Morphine Reaction?

Hi all, just curious to see what you thought of this -

65 yo male admitted to ER for acute back pain following a slip or strain (I forget which). I give 10 mg Morphine and (I want to say 30 mg but can't remember) of Gravol IM to ventrogluteal. Pt has not had Morphine before that he remembers.

So 15 minutes later the wife hits the callbell and I return to find the pt diaphoretic++, breathing quickly and deeply, appearing anxious. He was warm and clammy all over, even his wrists were wet. Wife reports that his eyes were rolling back in his head. V/S were WNL but BP was about 20 points lower when it was taken 1hr previous. Pt reported pain 0/10.

I wasn't sure what to say as I haven't seen a reaction like this one. I asked another nurse and she said morphine could do that sometimes. I am curious about the mechanism of action in relation to this. Can anyone shed some light on why this might happen?

Thanks
What does a histamine release look like...

That can be a pretty typical reaction for a decent sized dose of opiate in an opiate naive patient. IM will usually have a more delayed onset and peak, although not by much particularly if there is good blood flow at the injection site.

what did u do? is pt ok? what did doc think?

i strongly suspect the reaction is r/t the gavol...which diphenhydrimate is its equivalent, found in dramamine.these antihistamines have a very long list of side effects and interactions.although it doesn't specify diaphoresis, excellent chance of paradoxical reactions and restlessness, nervousness, palpitations, se's along those lines.leslie

My guess is that the MS04 dropped his pressure because it is a vasodilator. You would see all of the above sx with a significant drop in pressure in such a short amount of time.

Quote from canundergradHi all, just curious to see what you thought of this - 65 yo male admitted to ER for acute back pain following a slip or strain (I forget which). I give 10 mg Morphine and (I want to say 30 mg but can't remember) of Gravol IM to ventrogluteal. Pt has not had Morphine before that he remembers.So 15 minutes later the wife hits the callbell and I return to find the pt diaphoretic++, breathing quickly and deeply, appearing anxious. He was warm and clammy all over, even his wrists were wet. Wife reports that his eyes were rolling back in his head. V/S were WNL but BP was about 20 points lower when it was taken 1hr previous. Pt reported pain 0/10.I wasn't sure what to say as I haven't seen a reaction like this one. I asked another nurse and she said morphine could do that sometimes. I am curious about the mechanism of action in relation to this. Can anyone shed some light on why this might happen?Thanks

While Morphine is a vasodilator, it also induces a histamine release, which also causes (among other things) vasodilation. In any event, the end result was that the morphine dropped the patient's blood pressure and, in effect, produced a shock-like state. Administering diphenhydramine (Benadryl) along with the morphine can stop the histamine release and therefore blunt some of the effects. You do have to be aware that both can have some sedative effects, so some care must be taken if you do administer both together.Just doing a quick check about Gravol, yes it's an antihistamine, but the reaction observed is likely due to the morphine, not the Gravol... and I doubt the Gravol had enough time to become effective enough to blunt any histamine release caused by the morphine.

Quote from canundergradSo 15 minutes later the wife hits the callbell and I return to find the pt diaphoretic++, breathing quickly and deeply, appearing anxious. He was warm and clammy all over, even his wrists were wet. Wife reports that his eyes were rolling back in his head. V/S were WNL but BP was about 20 points lower when it was taken 1hr previous. Pt reported pain 0/10.Thanks

Quote from leslie :-Dgood point about pointing out the timing, DIVA RN.gravol was given im...so any reaction wouldn't have presented itself before then.morphine given iv...highly doubt reaction would be 15 mins later.i've given morphine my entire nsg life, in all routes, and have never seen or heard of a reaction like this.my instincts and knowledge, still point to the gravol.leslie

Quote from Kooky Korkywhat did u do? is pt ok? what did doc think?

No, I don't believe Gravol is used anywhere in the USA. It's related more to Dramamine than Benedryl, though. Google itThe "rush" part you describe could be the morphine, of course! I didn't know that was part of the equasion. 10mg may have been a "little" hefty for a opiate naive person, and if it was given IV push, it could have felt like the top of his head was coming off.By the way, this would not be considered a true allergic reaction...such as anaphylaxis but a reaction to a narcotic being given as an IV push...it could have and probably would have happened with demerol or dilaudid as well. I hate to think that the guy is labled as "allergic" to morphine because of this reaction or side effect. It is not like he went into anaphylaxis or stopped breathing and you had to reverse the effects with Narcan or call a code or something.The eyes rolling back, still sound like the gravol as does the increased RR and the anxiety. That stuff can cause some paradoxical symptoms. It just didn't sound like good old morphined

I don't think I've ever given dimenhydrinate at work, but I've taken it orally a few times for motion sickness. It made me feel awful each time. Drowsy, really dry mouth but with a racing heart and a very 'nervy' or 'worked up' type feeling at the same time. Just horrible, I'll never take it again!