introduced in the 2015 AHA guidelines (driving the change in the Cardiac Ischemia Medical Directive), where morphine can increase morbidity/mortality of patients in pain 7/10, but can balance risks associated to increased cardiac workload associated to severe pain (≥ 7/10) during a cardiac ischemia event. Please note that in this case, the care goal when administering morphine is to manage SEVERE PAIN happening during a cardiac ischemia event, which is slightly different than the care goal for the use of nitro (managing ACTIVE ONGOING cardiac ischemia SYMPTOMS inclusive of pain) and ASA (managing suspected cardiac ischemia chief complaint, even if INACTIVE at the moment of your care).

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