Chest Wall Rigidity and Morphine

Fentanyl is typically associated with chest wall rigidity, and I have never experienced this problem even after giving rather liberal doses. However, the case reports are undeniable. With morphine; however, I would be more concerned about the release of histamine causing respiratory signs and symptoms.

Dilute and over 5 min?

So, the other day I pushed 4mg MS IV undiluted over about 2 minutes. The pt. c/o tightness/heaviness in the chest, and increased work of breathing. Does this sound like an example of chest wall rigidity?

The patient was fine. I told them to relax and focus on long, slow breaths, applied O2, and advised them that the feeling would pass. It did.

No way dude, unless your pt was

Dilute and over 5 min?

4mg? That is not necessary and would not have changed the s/sx that Virgo reported.

May I ask, what is the histamine release? What does it cause? Is that what causes the awful feeling when dilaudid is pushed?

May I ask, what is the histamine release? What does it cause? Is that what causes the awful feeling when dilaudid is pushed?

Histamine is a biogenic amine (has a nitrogen group) synthesized from the amino acid histidine. It is found in great concentrations within mast cells and within the granulocytes called basophils. Histamine is a critical component of the inflammatory and immune process (two hands of the same concept really). Typically, IgE responses and injury cause cells to degranulate and release histamine. This is the underlying physiology of Ige mediated anaphylaxis; however, histamine has several receptors and multiple other effects. This should be covered in your anatomy and physiology classes in school.

Some medications can displace histamine and cause a shift and histamine release. Morphine is such a medication.

Histamine release.

Fentanyl causes the rigidity and if you really want to see it IRL, you can give Fentanyl slowly to a premie newborn and there is NO CHEST WALL MOVEMENT EVEN AFTER INTUBATION. Very, Very scary...thank God it lasts a very, very short time.

And I have pushed Morphine faster than that with histamine release as side effect--get the itching too.

Thanks. I have seen this reaction very little in my time on the floor, as I tended to give only 2mg at a time, diluted, and often into running IVF. Now that I'm in the ED, 4mg is the typical dose, and I don't dilute it as I now use a carpuject (used to draw it up in a 10cc NS flush when on the floor). I call this reaction the "morphine crush", because it is described by the patient experiencing it as a heaviness in the chest. In the scenario described in my OP, the reaction was much more intense than I've seen before. Usually it is much milder and very transient.

Sounds like the respiratory version of the fairly common localized histamine reaction you get when pushing morphine. How many times do you get itching and slight rash at the sight of infusion with MS? This is a localized histamine response, and not an allergy as I've seen some nurses report to patients...

How many times do you get itching and slight rash at the sight of infusion with MS? This is a localized histamine response, and not an allergy as I've seen some nurses report to patients...

I've only seen that once, proximal to the IV site.

I had this rxn in a 20 yof one night after pushing 4mg morphine iv. She very "Linda Blair" like flew up from a resting position, and started pounding her chest. Scared the **it out of me.... Fortunately the next shift nurse was in the room and is far more experienced than I. She calmed the girl down and after about a minute the feeling passed. Just not before scaring the heebie jeebies out of me first.