From the Guidelines
Morphine is a recommended initial intravenous medication for a patient presenting with chest pain when ketorolac (Toradol) is not an option. The typical starting dose is 1-5 mg IV, which can be repeated every 5-30 minutes as needed for pain control, while monitoring for respiratory depression and hypotension, as suggested by the 2013 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. Morphine not only provides effective analgesia but also offers beneficial hemodynamic effects for patients with suspected acute coronary syndrome by reducing preload through venodilation, which decreases myocardial oxygen demand. Additionally, morphine has anxiolytic properties that can help reduce the stress response in patients experiencing chest pain.
- Alternative IV options include fentanyl (25-50 mcg IV) for patients with morphine allergy or hypotension, or nitroglycerin (starting at 5-10 mcg/min) which provides both pain relief and coronary vasodilation in cases of suspected cardiac ischemia.
- Vital signs should be monitored closely after administration, particularly blood pressure and respiratory rate, as these medications can cause hypotension and respiratory depression.
- It is also important to consider the potential risks and benefits of morphine use, as highlighted by the 2013 ACCF/AHA guidelines, which downgraded the recommendation for morphine use for uncontrolled ischemic chest discomfort from a Class I to a Class IIa recommendation due to concerns about safety 1.
- The most recent guidelines, such as the 2024 American Heart Association and American Red Cross guidelines for first aid, emphasize the importance of prompt medical attention for patients with chest pain and recommend activating EMS immediately 1.
From the FDA Drug Label
5 mg should be given over a period of no less than 2 minutes. Wait an additional 2 or more minutes to fully evaluate the sedative effect. If additional titration is necessary, it should be given at a rate of no more than 1 mg over a period of 2 minutes, waiting an additional 2 or more minutes each time to fully evaluate the sedative effect. Narcotic premedication frequently used during clinical trials included fentanyl (1.5 to 2 mcg/kg IV, administered 5 minutes before induction)
The recommended initial intravenous (IV) medication for a patient presenting with chest pain when Toradol (ketorolac) is not an option is fentanyl.
- The dose of fentanyl can be administered at a rate of 1.5 to 2 mcg/kg IV.
- It is essential to titrate the dose according to the patient's response and clinical status, as individual response to the drug is variable 2.
From the Research
Intravenous Medication Options for Chest Pain
When Toradol (ketorolac) is not an option for a patient presenting with chest pain, several alternative intravenous (IV) medications can be considered. The choice of medication depends on various factors, including the patient's medical history, the severity of the chest pain, and the presence of any underlying conditions.
Recommended Initial IV Medications
- Morphine: According to the American College of Cardiology/American Heart Association guidelines on acute coronary syndrome (ACS) management, morphine is the drug of choice for patients with chest pain unresponsive to nitrates 3, 4.
- Nitrates: Nitrates, such as glyceryl trinitrate, can be used to relieve chest pain and are often combined with other medications, such as beta-blockers 5, 6.
- Beta-blockers: Beta-blockers can be used to reduce the workload on the heart and relieve chest pain, and are often combined with nitrates or morphine 5, 6.
- Alfentanil: Alfentanil is a narcotic analgesic that has been reported to produce more rapid pain relief than morphine 5.
Considerations and Potential Side Effects
- Morphine may increase adverse events in ACS patients, such as vomiting, hypotension, and respiratory depression 3, 7.
- The combination of beta-blockers and morphine may be associated with more side effects than beta-blockers alone 5.
- Nitrates have been associated with the relief of pain with few side effects 5.