Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Drives Protocol Changes in EMS and EMSMedRx



Tonight Jim Hoffman of EMS Office Hours is going to have a live podcast to discuss the way the NYC REMAC (New York City REgional Medical Advisory Committee) is planning on removing morphine from their chest pain/ACS (Acute Coronary Syndromes) protocols.

What Drives Protocol Changes in EMS

This is based on the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative.

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM, Peacock WF, Pollack CV Jr, Gibler WB, Peterson ED; CRUSADE Investigators.
Am Heart J. 2005 Jun;149(6):1043-9.
PMID: 15976786 [PubMed – indexed for MEDLINE]

RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups.

On the podcast presenting a bit of behind the scenes information on the way this decision was made will be Mark Albert. Mark is a pharmacist working for the NYC REMAC. Mark is starting a blog that will focus on pharmacology and EMS. This is an area I write about occasionally, but it is probably the part of EMS education that receives the least attention relative to the potential for misunderstanding/ignorance producing a very bad outcome.

EMSMedRx

Look forward to a pharmacist’s contribution and dedication to education, training, and research in the world on pre-hospital and emergency medicine. I am psyched to be a part of EMS and the great job you men and women do. I am a resource for you to learn more about medications.

Mark has provided some informative comments on pharmacology to my blog. He is just getting started, but I expect that this will be a must read blog for EMS.

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Comments

  1. Regarding your Protocol change taking Morphine out of the ACS protocol. Of the Morphine related deaths are they related to Respiratory or Cardiac issues or missuse of the Morphine. What was the average age of the patients and did they have any other underlying health issues. Can you please send a link to the study so that we can as a team discuss it. Thank You

    • Patricia Webster,

      There is no link that I could find to the full study on line, at least for free. If you have medical library access through an employer, school, et cetera, that is great.

      Here are the statements made about morphine for ACS from the 2010 AHA ACLS:

      The paper does not break down the deaths according to respiratory, except to indicate initial and/or prior CHF diagnosis/no initial and/or prior CHF diagnosis. I think that a part of the problem may be misuse of morphine. Another part may be similar to what has been a problem with the National trauma Data Bank® – inaccurate/incomplete data.

      The most important point may be the conclusion of the authors –

      This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

      NSTE ACS = Non-ST-segment Elevation Acute Coronary Syndromes.

      5 years after this was published, how is this study interpreted for treatment of possible ACS by the 2010 ACLS guidelines committee?

      Morphine is indicated in STEMI when chest discomfort is unresponsive to nitrates (Class I, LOE C); morphine should be used with caution in unstable angina (UA)/NSTEMI due to an association with increased mortality in a large registry (Class IIa, LOE C).44 The efficacy of other analgesics is unknown.

      2010 ACLS ACS
      Prehospital Management.

      http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S787#SEC1

      Analgesia
      Providers should administer analgesics, such as intravenous morphine, for chest discomfort unresponsive to nitrates. Morphine is the preferred analgesic for patients with STEMI (Class I, LOE C). However, analysis of retrospective registry data raised a question about the potentially adverse effects of morphine in patients with UA/NSTEMI.44 As a result, the ACC AHA UA/NSTEMI writing group reduced morphine use to a Class IIa recommendation for that patient population.3

      2010 ACLS ACS
      Initial General Therapy for ACS.

      http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S787#SEC4

      Footnote 44, the only reference for downgrading the use of morphine, is the study we will be discussing. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.

      The authors wrote –

      This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

      There does not appear to have been any prospective randomized trial to assess the results of CRUSADE. I searched ClinicalTrials.Gov, but there does not appear to be anything looking at morphine vs. placebo for ACS.

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