Morphine in ACS
Pt was a 62 y/o WF with extensive PMH of CAD s/p CABG, CHF, HTN and DM. She called EMS with a chief complaint of CP. She states this CP is similar to her prior angina chest pain and notes that her most recent visit was about 4 weeks ago for the same and she required stent placement at that time. Pt states the pain has been going on for the last 3 hours and was only partially relieved with 2 sublingual nitro prompting the 911 call.
On EMS arrival we found the patient lying on her bed in moderate discomfort due to her CP. Her initial vital signs were as follows: BP 103/83, HR 86, RR 18, 98% on RA. She rated her pain as an 8/10 in intensity. Following transfer to the gurney and transport to the EMS van, IV and O2 were established. Patient was immediately given 162mg of ASA and 1 0.4mg SL nitroglycerin and 2L O2 via NC. Her 12 lead ECG was non-diagnostic for STEMI. Pt reported pain had only decreased to 6/10 intensity. At this time a repeated BP showed a decrease to 96/66. EMS personnel then asked me what the next course of action would be in regards to administration of morphine. I advised against the use of analgesia and instead recommended to just continue en route to the hospital.
My decision revolved around several recent studies showing possibly deleterious effects of morphine in acute coronary syndrome and at very least no significant improvement in morbidity or mortality amongst all comers with regards to morphine’s use. Furthermore the patient’s relative hypotension, would have been a contraindication for morphine’s use.
Currently ACLS and ACC recommendations do not advocate for or against the use of morphine and further studies are required to see if the concerns from the CRUSADE trial with regards to morphine use will bear to fruition however rarely is morphine given pre-hospital and I feel JFRD should be proactive and remove it from protocol until these studies have been conducted and deem morphine safe.
Meine TJ, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J. 2005 Jun;149(6):1043-9.
Iakobishvili Z, et al. Use of intravenous morphine for acute decompensated heart failure in patients with and without acute coronary syndromes. Acute Card Care. 2011 Jun;13(2):76-80
Anderson JL, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157