# Heart patient--not sure i did the right thing



## Pfire2182 (Jan 14, 2014)

Okay I'm a first time user so go easy on me haha.  I'm a 31 year old basic first responder for my fire department and have been for 8 years, but in many areas I feel I'm still learning.  I have a huge passion for EMS and my goal is to become a paramedic eventually.

Tonight we had a possible heart attack, 60 y.o. male with 10/10 pain.  No prior history of heart attacks, but has history of TIA.  Pt had severe chest pain, radiating to his left arm, neck and back and SOB.  Normally we are on scene about 10 minutes with the pt before our medics arrive.  Protocols are to admin 4x baby aspirins or assist them in taking nitro if they have it.  Problem is the wife said he had taken coumadin about 40 mins prior so I was reluctant to give the baby aspirin in addition, but made a judgement call to do it anyway.  Now I'm second guessing myself and hoping I didn't make a mistake.

When the medics arrived, I briefed them and while he didn't say I screwed up by giving the baby aspirin he did kind of frown and say "oh...hmmm".  I'm not the kind of guy that needs patted on the *** all the time, so if I make a mistake I'd rather someone tell me so I can learn.  I'm not so thin skinned that I can't take constructive criticism.  

So opinions?  Should I have administered the aspirin on top of the coumadin the pt had already taken?  Especially given his history of TIA?  This just happened so I won't get an update on his condition till tomorrow, but I would like to sleep good tonight knowing I didn't further jeopardize this man's health.  Any feedback--good or bad--is appreciated. 

Thanks....everyone stay safe out there.
Mike


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## Tigger (Jan 14, 2014)

I don't see much issue. To speak simply, Warfarin is a "blood thinner" and Aspirin interferes with platelet agitation. Taking both together routinely would certainly increase risks associated with bleeding, but giving ASA one time to a suspected ASA patient should not be an issue and is recommended in many protocols.

I am not able to find much in the way of research to back this up, just that many systems call for ASA use in Warfarin patients.


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## VFlutter (Jan 14, 2014)

You should have given the Aspirin. It is one of the very few medications that actually reduces morbidity and mortality. First of all, ASA and Coumadin do two totally different things to the body. "Blood thinner" is a horrible term for Aspirin even though many describe it as such. It is an antiplatelet or antiagregate. Secondly, a pill taken 40 minutes ago is just starting to take effect if at all. You are a long ways off from therapeutic peak, especially with Coumadin. And lastly, many patients take full dose aspirin and Coumadin every day. It's all good. They won't start bleeding out their ears and eyes.


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## Anjel (Jan 14, 2014)

You are fine. 

Coumadin is not a contraindication for ASA in the cases of AMI. The benefits of ASA outweighs the risk of bleeding complications. 

Also ASA isn't a "blood thinner". It is an anti-platelet. The risk would be greater if the patient was taking his coumadin and taking 324mg of ASA on a daily basis. 

But this is an emergency situation and ASA is one of the drugs that has been proven to benefit the patient greatly.

EDIT: Totally what everyone else said while I was typing this lol


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## VFlutter (Jan 14, 2014)

On top of all that if they do suspect AMI/ACS they will get a nice dose of Anticoags in the ER.


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## unleashedfury (Jan 14, 2014)

ACLS guidelines suggest 325 MG of Aspirin for suspected cardiac events. 

There are only three known contraindications in my system

1. The patient has a aspirin allergy.
2. The patient has already taken 325 of Aspirin
3. A history of GI Bleeds 

all of the blood thinners Coumadin, xarelto, pradaxa, and the such are not contraindications.

Most definitely not a contraindication in a life threatening event. You did the right thing as a responder You identified the symptoms got a assessment and history of illness and provided a initial treatment plan. 

A lot of medics believe that interventions prior to performing a 12 Lead ECG can change the results of STEMI vs NON STEMI MI. 

Aspirin has been proven to increase survival rates during heart attacks just watch the bayer commercials they brag all about it.


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## Pfire2182 (Jan 14, 2014)

*Thanks*

Thank for all the responses.  You gave me some peace of mind, and more importantly you some valuable information.  Take care folks.


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## VFlutter (Jan 14, 2014)

unleashedfury said:


> A lot of medics believe that interventions prior to performing a 12 Lead ECG can change the results of STEMI vs NON STEMI MI.



I have some seen some pretty drastic T wave pseudo-normalization with nitro. Not that I would withhold it but I would try by best to get a 12 lead before.


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## Handsome Robb (Jan 14, 2014)

I'm gonna give you a push in the right direction. 

you've been a MFR for 8 years and plan on going to paramedic school? Get your *** in gear then you wont have this problem!!! 

Without knowing more about the patient you did the right thing.


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## mycrofft (Jan 14, 2014)

*FDA info*

http://www.drugs.com/pro/warfarin.html
AND I QUOTE:

"7.2 Drugs that Increase Bleeding Risk

Examples of drugs known to increase the risk of bleeding are presented in Table 3. Because bleeding risk is increased when these drugs are used concomitantly with Warfarin, closely monitor patients receiving any such drug with Warfarin.


Table 3: Drugs that Can Increase the Risk of Bleeding
Drug Class	Specific Drugs
Anticoagulants	argatroban, dabigatran, bivalirudin, desirudin,
heparin, lepirudin
Antiplatelet Agents	aspirin, cilostazol, clopidogrel, dipyridamole,
prasugrel, ticlopidine
Nonsteroidal Anti-Inflammatory Agents	celecoxib, diclofenac, diflunisal, fenoprofen,
ibuprofen, indomethacin, ketoprofen,
ketorolac, mefenamic acid, naproxen,
oxaprozin, piroxicam, sulindac
Serotonin Reuptake Inhibitors	citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, paroxetine, sertraline, venlafaxine, vilazodone."


HOWEVER, the amount of ASA was pretty small.

Ask your medical director or re-read your protocols.  The only reason I rewrote this from "don't give aspirin" is that people on coumadin can temporally lose its protection by getting too much Vitamin K on board and hence have an angina attack (or an embolic stroke, etc); then the ASA might be indicated, but know your protocols and talk to your bosses first.


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## unleashedfury (Jan 14, 2014)

Chase said:


> I have some seen some pretty drastic T wave pseudo-normalization with nitro. Not that I would withhold it but I would try by best to get a 12 lead before.



Yes that's what I was instructed nitro can cause ECG changes. Aspirin not so much. However students from another course told me that they were to provide no interventions prior to 12 Lead ECG's due to the fact that it may affect abnormalities. I don't agree with that statement.


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## mycrofft (Jan 14, 2014)

OP writes nitro OR ASA. Why not both?

PS "No-Nitro" causes change too: the Kansas Sign: _______________________________________________________


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## KellyBracket (Jan 17, 2014)

Pfire2182 said:


> Problem is the wife said he had taken coumadin about 40 mins prior so I was reluctant to give the baby aspirin in addition, but made a judgement call to do it anyway.  Now I'm second guessing myself and hoping I didn't make a mistake.



If your medical director didn't want you to give ASA when a patient is taking warfarin, they would have written that. Also, warfarin has a long onset of action, so don't worry about the time frame. 

As for ASA, NTG, or O2 causing spontaneous resolution (SR) of a STEMI, the evidence is poor and mixed. You can read a brief review of the subject I wrote at my blog, "When the STEMI disappears before you get to the ED! "

http://millhillavecommand.blogspot.com/2013/04/when-stemi-disappears-before-you-get-to.html 
I copied the relevant section below:


> Although SR may occur in up to 15% of STEMIs, this isn't well-studied. One of the studies mentioned above ("Relation of clinically defined spontaneous reperfusion to outcome in ST-elevation myocardial infarction") checked whether SR occured more often in patients who received aspirin or heparin from EMS or in the ED, and didn't find an association:
> 
> Dr Smith describes a STEMI case in which he felt that nitroglycerin had caused SR, and thus contributed to a delay in PCI. In his discussion he cites an abstract from an EMS study, possibly the world's only clinical study on this topic. The brief version is that 6% of STEMI patients had partial or total SR in the period after NTG administration. Of course, it was retrospective, uncontrolled, etc.
> 
> ...


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## Ewok Jerky (Jan 17, 2014)

if my patient is having a stemi, and medics are 40 minutes out, i hope i can "mask" the st changes with ASA rather than let the MI evolve while im twittling my thumbs.

and yes ASA + warfarin increase the risk of stroke, but who cares when this guy is probably having an MI right NOW.


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## Handsome Robb (Jan 17, 2014)

beano said:


> if my patient is having a stemi, and medics are 40 minutes out, i hope i can "mask" the st changes with ASA rather than let the MI evolve while im twittling my thumbs.
> 
> 
> 
> and yes ASA + warfarin increase the risk of stroke, but who cares when this guy is probably having an MI right NOW.




Wait how are planning on "masking" the changes with aspirin?

The MI is going to continue to evolve until perfusion can be restored.


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## Ewok Jerky (Jan 18, 2014)

Robb said:


> Wait how are planning on "masking" the changes with aspirin?
> 
> The MI is going to continue to evolve until perfusion can be restored.



Maybe I wasn't very clear the way I said it.  What meant was, I would rather administer an intervention that reduces mortality rather than wait for the 12-lead and then give asa 30-40 later.


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## ChrisV (Mar 3, 2014)

Did it right.  Job well done.  Screw the lousy medic, what he should have said was "thank you".  A great Basic is far better than a mediocre Medic.


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## exodus (Mar 3, 2014)

beano said:


> Maybe I wasn't very clear the way I said it.  What meant was, I would rather administer an intervention that reduces mortality rather than wait for the 12-lead and then give asa 30-40 later.



Why does a 12 lead take 30 or 40 mins? A 12 lead takes ~2 or 3 at most.  If it's a legit chest painer who appears in distress, simply cut their top off to get access if it's hard.


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## chaz90 (Mar 3, 2014)

exodus said:


> Why does a 12 lead take 30 or 40 mins? A 12 lead takes ~2 or 3 at most.  If it's a legit chest painer who appears in distress, simply cut their top off to get access if it's hard.



I believe in this situation transporting ALS was some distance away. Even as an ALS provider, I often give ASA prior to getting the 12 lead. No biggie for me to grab the aspirin as my EMT sets up 12 lead cables.


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## the_negro_puppy (Mar 4, 2014)

unleashedfury said:


> Yes that's what I was instructed nitro can cause ECG changes. Aspirin not so much. However students from another course told me that they were to provide no interventions prior to 12 Lead ECG's due to the fact that it may affect abnormalities. I don't agree with that statement.



If my patient has borderline blood pressure or other concerns, I will give Aspirin, but do a 12 lead and get IV access first before I start giving Nitro and Morphine.


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