# Nitro or not?



## 18G (May 12, 2014)

43 yo male is at a cancer treatment center receiving a blood transfusion (1 unit PRBCs) for low H&H secondary to cancer complication. Patient received the entire unit of blood at which time he became SOB and faint crackles were noted in the lung bases. RN reports and patient gives impression of non-compliance with medical treatment and specifically with not taking his Lasix. Patient is also on a sodium restricted diet and patient is morbidly obese at 340lbs. Some lower extremity edema is present. Neck is obese so it's difficult to assess JVD. Patient did say he didn't sleep well last night due to waking up SOB. RN advised that patient was a little short winded when he arrived. 

Patient has no CHF history but does have renal failure history of which was reported to be acute and now resolved. My impression is a volume overload status which is causing the SOB and crackles. In other words CHF. BP wasn't high and was 120s/70s, HR 110, RR 28. SpO2 99% on 2lpm. 

ETA to the hospital was literally one minute across the parking lot. 

Would you have given nitro to this patient to expand the vascular container to better accommodate the excess volume and reduce the pulmonary vasculature pressure even though patient is not hypertensive?

Thoughts?


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## 18G (May 12, 2014)

And patient did receive two doses of Bumex prior to arrival.


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## Rialaigh (May 12, 2014)

Short answer is no, Patient will get a hefty dose of lasix (being that large) in the ER and will hangout and likely get admitted due to lab work that will no doubt be all jacked up. 

The real question is whether this patient gets diagnosed with CHF or with pulmonary edema due to acute flair up of renal failure. Not sure if Lasix is the long term answer or if it is dialysis, Lasix however is the short term answer...


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## VFlutter (May 12, 2014)

18G said:


> My impression is a volume overload status which is causing the SOB and crackles. In other words CHF. BP wasn't high and was 120s/70s, HR 110, RR 28. SpO2 99% on 2lpm.



Volume overload does not automatically mean CHF. Even though it is a  strong possibility, most CKD patients end up with Cardio-Renal  syndrome, I would not assume "CHF". Nephrotic Syndrome can present very similarly. 



18G said:


> ETA to the hospital was literally one minute across the parking lot.
> 
> Would you have given nitro to this patient to expand the vascular container to better accommodate the excess volume and reduce the pulmonary vasculature pressure even though patient is not hypertensive?
> 
> Thoughts?



I see no reason to give nitro. The patient is saturating fine on 2L and only mildly tachypneic. Let him get a work up in the ER. 

A few SL Nitro are just bandaids. A crashing APE patient needs a Tridil drip upwards of 50mcg/min.


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## Akulahawk (May 13, 2014)

Personally, no. I wouldn't give the nitro. Not even nitro paste if I had that available. While that patient isn't exactly "well" that patient isn't (so far) showing me that they're about to circle the drain. Also, given that the ED is about 1 minute away, I'm even less inclined to pull out the nitro, let alone give lasix. Now if we were MUCH further out, I'd consider lasix and I'd have the nitro on standby and have CPAP ready should that be available as well. 

Still, I just don't see this patient suddenly and acutely crumping between my arrival and delivery to the ED.


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## Angel (May 13, 2014)

you COULD give nitro even with that BP but for this specific situation i would not. He is compensating (for now) and with the 1 min eta to the ER it seems unnecessary.


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## LondonMedic (May 13, 2014)

I wouldn't usually give GTN outside of sympathetic acute heart failure.

I think the OP is right, this sounds like a relatively clear cut volume issue. But I suspect it's more likely to be renal rather than cardiac. Either way, a bit of fruse is the way forward in the first instance.


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## Clare (May 13, 2014)

Hmm, considering the "overall clinical picture" I would not give GTN.

The expansion of intravascular volume with and recent history of not taking frusemide lead me to believe that GTN is not indicated as this is not cardiac failure.

As an aside, I once saw a guy with his lower legs swollen so bad that when he restarted his frusemide they drained 6 kg of water off him.


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## 18G (May 13, 2014)

I decided not to give NTG in this case but the thought crossed my mind so wanted to see what others would have been thinking. 

Even in a "normal" heart that is volume overloaded, NTG can have some benefit to expand the vasculature to reduce preload which would be beneficial just like in CHF. This is what I was thinking when considering NTG. Any additional thoughts?


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## cruiseforever (May 13, 2014)

No Nitro.  If I would want to give Nitro to this pt. it would require a call to med. control.  Systolic B/P has to be 140 or better.


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## Medic Tim (May 13, 2014)

cruiseforever said:


> No Nitro.  If I would want to give Nitro to this pt. it would require a call to med. control.  Systolic B/P has to be 140 or better.



what is your protocol?... never heard of 140 being the basement to give nitro.


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## Carlos Danger (May 13, 2014)

Chase said:


> Volume overload does not automatically mean CHF. Even though it is a  strong possibility, most CKD patients end up with Cardio-Renal  syndrome, I would not assume "CHF". Nephrotic Syndrome can present very similarly.
> 
> 
> 
> ...



This.


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## cruiseforever (May 13, 2014)

I will try to post again later


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## cruiseforever (May 14, 2014)

Medic Tim said:


> what is your protocol?... never heard of 140 being the basement to give nitro.



With our protocol for CHF/Pulmonary Edema, the B/P needs to be 140 or greater.  To use Nitro in suspected cardiac cond. the B/P needs to 110 or greater.

If the B/P is below these limits med. control needs to be contacted.


Link to our protocols if your interested     http://www.hennepin.us/~/media/henn...al/documents/als-protocols-large-redacted.pdf


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## TransportJockey (May 14, 2014)

cruiseforever said:


> With our protocol for CHF/Pulmonary Edema, the B/P needs to be 140 or greater.  To use Nitro in suspected cardiac cond. the B/P needs to 110 or greater.
> 
> If the B/P is below these limits med. control needs to be contacted.
> 
> ...



Really? That's an awfully high floor for NTG admin. I can give it down to 90 SBP.


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## ABQmedic (Jun 29, 2014)

18G said:


> 43 yo male is at a cancer treatment center receiving a blood transfusion (1 unit PRBCs) for low H&H secondary to cancer complication. Patient received the entire unit of blood at which time he became SOB and faint crackles were noted in the lung bases. RN reports and patient gives impression of non-compliance with medical treatment and specifically with not taking his Lasix. Patient is also on a sodium restricted diet and patient is morbidly obese at 340lbs. Some lower extremity edema is present. Neck is obese so it's difficult to assess JVD. Patient did say he didn't sleep well last night due to waking up SOB. RN advised that patient was a little short winded when he arrived.
> 
> Patient has no CHF history but does have renal failure history of which was reported to be acute and now resolved. My impression is a volume overload status which is causing the SOB and crackles. In other words CHF. BP wasn't high and was 120s/70s, HR 110, RR 28. SpO2 99% on 2lpm.
> 
> ...




Nitro and Lasix have hugely fallen out of favor here in NM.  Given his current vitals, keep him in position of comfort and transport on O2.  If this patient were in severe respiratory distress, he would have been placed on CPAP.  Had the transport time been longer, Morphine could have been considered as well.  

I've been a paramedic for 20 years and I never would have guessed that I would see Nitro and Lasix leave our protocols.


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## NomadicMedic (Jun 29, 2014)

I can see getting rid of the lasix, but what's reasoning behind eliminating the NTG?


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## Tigger (Jun 29, 2014)

DEmedic said:


> I can see getting rid of the lasix, but what's reasoning behind eliminating the NTG?



I have similar questions. Our new medical director wants first responding EMTs to treat acute CHF exacerbations with nitro prior to ALS arrival with online control. He said he is also considering allowing them to treat acute hypertensive crises with call in which I have greater concerns with but alas.

My agency has standing orders for nitro infusions with a pump and they have been extremely beneficial. Not sure I'd want that to disappear, especially since we now rarely need to give Lasix and mess with electrolyte balances.


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## TransportJockey (Jun 29, 2014)

I carry NTG infusions ans paste for use in pulmonary edema cases like CHF. we also still carry lasix and bumex if we need diuretic. CPAP is still my primary go to for it though.


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## Tigger (Jun 29, 2014)

TransportJockey said:


> I carry NTG infusions ans paste for use in pulmonary edema cases like CHF. we also still carry lasix and bumex if we need diuretic. CPAP is still my primary go to for it though.



CPAP plus nitro infusion seems to be the go to for the EDs around here. No reason to take the mask off or anything like that. I'm happy to have the same options at work.


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## Akulahawk (Jun 29, 2014)

18G said:


> I decided not to give NTG in this case but the thought crossed my mind so wanted to see what others would have been thinking.
> 
> Even in a "normal" heart that is volume overloaded, NTG can have some benefit to expand the vasculature to reduce preload which would be beneficial just like in CHF. This is what I was thinking when considering NTG. Any additional thoughts?





TransportJockey said:


> I carry NTG infusions ans paste for use in pulmonary edema cases like CHF. we also still carry lasix and bumex if we need diuretic. CPAP is still my primary go to for it though.



While nitroglycerin is very good at vasodilation, I'm not that big of a fan of the sublingual tabs or sprays because you're not able to titrate it for effect. I'm not saying you can't use it, but I would be overjoyed if we could do nitro infusions around here for that, but even given the 1 min ETA this patient had to the ED, _if_ I had to treat this patient, I'd probably start with CPAP first and add the nitro gtt later if needed. 

If the patient is compensating nicely (and apparently is) and doesn't decompensate when I sit him/her down on the gurney, I'm just going to give a nice & comfortable ride over to the ED and let them figure out this patient's problem.


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## Brandon O (Jul 29, 2014)

Could be TRALI. Seems a bit fast though.


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## coolidge (Jul 29, 2014)

So how did this patient's care and diagnosis resolve?


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## ABQmedic (Jul 29, 2014)

DEmedic said:


> I can see getting rid of the lasix, but what's reasoning behind eliminating the NTG?



Oops.  Time to eat some CROW.  Our new protocols include NTG.  My apologies for speaking before seeing the end product.:blush:


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## medicaltransient (Nov 3, 2014)

No. Could be some kind of exudate due to cancer or increased WBC from cancer.


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