Nitro vs Morphine - page 2

In a coronary care unit, how do you make the decision to give nitro-vs-morphine for unrelieved cp? The example I am thinking of is a guy who came in thru the ED with CP, no EKG changes, and then continued to have cp. Every two... Read More

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    For unrelieved CP w/initial EKG changes: depending on changes, in our ER we give NTG SL, morphine, O2, ASA, cardiac enzymes, rainbow draw. If stable, cath in AM; unstable, stat cath. May start NTG gtt.

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    previous poster wrote 'ruled in from a non cardiac source-? like anemia/shock trauma? -i sense a teachable moment for me please elaborate so i can see ifm thinking along the same lines thanks!
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    noncardiac chest pain-
    musculoskeletal pain
    esophageal spasm
    abd source
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    CRUSADE is demonstrating that those treated with Morphine have double the mortality rate than those not given morphine.

    If one were to use opiates/opioids, I would suggest fentanyl - faster, nicer and an all around better drug.
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    In our facility patients receive both NTG and morphine (or derivate) most of the time unless one of the two is contra-indicated or there is a clear non-coronary cause for the ongoing chest pains.

    With NTG coronary bloodflow is increased thus increasing oxygen supply to the heart. At the same time pain increases the oxygen demand of the body and thus the oxygen demand of the heart, so these patients deserve added pain relief.

    @ ShaunES: I agree that in most situations fentanyl is superior to morphine. However if these chest pains are accomodated by dyspnea I would prefer morphine. Morphine is better at reducing dyspnea feelings than fentanyl is.
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    Morphine is also more vasodilatory than fentanyl and will provide more of an increase in myocardial oxygen delivery.
    Additionally the increase in mortality with morphine demonstrated by the CRUSADE study was in non-STEMI patients. It's also a non-randomized retrospective study, so who knows if the patients receiving morphine were just more sick (and therefore had a higher mortality rate). They make it look like morphine causes increased MI, CHF, death, etc. This may be because these patients were more painful and had worse disease. It may be because morphine DOES cause these things. You would need a large randomized controlled trial to determine this.
    Like Belgian said above, these folks need analgesia, and morphine is (probably) the best choice.
    BelgianRN likes this.

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