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Thursday, June 26, 2014

For better pain control, add a benzo? (Part 2 - Chest pain)

In my last post, I reviewed a recent study that demonstrated that adding a benzodiazapine (or "benzo") to morphine didn't seem to help in treating traumatic pain, and may increase the rate of side effects. But what about atraumatic pain? Specifically, what about chest pain?

Well, at least chest pain from suspected cardiac ischemia...

You can probably skip the ECG in this case.
So, could adding Ativan or Versed help when treating chest pain?

Background
There are some good reasons to think that controlling anxiety, and not just pain, would help in the treatment of patients with acute coronary syndrome, and especially STEMIs. For example, anxiety during an MI can cause an increased heart rate, and thus worsen oxygen demand, and so potentially worsen the cardiac ischemia. 

So, if we give beta-blockers to address this issue, why not treat the problem right at the root?  

A review from 2003 looked over the basic science, a few small clinical trials, and also the side effect profile of using diazepam or similar agents in acute or subacute ACS. The conclusion was pretty enthusiastic about using benzos, describing the potential risk-benefit ratio as very favorable.
"In conclusion, the authors disagree on whether the chief benefit of adding
benzodiazepines is tasting great, or in being less filling."
The studies they reviewed, however, were small, had conflicting results, and didn't apply to EMS very well. Fortunately, our Swedish friends stepped up to the plate, and conducted a randomized prehospital trial to answer this question.
 
The Study
Methods
The authors of Anxiolytics in patients suffering a suspected acutecoronary syndrome: multi-centre randomised controlled trial inEmergency Medical Service studied if adding midazolam (Versed) to standard analgesia (morphine) could help patients with chest pain. The study included EMS systems from across the Swedish region of Västra, including 500 prehospital personnel, 60 ambulances and one EMS boat.

"Squad 51 responding 11:33. KMG365"
The “usual” dose of morphine was 5 mg, while midazolam was given in 0.5 mg boluses until a total of 1-2 mg had been given. The primary outcome was the pain level at 15 minutes after the decision to give analgesia. 

Results 
After looking at the 1763 patients enrolled in the trial, they found.... no difference. Even when they looked at the subset of 599 patients who turned out to have real ACS diagnosed in the hospital, there was no benefit to adding a benzo for pain relief. 



The addition of midazolam seemed to reduce the heart rate and blood pressure to a statistically significant degree, but the clinical effect was pretty minimal.

Unfortunately, the benzo-getting patients more often became drowsy (or “dozy,” per the authors' language), much like in the trauma patients in my prior post.

Limitations
Yes, the study could have been done better. Many potential patients were not enrolled, and we don't know if they were different from the enrolled folks. Many of the secondary endpoints were vaguely defined, and not based on the patients' self-report. For example, the degree of anxiety, unlike pain, was judged by EMS personnel.

Lastly, while the trial was randomized, the EMS personal were not blinded to the study drug. In other words, EMS knew who got midazolam, and who didn't. This could have introduced some bias in the results (although I would expect it only would have made the midazolam group report better pain relief).

The Bottom Line
This trial may have had some shortcomings, but it did not suggest a clinically significant role for benzos in treating chest pain of suspected cardiac origin. So, we don't have to figure out a way to add a "B" into MONA!


16 comments:

  1. I am bold enough among many others to state that there is now a potent cure to this sickness but many are unaware of it. I discovered that I was infected with the virus 3 months ago, after a medical check-up. My doctor told me and I was shocked, confused and felt like my world has crumbled. I was dying slowly due to the announcement of my medical practitioner but he assured me that I could leave a normal life if I took my medications (as there was no medically known cure to Herpes). I went from churches to churches but soon found that my case needed urgent attention as I was growing lean due to fear of dying anytime soon. In a bid to look for a lasting solution to my predicament, I sought for solutions from the herbal world. I went online and searched for every powerful trado-medical practitioner that I could severe, cos I heard that the African Herbs had a cure to the Herpes syndrome. It was after a little time searching the web that I came across one Dr Itua(A powerful African Herbal Doctor), who offered to help me at a monetary fee. I had to comply as this was my final bus-stop to receiving a perfect healing. My last resolve was to take my life by myself, should this plan fail. At last it worked out well. He gave me some steps to follow and I meticulously carried out all his instructions. Last month, to be precise, I went back to the hospital to conduct another test and to my amazement, the results showed that negative,Dr Itua Can As Well Cure The Following Desease…Cancer,Hiv,Herpes, Hepatitis B,Liver Inflammatory,Diabetis,Fribroid, Dercum,Get Your Ex Back, You can free yourself of this Herpes virus by consulting this great African Herbal Doctor via this e-mail: drituaherbalcenter@gmail.com or call and whatsapp him on +2348149277967 He will help you and his herb medication is sure. he has the cure on all disease .You can talk to me on INSTAGRAM..tashamoore219....

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    Replies
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  2. 6 months ago I was diagnosed with COPD with 55-60% lung capacity. My doctor just said all the crying , stomping your feet will not change it so just accept it and basically patted me on the back and sent me home to die. I was devastated and was afraid to do anything. I stopped riding my bike, I was afraid to do anything that would cause any exertion. It consumed my thoughts with every breath and the fear of what to expect was almost more than I could deal with. So I couldn't get myself all time I decided to find a herbal cure online and I came acrose Doctor Itua on how he cure several people suffering from Hiv, and Herpes I gave him a call on this Number +2348149277967 also chat on whatsapp he gave me all the details about the cure i paid him for the medicine after 5 working days i receieve my herbal medicine ,I use it for two weeks that is how I get Cured and today I'm living healthy and fine I give him thanks also promise him to testify about his work,He Can also cure the following deseases..Copd,Herpes,Hiv,Hepatitis,diabetes,
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  4. Hello viewers around the Globe, I was despondent because i had a very small penis, about 2.5 inches soft and 4 inches hard not nice enough to satisfy a woman, i have been in so many relationship, but cut off because of my situation, i have used so many product which doctors prescribe for me, but none could offer me the help i searched for. i saw some few comments on the internet about this specialist called Dr, OLHIA and i decided to contact him on his website i saw on the internethttp://olihawonderfulherbs.webs.com/ so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words with his herbal pills for Penis Enlargement, Within 3 week of it, i began to feel the enlargement of my penis, " and now it just 4 weeks of using his products my penis is about 9 inches longer, and i had to settle out with my Ex girlfriend Ella, i was surprised when she said that she is satisfied with my sex and i have got a large penis. Am so happy, thanks to Dr OLIHA I also learn that Dr OLIHA also help with Breast Enlargement Hips and Bums Enlargement etc.. If you are in any situation with a little Penis, weak ejaculation, small breast_hips_bums do get to Dr OLIHA now for help on his email {oliha.miraclemedicine@gmail.com} or whats app him number: +2349038382931

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  7. Hello viewers all over the globe I am Caroline from USA, I have been suffering from HPV virus for the past 2 years now, I have went to several hospitals taking different treatment from doctors but still yet no improvement, I have done research on internet seen different testimony how some people get cured but I don’t believe does testimony again because of what happened to me I have contacted so many doctors online, they all ask for is money I was scammed by 3 different doctors over $2000 still yet I was not cured so I tell a friend of mine about my problem she tells me to contact dr oso that his very good in healing people with his medicine that she was cured from herpes by this some Dr oso I don’t believe her on thing she showed me her results on how was cured she gives me his Email few weeks later I contacted him and tell him about my problem he tell me not to be worried that his going to prepare the medicine and send to me through EMS delivery so after some days I received the medicine and I was take it as he Instructed me few weeks later I go for check up to no if I’m finally cured, could you believe me when the results come out I was negative I jump up I was very happy. Please my dear friends if you have any kind of diseases or virus please contact Drosohaberhome@gmail.com/ dr.osoherberhome1@outlook.com or WhatsApp +2348162084839. you can email me to for more info about dr oso . toddcaroline79@gmail.com. Thank you so much Dr oso I’m forever great full please my dear friends don’t believe on does comment online they all fake doctors. only Dr oso I see real. Please beware of scammers.........

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  8. My name is Mira Emma , i am from New York City. I was suffering from HIV disease for over 4 years, i was hopeless until one of my friend directed me to a man called Dr Udi, she said he cures the sickness and also said he has also helped her friend, i never believed her but after alot of talk, i decided to give him a try, just few days ago i contacted him and he told me what to do which i did and he cast a spell for me and told me to go for a test which i also did and when the result came out i was surprised to see that i am negative. I am proud to tell you the i am the most happiest person on earth I Give thanks to Dr Udi.. If you are having any problem and you need help, You can contact him with his email drudiherbalhome@gmail.com or Whatapp: +2348051243538.

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  11. Hello everyone!! I was diagnosed of Genital Herpes Simplex Virus (HSV) in 2016 and I have tried all possible means to get cured, i even visited Some Hospital where they gave me some drugs like Famvir, Zovirax and Valtrex which are very expensive but all to no avail, until i saw a post in a health forum about a herbal doctor OLUTA from West Africa who prepare herbal medicine to cure all kind of diseases including Herpes Simplex Virus, at first i doubted if it was real but decided to give it a try, when i contact this herbal doctor via his email he sent me a herbal medicine through UPS delivery service, when i received this herbal medicine, he gave me step by instructions on how to apply it, when i applied it as instructed i was totally cured of this deadly disease within 14 days of usage, if you are suffering of this diseases you can as well Contact this great herbal doctor via his email; dr.olutaspellcaster@gmail.com or call or whatsapp Dr OLUTA on this +2349065326267? HIV/AIDS,DIABETES,CANCER,HEPATITIS ABC,DARIA,Chronic, Arthritis. God bless you sir....

    ReplyDelete
  12. I am John Danilla from UK( northern ireland), i want to share a
    testimony on how a powerful spell caster cured my HIV disease, i was
    diagnosed of this disease, in the year 2009, last week i saw a testimony on
    Dr.Akioya on how he cured an HIV patient, so i contacted him through phone
    call and he asked me to email him, which idid, so he told me that all my
    problems is over and then he decided to do an healing spell spell for me so
    after he finished it, he told me to wait for just 24 hours and then i
    should go for a test, so i really did as he had said, so my greatest
    surprised when i went to the hospital to go for an HIV test, the Medical
    doctor diagnosed that, i am now HIV negetative at first i was amazed and
    now i have come to realise that this spell caster Dr. Akioya is a very
    powerful one and a real spell caster. So viewers of this should please join
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    ReplyDelete
  13. I am so happy, i never believe i will be this happy again in life, I was working as an air-hoster ( cabby crew ) for 3years but early this year, i loose my job because of this deadly disease called Herpes virus (HSV), I never felt sick or have any symptom, till all workers were ask to bring their doctors report, that was how i got tested and i found out that am HSV positive that make me loose my job, because it was consider as an STD and is incurable disease, i was so depress was thinking of committing suicide, till i explain to a friend of mine, who always said to me a problem share is a problem solved, that was how she directed me to Dr Isibor, that was how i contacted him and get the medication from this doctor and i got cured for real, I just went back to my work and they also carry out the test to be real sure and i was negative. Please contact this doctor if you are herpes positive or any STD diseases his email is: drisiborspellhome@gmail.com or you can call or whatsApp his mobile number on +2348107855231.

    ReplyDelete
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    ReplyDelete