Fentanyl for Cardiac Ischemia

Question#: 677

Question:

 Why Fentanyl is not replacing Morphine in our ischemic chest pain protocole?

Fentanyl have a shorter onset, Fentanyl is probably causing less nausea and vomiting to patients. Fentanyl cause less hypotension than morphine?

Answer:

Currently the AHA recommends that Morphine be used for suspected cardiac ischemia in low doses. 1-2mg is the recommended dose (2mg as per the ALS PCS) to counteract the pain and help with anxiety. Furthermore, Morphine is especially valuable for patients that are also experiencing pulmonary edema as it can help alleviate work of breathing. The multiple actions of Morphine therefore make it the opioid of choice for cardiac ischemia. We can also appreciate that sometimes patients will develop nausea and/or vomiting due to the Morphine. To assist in preventing this, it is recommended to administer the Morphine via a very slow push. If this fails to work, however, you may then need to utilize either Ondansetron or DimenhyDRINATE for the patient’s nausea and/or vomiting. The very slow push should also help prevent hypotension in your patient, but again, if this fails, and the patient meets the indications, fluids may be administered.

On the other hand, you mentioned, there may be calls where your patient is hypotensive but still requires pain management during their cardiac event. In this case, a patch to a BHP is required to discuss the potential use of FentaNYL. A very low dose of 25-50mcg will most likely be the recommendation from the BHP, but again, this is a required patch to receive an order. Another instance this may arise would be in the patient had a known allergy to Morphine.

Attached to this email is some further reading regarding Morphine use in cardiac ischemia.

References:

https://www.rppeo.ca/paramedic-practice/medical-direction/medicask/medicask-answers-all/255-medical-directives/cardiac-ischemia/1037-morphine-vs-fentanyl-in-the-presence-of-an-rvi.html
Bonin, M. (2018) Effect and Safety of Morphine Use in Acute Anterior ST-Segment Elevation Myocardial Infarction. https://www.ahajournals.org/doi/10.1161/JAHA.117.006833

Chen A, Shariati F, Chan T, Lebowitz D. A Review of Adverse Outcomes Following Intravenous Morphine Usage for Pain Relief in Acute Coronary Syndrome. Cureus. 2018 Sep 4;10(9):e3246. doi: 10.7759/cureus.3246. PMID: 30937227; PMCID: PMC6435004. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6435004/

Tanaka K, Kersten JR, Riess ML. Opioid-induced cardioprotection. Curr Pharm Des. 2014;20(36):5696-705. doi: 10.2174/1381612820666140204120311. PMID: 24502571; PMCID: PMC4216587. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216587/

Weldon E.R., Ariano R.E., Grierson R.A. Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain. Prehosp Emerg Care. 2016;20(1):45-51. doi: 10.3109/10903127.2015.1056893. Epub 2015 Aug 17. PMID: 26727338. https://www.tandfonline.com/doi/full/10.3109/10903127.2015.1056893