When should Emergency Medical Services (EMS) use hydromorphone (Dilaudid) over fentanyl for pain management?

When to Use Hydromorphone (Dilaudid) Over Fentanyl in EMS

EMS should choose hydromorphone (Dilaudid) over fentanyl when longer duration of analgesia is needed, in patients with hemodynamic considerations such as generalized edema, coagulation disorders, or poor peripheral circulation, and when extended transport times are anticipated. 1

Primary Considerations for Opioid Selection in EMS

Pharmacokinetic Differences

• Fentanyl advantages:

  • Faster onset of action (1-2 minutes) 2
  • Lower incidence of side effects 1
  • First-line recommendation for acute moderate-severe pain in emergency settings 1

• Hydromorphone advantages:

  • Longer duration of action
  • 7.5 times more potent than oral morphine 3
  • Better option for extended transport times 1

Patient-Specific Factors

Choose Hydromorphone When:

1. Extended transport times are anticipated and longer duration of analgesia is beneficial 1
2. Hemodynamic considerations are present:
   • Generalized edema
   • Coagulation disorders
   • Poor peripheral circulation 1
3. Ventilator compliance issues exist (hydromorphone may improve ventilator synchrony) 4
4. Tachyphylaxis to fentanyl has developed (patients requiring escalating doses) 4

Choose Fentanyl When:

1. Rapid onset of analgesia is critical
2. Renal impairment is present (fentanyl is safer in chronic kidney disease stages 4-5) 1
3. Shorter duration of action is preferred
4. Intranasal administration is needed (when IV access is difficult) 5

Dosing Considerations

Hydromorphone

• No established EMS protocol in the evidence provided
• In hospital settings, transition from fentanyl to hydromorphone typically uses a ratio where 100 μg/h of fentanyl converts to approximately 1 mg/h of hydromorphone 4

Fentanyl

• Initial dose: 1 mcg/kg
• Subsequent doses: ~30 mcg every 5 minutes as needed 1
• Can be administered intravenously or intranasally with comparable effectiveness 5

Efficacy Comparison

Both medications are effective for pain management:

• Morphine and fentanyl achieve effective analgesia in approximately 80% of patients 5
• Fentanyl has been shown to provide comparable pain relief to morphine in studies of chest pain 6
• Hydromorphone may provide better pain control in patients who have developed tachyphylaxis to fentanyl 4

Safety Considerations

• Respiratory depression risk exists with both medications and should be monitored closely 1
• Hypotension appears to be less common with fentanyl compared to morphine (0% vs 5.1%, though not statistically significant) 6
• Adverse events with fentanyl administration are generally low (1.6% in one study) 7

Common Pitfalls to Avoid

1. Failing to consider transport time when selecting an opioid
2. Overlooking patient-specific factors like renal function or hemodynamic status
3. Not accounting for prior opioid exposure which may affect response
4. Inadequate monitoring for adverse effects, particularly respiratory depression
5. Using the same dosing approach for all patients regardless of age (patients ≥70 years typically require lower doses) 7

Algorithm for Decision-Making

1. Assess transport time:

   • If short (<30 minutes): Consider fentanyl
   • If extended (>30 minutes): Consider hydromorphone

2. Evaluate patient factors:

   • Renal impairment: Prefer fentanyl
   • Hemodynamic concerns: Prefer hydromorphone
   • Ventilator synchrony issues: Prefer hydromorphone

3. Consider administration route:

   • No IV access: Fentanyl can be given intranasally
   • IV access established: Either medication appropriate

4. Evaluate prior response:

   • Previous tachyphylaxis to fentanyl: Use hydromorphone
   • Known allergy to phenanthrenes: Use fentanyl (phenylpiperidine class)