Administering nitroglycerin for cardiac patient

[redbull]

If a patient has cardiac chest pain, how would you administer nitroglycerin?

Via tablets or spray? Does it matter?

 

[TransportJockey]

Depends. Are you allowed to? I know in NM I could as an EMT-B if the pt has a script for it and had their own (we would actually tend to use the NTG spray or tabs on the bus since a lot of peoples NTG is not as potent as it should be due to improper storage). Really there's no difference in which I would pick. Both deliver usually .03-0.4mg NTG per tab/spray. That being said, if a basic decides to give it they damn well better monitor vitals VERY carefully

 

[MrBrown]

We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn

I haven't seen GTN tablets here

 

[TransportJockey]

We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn

I haven't seen GTN tablets here

The NTG tabs I'm talking about ARE SL tabs... Were you thinking like a PO tab?

 

[abckidsmom]

We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn

I haven't seen GTN tablets here

Do you mean you've used spray forever?

We've used SL Tabs since the beginning of time, and have never even tried spray. And I laugh every single time you spell NTG backwards.

 

[WolfmanHarris]

Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.

In terms of protocol ours

Conditions
- HR between 60 and 160 bpm
- Systolic BP >100 mmHg
- No drop in systolic drop of greater than one third from prior BP
- Hx of previous NTG use or IV established
- No medications containing sildenafil (ED meds, revatio)

Administer 0.4mg q 5 min to a maximum of 8 doses.

 

[Sassafras]

I would administer whatever form their doctor prescribed since EMT-Bs can not give nitro here, merely assist with their own prescription. Protocols FTW.

 

[MrBrown]

Yes I am meaning like a PO GTN tablet, apparently they do exist.

We have always used the aerosol SL spray

 

[the_negro_puppy]

Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.

In terms of protocol ours

Conditions
- HR between 60 and 160 bpm
- Systolic BP >100 mmHg
- No drop in systolic drop of greater than one third from prior BP
- Hx of previous NTG use or IV established
- No medications containing sildenafil (ED meds, revatio)

Administer 0.4mg q 5 min to a maximum of 8 doses.

Our protocol is pretty similar except

HR 50-150
Systolic bp greater than 100
No current CVA or suspected ehad injury
Precaution for inferior MI

 

[WolfmanHarris]

Our protocol is pretty similar except
Precaution for inferior MI

This is covered in the language. All of our medical directives say "The Paramedic may..." rather than "The Paramedic will..." so I do have discretion to withold, provided I document it and can justify it.

 

[mar7967]

Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.

In terms of protocol ours

Conditions
- HR between 60 and 160 bpm
- Systolic BP >100 mmHg
- No drop in systolic drop of greater than one third from prior BP
- Hx of previous NTG use or IV established
- No medications containing sildenafil (ED meds, revatio)

Administer 0.4mg q 5 min to a maximum of 8 doses.

In NY, the patient must be prescribed NTG...

Out contraindications are:
(1) Blood pressure below 120 mmHg systolic
(2) Heart rate less than 60 bpm
(3) Medication not prescribed for the patient
(4) Pediatric patient
(5) Any patient having taken medication for erectile dysfunction (e.g., Viagra™, Levitra™, or Cialis™) within the
past 72 hours. Medical consultation is required to override this contraindication.

We can give up to 3 doses of 0.4mg SL tablet, including what the pt took PTA. (so if they took 2 doses before we got there, we can only give one more.)

 

[redbull]

This is in regards to a quiz question last night. I read in the Brady text it didn't say anything about preference. But both were options on the quiz. :glare:

 

[abckidsmom]

This is in regards to a quiz question last night. I read in the Brady text it didn't say anything about preference. But both were options on the quiz. :glare:

In that case, I bet they were looking for a local protocol answer.

 

[jjesusfreak01]

My instructor states that the sublingual spray is unsanitary, since you are holding it right in front of someones mouth. Of course, that makes pretty much everything else used in pt care unsanitary too.

 

[WolfmanHarris]

My instructor states that the sublingual spray is unsanitary, since you are holding it right in front of someones mouth. Of course, that makes pretty much everything else used in pt care unsanitary too.

Your instructor may not be entirely competent.

Suggest he look up the enteral route of medication administration.

 

[vquintessence]

Your instructor may not be entirely competent.

Suggest he look up the enteral route of medication administration.

I'm assuming he [instructor] is referring to the pt breathing on the NTG spraying device, and all the contagions being able to indefinitely survive in the outside environment, ready to spring upon the unsuspecting cardio/pulmonary pts.

But yeah, I'm with your determination.

 

[Shishkabob]

I would administer whatever form their doctor prescribed since EMT-Bs can not give nitro here, merely assist with their own prescription. Protocols FTW.

Eh, I do my own loophole for my EMT when giving nitro. Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.


I'm going to give it anyhow, so it's really of no difference.

 

[vquintessence]

Eh, I do my own loophole for my EMT when giving nitro. Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.


I'm going to give it anyhow, so it's really of no difference.

While I think your heart is in the right place, you're putting their license/cert at serious risk. Hopefully you're not also documenting them being the ones to administer.

Just a grump peeping in from the outside

 

[Shishkabob]

While I think your heart is in the right place, you're putting their license/cert at serious risk. Hopefully you're not also documenting them being the ones to administer.

Just a grump peeping in from the outside

Eh, that's the gray area. State of Texas allows EMTs to give nitro, regardless of whether it's the patients own or not. The EMT section of the company protocols state "Administer prescribed nitro".


But of course I put down that it's me giving it, because it technically is, even if not physically as I'm the one making the decision.


But that is also where I draw the line: Allowing an EMT to give a medication that is already within his scope that he's allowed to give. He doesn't do any Intermediate/Paramedic drugs, no IV drugs, etc etc.

 

[WolfmanHarris]

In Ontario medical directives have been interpreted to allow a BLS provider to perform to ALS protocols when the skill is within their scope.

For example: When treating acute cardiogenic pulmonary edema, my directives as a PCP allow a dosage of 0.4mg NTG SL. An ACP may give 0.8mg. If I am on scene with an ACP I may spray the NTG twice per dose for 0.8mg since the delivery of SL meds is within my skill set, even though that dosage is outside my directives since the ACP is saying, "Hey, give them two sprays for me."

This also goes for hitting the shock button on a manual defib setting. While I operate in semi-auto mode, the ACP is the one interpreting the monitor and saying, "Okay charge to this for me and hit shock please." The pushing of the button isn't of any concern to Medical Direction, the decision making is.