Читать книгу Emergency Medical Services - Группа авторов - Страница 232

A large retrospective case series of hospitalized patients with non‐ST segment elevation ACS found that patients who received morphine had a higher mortality than those who did not [39]. It is unclear whether this was a causal effect or simply indicated that those who required morphine may have had more severe disease. A possible mechanism of harm from opiate therapy may be an interaction between opiate administration and platelet reactivity [40]. The AHA/ACC treatment guidelines for patients with unstable angina or non‐ST‐elevation MI (NSTEMI) reduce the strength of recommendation for morphine from Class I to Class IIa for patients with non‐STEMI [41]. The 2013 AHA/ACC STEMI Guidelines give morphine a Class I recommendation in STEMI patients because those patients are going to have reperfusion therapy [16]. The recommended dose of morphine for the patient with chest pain is 2–4 mg intravenously with increments of 2–8 mg intravenously repeated at 5‐ to 15‐minute intervals when pain is not adequately controlled with nitroglycerin.

Morphine sulfate has traditionally been the treatment of choice for prehospital patients suspected of ACS/STEMI. A common prehospital alternative is fentanyl. A prospective, randomized, prehospital clinical trial found the latter to be a safe and effective alternative to morphine sulfate, resulting in similar analgesia with no significant difference in hypotension [42].