We routinely use iv metoclopramide in trauma victims receiving opiates.
This is partly to avoid the unpleasant and potentially dangerous spectacle of a C-spine
immobilized patient suffering morphine-induced hurling. The other advantage is that anyone
heading towards urgent theatre needs a stomach as empty as possible (preferably downwards)
prior to a rapid sequence tubing.
This is not evidence based, merely anecdotal. In the 7 years I've been pretending to do
A&E, I've never seen a dystonic reaction, severe or otherwise, due to metoclopramide I've
given., and no-one's ever told me about any late reactions on the ward either. Before A&E,
in a year's gassing, I also never saw a dystonic reaction due to single dose anti-
chuckacillin, despite recovering hundreds of patients after anti-emetic pre-meds.
I also tend to use small doses of metoclopramide iv in kids needing morphine for bent-
double forearm #s etc. I know my colleagues rarely do, but again, I've never seen a
dystonic reaction due to metoclopramide I've given, and they rarely seem to vomit after.
I've had to run to fetch vomit bowls plenty of times for patients given morphine (but not
metoclopramide) by my colleagues. Please could someone point me in the direction of some
good evidence on this to convince me not to give anti-emetics to kids, as I think I may be
in a minority of one.
And in case you're sitting there thinking "this bloke wouldn't recognise a dystonic
reaction if one hit hom in the eye", I have seen them before, but only after several doses
of (usually) a phenothiazine.
If you're now sitting there incredulous that I've never seen single dose metoclopramide
induced dystonia, then I'm equally incredulous at the abstract posted by Cliff Reid
suggesting 44% incidence of akathisia after 1-dose prochlorperazine! This certainly
doesn't seem to be a problem with metoclopramide. I can feel a trial welling up inside me.
As regards MI requiring opiates: we routinely use metoclopramide here too. Not
prochloperazine (drops BP) or cyclizine (raises BP, but preferred if parkinsonian). Bad
enough having an MI, but chunderinging, half sedated by opiates into your oxygen mask
would put a bit of a strain on the old ticker, and vagal reflex may not be ideal on
conduction either.
Sorry, rambling without my boots on again.
Dr G Ray
Staff Grade
A&E
Sussex
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