# Adminstering Nitro w/out a line in place



## Sizz (Apr 23, 2012)

Hey all,

I want to run something past you all and get your feedback. I'll give you the short version summed up:

A few weeks back I was working with my part-time company which is an ALS county service, and was paged to an assisted living facility for a "chest pain" call. 

Upon arrival we find an elderly lady with dementia along side a nurse that takes care of her on a normal basis. The pt appears a bit skittish and almost freighted that we're there , but does not seem to be in distress or showing your classical signs of a serious cardiac issue. Nurse stats earlier in the day the pt had complained of chest pain, and this evening she again mentioned she had discomfort in her chest. The pt is put onto the monitor which if I recall was slightly sinus tach, nurse states the pressure she received was 190/100 and we obtain something similar on scene as well. Pt is on a new medication for anxiety , a dementia medication, but no hypertensive medication I can recall. I administered our chewable ASA then packaged the pt and loaded for transport.

It's my call and I'm with another medic who has 6+ months more experience than I and is a full timer with the company, a 10 yeared Medic arrives to "assist" on the call(the call crew show's up and helps on calls in town upon hearing a page upon their own discretion....not always sure why but they always have done this). As soon as I get into the rig both of the other medics are racing for the nitro and shoving it down my pt's throat. I stated I want a line in place before hand(I feel it's necessary if you're giving any medications and my full-time ALS job it's required / protocol) and both of them come back to me with " She's hypertensive and needs nitro now" the line an wait....I let back at this point as I knew the 10 yr medic and other would not agree with me and would still continue with the med without my discrection. The pt started to throw PVC's and even had a slight run of v-tach (a symptomatic) after nitro was given the medic on with me attempted 2 IVs , failed and I was able to secure one myself. During this time the 2nd crew is paged out at which point the elder medic left(how ironic is that, even being on the opposite side of town ya?!). 

Anyhow we transported the pt and afterwords I expressed my concern and that I was unhappy with what had happened. The medic I was on with told me he use to "follow the same rule of thumb" but he's never had any issues and was apparently advised by a big city medic way back when that "Never withhold treatment that reduces pain to the pt - NTG". He then mentions if something would have happened with pt he would just drop an IO into them and work em. Later tries explaining the good old sad :censored::censored::censored::censored: story I hear from people from time to time - "People take nitro all the time at home, do they have an IV in place, do they have issues...." 

Our pt never really expressed pain or discomfort to us - she did not really understand much that was happening nor the 1-10 scale etc.  

Secondly I'm trying to avoid having to bottom out the pt in the first place causing a draw on the cardiovascular system and having her  arrest in the first place...so let's avoid this  - to the IO response.

And lastly I told him that "Yes, pt's are prescribed nitro at home but USUALLY this is for a diagnosed case of angina where the their cardiac history has been looked over extensively and usually are not have right ventricle issues or it most likely would not be prescribed...it's more of a controlled than dropping 400mcg of nitro into a random chest pain / hypertension. 

Who know this pt could have had hypertension for 12 hours before it was caught...taking the couple minutes to setup and start a line is not going to make or break this pt. 

Sadly I've seen this happen with other calls from other medics with this company even with normotensive pt's  having chest pain vs the hypertensive pt we had. 

I do not agree with this, although I'm not sure how to approach it if I should even attempt to but next time I'm working for this company you can bet I'm going to make it clear up front if you decide to bypass my treatment and give this pt nitro without my consent it's YOUR pt now and you'll be attending and reporting. 

Any thoughts on how you would handle the situation or just in general?


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## 18G (Apr 23, 2012)

A few things.... first off... if this was your call and YOUR patient no other Medic (regardless of experience) should be stepping in and making treatment decisions especially when they end up bailing on you for another call. 

I think it is prudent to have a line before NTG in some cases but don't think it's an absolute. More importantly, what was the 12-lead showing? I do believe in trying to get a 12-lead pre-treatment. This way, you will be able to pick up the inferior wall MI / RVI prior to giving NTG even if you had a line started. 

I see where your peers are coming from. If the B/P is truly 190/100 I wouldn't be fearful about giving NTG without a line... at least not the initial dose. Think about that pressure. If a patient is having an ACS, a pressure that high is very taxing on the heart. Diastolic pressure correlates to afterload and at 100mmHg it is a great force the heart has to overcome to eject blood. I have never seen a single nitro drop a pressure by more than a 100 points which would put the patient into an area for concern.

Also, a lot of patients with inferior wall MI / RVI are hovering around the border-line hypotension range or low end like SBP 110-115's. In this case, yes I would want a line first before nitro. Heart rate is also often on low end or bradycardic with inferior wall / RVI and commonly seen with a heart block, N&V. 

Where I work, BLS protocol allows Basics to give NTG on their own (carried on the ambulance) without IV access. So its not an absolute.


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## Medic Tim (Apr 23, 2012)

18G said:


> A few things.... first off... if this was your call and YOUR patient no other Medic (regardless of experience) should be stepping in and making treatment decisions especially when they end up bailing on you for another call.
> 
> I think it is prudent to have a line before NTG in some cases but don't think it's an absolute. More importantly, what was the 12-lead showing? I do believe in trying to get a 12-lead pre-treatment. This way, you will be able to pick up the inferior wall MI / RVI prior to giving NTG even if you had a line started.
> 
> ...



agreed


where I work as long as the sys pressure is over 110 we can give it without a line.


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## Aidey (Apr 23, 2012)

The other medics probably shouldn't have over run you, but I also don't think a line is mandatory for giving nitro. As was mentioned above, you can determine the likelihood of right sided involvement based off of the 12 lead and assessment. In low chance cases I don't have a problem giving nitro before I have a line.


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## DrParasite (Apr 23, 2012)

is 190/100 really cause for "stuff nitro down her throat" as fast as possible?  190/100 isn't all that high... now if you said 240/140, with other ACS related symptoms, than i'm going to start saying time is def of the essence.

Was he grossly diaphoretic?  or showing any other signs of poor perfusion?  if not that i'm still not rushing.

IV access is nice because 1) protocol requires it and (more importantly) 2) if something happens, or you need to push IV meds in a hurry, you already have the line in place, and don't need to start fishing for access.  

If the patient is hypertensive, odds are the NTG won't drop their BP into a problematic rate.  however, if they have another problem unrelated to the htn, and needs medication, I'd rather have the line in place, than have them go into vtach and then be found behind the 8 ball.


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## Handsome Robb (Apr 23, 2012)

With pressures like that you probably aren't going to bottom them out with a spray of nitro. I'd personally be comfortable giving it without a line but a line would be high on my list of priorities. Personally I'd only give the first spray before getting a line but that's also because she's probably not the easiest stick so if she's hypertensive it may make the line easier to obtain. 

Like someone said, this was your call, why were the other medics walking all over you? Personally this one would go up the chain to an appropriate supervisor. My call, my responsibility, my treatment path. 

What did the 12-lead show? In my opinion we should be getting a 12-lead before administering NTG, as it helps us build a trend to show responses to treatments. That is our protocol and my personal preference along with the emergency physicians and cardiology groups here.

I've got a zinger...You had 3 paramedics on scene. Why can't one be capturing a 12-lead while the other works on obtaining a line and the 3rd gets the NTG and other meds ready and possibly the first spray onboard after the 12-lead is finished? Delegation or resources at it's finest. Rather than arguing on scene in front of the patient. 

You were put in a pretty :censored::censored::censored::censored:ty situation, if you are attending the call no other medic should step in and start making treatment decisions, regardless of their seniority or experience, unless you are doing something that is going to harm the patient. By the sounds of it you definitely weren't doing anything that could harm her.


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## Aidey (Apr 23, 2012)

The pt was reportedly having chest discomfort, which is arguably a good reason to give nitro in this case. If they were giving it only because of the BP that is a no no. Treating asymptomatic HTN in the field is stupid. The current recommendation is that people with HTN have their BP lowered over weeks so their body can adjust. Afterall, their BP didn't go up suddenly, it shouldn't go down suddenly.


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## 18G (Apr 23, 2012)

Just to touch on the B/P issue. In the older population who present with ACS and found to be hypertensive I think of CHF. A lot of CHF patient's present with hypertension as the neurohormonal compensatory response. Just something to think about too as CHF can cause B/P to spike quickly and that is a case were B/P reduction is quickly needed.


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## Aidey (Apr 23, 2012)

True, but in that case you aren't lowering their BP just for the sake of getting a better number. You are lowering it to treat a specific issues that are present. Plus those pts are usually have some other symptom aside from HTN.


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## Shishkabob (Apr 23, 2012)

If it's your patient, it's your call, and it's bad taste to have the others just override you.


Having said that, I personally don't require an IV in place before I give NTG.  It's something I prefer to have, but lack of it won't keep me from giving it.  As has been stated, many patients take it every day without starting their own IV with little chance of negative outcome.

If a BP is 110/70, I'd prefer a line.  If it's 190/100, it's either/or.  If it's a hard stick, I go ahead with the NTG.  I have the IO to fallback on if need be.  You're not likely to drop from 190/100 to 60/p from a single SL nitro, but the NTG COULD potentially relieve the pain.



Do you also require an IV for Fentanyl or benzo administration given IN?


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## usalsfyre (Apr 23, 2012)

It's all about the situation. I will (and have) given up to four NTG tabs simultaneously to a fulminant CHF patient prior to having a line, so that once I got the CPAP mask on it stayed on. I've yet to kill one of these patients. A protocol saying you must have a line is your medical director's way of saying "I don't trust you not to be stupid".

I won't give it without a 12 lead in hand though.


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## Akulahawk (Apr 23, 2012)

If that patient's got a BP of 190/100, I wouldn't fear about giving NTG to her without a line. That small amount of NTG probably won't drop her pressure enough to make much of a difference, even if she has an IWMI or RVI. Now if her vital signs were near normal or slightly low from what I'd expect, I'd hold the NTG until after I get a 12-lead, and possibly establish a line. I wouldn't necessarily give the NTG specifically for reducing the BP though. There are other meds that can do that and that last longer. Sometimes the best Tx is to do nothing but provide a nice, quite ride in. Sometimes, you have to empty the shelves of whatever drugs you have... if it's indicated. 

In her case, I'd probably be inclined to have one of the other medics get an EKG going (preferably a 12-lead), another flood a line for me and get things ready in the ambulance, while I continue evaluating the patient and devise a treatment plan. If my plan calls for NTG, I'll be the one to order it. 

Also, if that patient is _my_ patient, _I_ am the person in charge of her care until _I RELINQUISH IT_ specifically to someone else. If any other medic bulldozes in, and tries to take over care, I'm more than happy to tell them that they can take over complete responsibility for the patient... and that means riding all the way into the hospital while taking care of that patient and doing _ALL OF THE PAPERWORK._ That also means taking all the credit or blame for what happens with that patient.

That pretty much lets the 30-year volunteer medic that just decided to vanish... vanish from the scene that much quicker, and your partner make a very quick decision about whether or not they want to do all the paperwork for a patient that initially wasn't theirs...


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## NYMedic828 (Apr 23, 2012)

Out here the protocols for my city/volunteer employment clearly state

NTG can be admin in 0.4mg q3-5 does with a bp of 

greater than 120 systolic without IV access
greater than 100 systolic with IV access.

The only patients I ever give NTG to without a 12 lead are patients in severe APE that we need to get moving with. If I can hear them drowning and they are HTN we usually do a 3 lead, give them a double spray, stick an IV in if possible and head to the vehicle.

I really don't see anywhere that I could feel it necessary to administer nitro with a BP around 120 let alone 100 IV or no IV. There is no reason to risk creating further problems whether they are easily resolved or not. 

I was always taught that we give nitro to reduce the workload of the heart and as a diagnostic tool to make a presumptive diagnosis of ACS. It is not primarily given as a pain treatment. Thats just an added bonus. If my primary concern is to treat pain, I have plenty of morphine to go around.

Just like everything else, clinical judgment is paramount. IV should always come first in my mind at a minimum as a preventative measure. If my patient could deteriorate, I want to be ready. Unfortunately many times we may not be able to get that IV, but if the patient has a cardiac history and is hypertensive im not going to withhold a treatment that could improve their condition greatly.


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## the_negro_puppy (Apr 23, 2012)

Was she currently complaining of pain/pain symptoms when you gave the nitro? We only give it here if they have current symptoms. No pain/ discomfort = no nitro.

We routinely give up to 2 x spray without an IV


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## Sizz (Apr 23, 2012)

*Thank you for the replies*

Thanks guys for the feedback,

To answer some commonly asked questions and to clear up a few things is yes a 12 lead ECG was done initially inside the retirement home  upon applying the cardiac monitor- sinus tach. 

The pt had pretty bad dementia and I could not gather she was having all that much pain, even upon asking and making it as simple as I could she really had little to no pain if any it appeared when she pointed out a pain area it was upper GI lower chest which did change to other area's but again she was freighted anyhow by us and did not seem to grimace in much of any pain, I feel the nurse attending might have "caught wind of the word pain in the chest area and hit 911 as a precaution etc. 

Not much "fighting went on" other than I made the other 2 very aware I did not agree at the time with the NTG being given before my line was in place. Once we loaded the pt in our 10 min time frame and the NTG was given , the my partner was attempting a line while I tried to further evaulate the pt's pain / symptoms and anything else I could get out of her but again she pretty much gave me the blank, confused look and was not answering my questions properly due to her dementia. Once the NTG was given the 3rd medic (who joined us that was on 2nd call) caught a PVC on the monitor at which point a strip was printed, a second ECG was captured along with the run of V-tach that resolved within 10-15 seconds...at which point she was tripped out...and left. No IV was  yet established as my P was having no luck with his few tries, I was able to secure a line and then we headed to the ED. 

I've picked up a lot from this forum post which has helped me and also allowed me to lighten up a bit on the situation but I completely agree ...next time if it's my pt it's my care / path otherwise it's your pt and problems and paperwork like mentioned! I would only expect someone to step in and take action if I'm making a mistake or making a call that could cause unintentional harm ....but of course that was not the case. 

Thank you again your replies have been helpful


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## 18G (Apr 23, 2012)

Nursing home patients with dementia can be really hard to assess so I hear ya. Absence of ischemic 12-lead changes surely isn't 100% confirmatory of no cardiac issue, but if the 12-lead is normal and the pt. is not evidencing or stating chest pain or some kind of anginal equivalent I would probably withhold NTG. Sometimes providers (not saying you) can get pulled into a complaint stated by dispatch or someone else onscene. 

You seem like you have a great attitude and are very humble which makes a great Medic. This forum is a great resource and has helped me a lot.


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## NYMedic828 (Apr 23, 2012)

What did the call come in as anyway?


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## TheLocalMedic (Apr 23, 2012)

Our protocols give precedence to NTG over an IV for treating ACS.  Granted, you want to get that IV in case they crump on you, but with a strong pressure, I wouldn't worry too much about it, even if they were having an inferior wall or right ventricular infarct.  

In fact, our protocols state to start with a double dose of 0.8 mg if the pressure is over 150 systolic.


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## Tigger (Apr 24, 2012)

Even at my mickey-mouse level of certification we are not required to have a line in place before administering Nitro. Given that I have never been in such a situation where I am the highest level provider on-scene I have never really been in a position to make that call. What do others think about getting a saline lock in place first, is it worth the time?


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## Akulahawk (Apr 24, 2012)

In this particular setting, if you're going to put in a lock, you might as well put in a line. You probably can convert over to a lock later, or just let the hospital staff do that.


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## Tigger (Apr 24, 2012)

Akulahawk said:


> In this particular setting, if you're going to put in a lock, you might as well put in a line. You probably can convert over to a lock later, or just let the hospital staff do that.



I was thinking more that fluid is not always indicated for many of these patients but if they were to bottom out the access would be there and it would be a quick affair to get a line going.

It seems like everyone that comes via ambulance to an ER where I live comes in with a lock already established. I'm not sure if it's the hospital wanting this (doubtful) or the crews.


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## Underoath87 (Apr 24, 2012)

Sizz said:


> It's my call and I'm with another medic who has 6+ months more experience than I and is a full timer with the company, a* 10 yeared Medic* arrives to "assist" on the call(the call crew show's up and helps on calls in town upon hearing a page upon their own discretion....not always sure why but they always have done this).
> 
> She's hypertensive and needs nitro now" the line an wait....I let back at this point as I knew the *10 yr* medic and other would not agree with me and would still continue with the med without my discrection.



I think the word you're looking for is "tenured". 
http://en.wikipedia.org/wiki/Tenure_(academic)


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## 18G (Apr 24, 2012)

Tigger said:


> I was thinking more that fluid is not always indicated for many of these patients but if they were to bottom out the access would be there and it would be a quick affair to get a line going.
> 
> It seems like everyone that comes via ambulance to an ER where I live comes in with a lock already established. I'm not sure if it's the hospital wanting this (doubtful) or the crews.



Every patient should get a lock unless maybe an arrest patient. I hate when people connect the line directly to the hub of the catheter. It becomes a pain in the butt when you need to change the line, run a new med through the site, etc. 

And honestly, unless the patient needs fluid I just place a lock for a med route and don't hang fluid.


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## Medic Tim (Apr 24, 2012)

Tigger said:


> I was thinking more that fluid is not always indicated for many of these patients but if they were to bottom out the access would be there and it would be a quick affair to get a line going.
> 
> It seems like everyone that comes via ambulance to an ER where I live comes in with a lock already established. I'm not sure if it's the hospital wanting this (doubtful) or the crews.



The hospitals where I have worked (US and Can) prefer locks, that way it is easier to convert over to pump or whatever tubing. They hate it when we hook the drip set directly to the catheter. Every IV I start is a lock. If I Need fluid I will hang a line off of the lock.


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## DrankTheKoolaid (Apr 24, 2012)

Lock is definately the way to go, IMO. Unfortunately the SL we use is more expensive then the Primary w/ ext tubing + the 1L NS bag combined....   So if the hospital wants it they are going to have to add it themselves in the ED


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## MSDeltaFlt (Apr 24, 2012)

There is a reason why you would not want to give NTG without a line in place first. That reason would if he/she has 2 or more blocks on their 12 lead (AVB, fascicular block, and/or BBB).  Because those pts would be more susceptible to marked hypotension due to sudden decrease in preload. So if you do give NTG without a line, please be careful. 

It takes at least 10 "atta-boys" to counteract one "oh sh@tter".


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## Bosco836 (Apr 24, 2012)

Our Nitro protocol here requires IV access UNLESS the pt. has a previous hx. of Nitro use.


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## NYMedic828 (Apr 25, 2012)

So my partner and I just had a discussion in the back of the vehicle with a patient relating to this topic.

Our patient was

74 male
4 hours chest discomfort just came in on a flight from Jamaica.
BP 172/104
HR 94 demand pacemaker.
SPo2 100%
RR 18
3/12 occluded by pacemaker.

He had no actual pain but he had pressure mid sternal no radiation.

Hx of HTN and cardiomyopathy with an ejection fraction down to 15% he claims.

Did not take morning meds. 


Anyway, we had a student with us so I was doing paperwork while they did patient care. They gave 162mg ASA and were unable to attain IV access. I suggested we give a trial of 0.4mg of NTG regardless because he was Hyper and missed his meds. 

My partner disagreed and said he doesn't want to give it because it could bring his ejection fraction down even further by potentially dropping his pressure. I argued that I felt the opposite would occur because his medicated pressure is normally lower regardless. On top of that, there needs to be a happy medium between what pressure actually effects his hearts ability to pump efficiently. I suggested that his pressure being high may actually be lowering his ejection fraction further. Both situations being unlikely to be the cause, I like to use NTG as a diagnostic tool since odds are it will do no harm with hypertension.

I like to use the analogy of pumping up a tire that gets harder to put air into as it increases in pressure.

He also argued the potential right sided MI which we can't see. Again, hypertension as is I wasn't too worried about a single trial spray.

In the end we have the one spray, nothing happened as expected.


So what would you guys say was the truly right move?


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## usalsfyre (Apr 25, 2012)

Full NTG regimen till the patient was pain free if it worked. You were right about EF, not your partner.

Why wouldn't you be able to check V4R for right sided ischemia?


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## MassEMT-B (Apr 25, 2012)

NYMedic828 said:


> So my partner and I just had a discussion in the back of the vehicle with a patient relating to this topic.
> 
> Our patient was
> 
> ...



Just a question from a student. While it would decrease his systolic, it would also decrease his diastolic so, wouldn't that actually make his heart be able to pump easier with a lesser resistance to over? Making up for what ever drop in systolic there is?


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## NYMedic828 (Apr 25, 2012)

Kinda feel stoopid. V4r didnt even go through my mind. I've never tried it on someone with a pacemaker. Aren't most pacemakers actually implanted in the wall of the right ventricle? 




MassEMT-B said:


> Just a question from a student. While it would decrease his systolic, it would also decrease his diastolic so, wouldn't that actually make his heart be able to pump easier with a lesser resistance to over? Making up for what ever drop in systolic there is?



Yep. That's exactly what my point was to him.

The bike pump analogy I was talking about makes it a simple concept.

If you are pumping up a tire that is empty, you can effortlessly operate the pump. When the static pressure inside the tire is higher, it gets harder and harder to push down that plunger. 

The person/bike pump represents the heart.
The air represents blood.
The static pressure in the tire represents diastolic pressure.
Pushing down the plunger represents systolic.

The pressure the left ventricle actually works against or afterload is attained from a few factors but the actual concept is pretty simple.

If the pressure the heart has to work against is higher, the heart has to work that much harder. In a diseased heart, the heart may not be able to compensate sufficiently for that increase in effort resulting in symptoms such as chest pain.


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## systemet (Apr 25, 2012)

NYMedic828 said:


> I was always taught that we give nitro to reduce the workload of the heart and as a diagnostic tool to make a presumptive diagnosis of ACS.



A quick point to make here --- relief or reduction of pain with nitrate administration is not proof positive that the pain is of cardiac etiology.  Nitroglycerin will also remove pain of non cardiac origin, e.g. that associated with smooth muscle spasm.


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## EMSpursuit (May 2, 2012)

I agree, dependent on BP.  If boarder line I would want an IV.... especially if the patient is a hard stick.... if great veins than probably different.


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## TheLocalMedic (May 3, 2012)

So you don't have a line, you give nitro, and their pressure plunges.  OMG!  BELLS AND WHISTLES!!!  WHAT THE F*** DO WE DO NOW!!!  AAAHHH!!!  

Lay them back, kick their toes up, throw in a line (don't forget that a quick EJ is sometimes an easy mark) or if you can't nab one then go for the IO.  

HOWEVER>>>  99% of the time giving your first dose of nitro won't cause such a dramatic result.  Yeah, yeah...  I'm sure there's one or two of you out there that have "seen this happen" or heard about your cousin's friend's old classmate's medic buddy that had a patient "crash" on them from a single dose of nitro.  But it's really very uncommon.  Monitor their pressure, if there's a significant drop after the first dose then you should be a little cautious.  Generally speaking though, it's the second or third dose you have to watch out for in those right ventricular infarcts.  

Just observe and report, soldier.


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## TheLocalMedic (May 3, 2012)

And nitro doesn't last too long, either.


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## systemet (May 3, 2012)

TheLocalMedic said:


> So you don't have a line, you give nitro, and their pressure plunges.  OMG!  BELLS AND WHISTLES!!!  WHAT THE F*** DO WE DO NOW!!!  AAAHHH!!!



Hope they don't code.  Try and get the IV access that I should have had in the first place.  Wonder why I chose to give a medication that hasn't been demonstrated to improve long term outcomes but has been demonstrated to provoke rapid hypotension in some patients without getting IV access first?  Hope the medical director doesn't audit my PCR.  Wonder a little about what I'm going to eat for lunch.



> Lay them back, kick their toes up, throw in a line (don't forget that a quick EJ is sometimes an easy mark) or if you can't nab one then go for the IO.



With the caveat that the hospital will love you if you miss that EJ and fibrinolytics were an option.  Or that it might not be so great if you were planning to give them.



> HOWEVER>>>  99% of the time giving your first dose of nitro won't cause such a dramatic result.



So we're giving a medication that theoretically should reduce infarct extension by reducing preload and hence wall tension / oxygen demand; and may have some secondary effects like reducing pain / anxiety / sympathetic outflow, etc.  

But we can't wait the seconds or minute(s) to get an IV first, and we're willing to accept the definite risks of infarct extension if we bottom coronary oxygen delivery by sewering arterial pressure?  And the very real risk of a sudden arrhythmia and/or cardiac arrest?  Let alone the compensatory tachycardia we may see if we reduce the pressure too far, which is probably going to increase the oxygen demand we were seeking to reduce in the first place?  (Assuming they're physiologically capable of increasing their rate, in which case something worse is going to happen?)

Exactly what benefit is there to giving NTG a minute earlier?  Or five minutes earlier?  Especially if the patient has been having chest pain for an hour and a half before calling 911?



> Yeah, yeah...  I'm sure there's one or two of you out there that have "seen this happen" or heard about your cousin's friend's old classmate's medic buddy that had a patient "crash" on them from a single dose of nitro.  But it's really very uncommon.



It is, absolutely.  Because most of the patients we give nitroglycerin to aren't having an MI.  Most, at best, are having some milder form of ACS, a fair majority have a noncardiac etiology.  Only a very small percentage of our patients are (i) infarcting, (ii) infarcting their right ventricle, (iii) having an RVI that's preload-sensitive.

I'm just not sure how this justifies rushing to give the NTG?  Why not take a few seconds, breath, get a 12-lead, give some ASA, take a look for changes suspicious for RVI, put an IV in, and not fall all over ourselves to give a potentially lethal drug without some thought of doing it safely?

If they've got a non-cardiac etiology, then the NTG will either relieve the pain or it won't.  If they're not having an MI, then we're probably not going to provoke one by waiting a minute or two to give NTG.  If they're having an MI, it's not like there's a truckload of evidence that NTG has a huge effect, compared to, say, ASA.  The delay associated with obtaining IV access is likely to be negligible, and now when you give the NTG, if they do sewer, you can actually do something about it in a timely manner.  

It seems like working a code where you've already got an IV in place, and can add some preload, or even bolus epinephrine, might be preferable to working a code where you have no immediate access for fluids, no immediate access for medication administration, and you're crossing your fingers that either you get access quick enough to do something about the preload, or that the t1/2 of the NTG is short enough, and their infarcting heart healthy enough that you get ROSC?




> Monitor their pressure, if there's a significant drop after the first dose then you should be a little cautious.



Providing that the first sign of your precipitous hypotension isn't the patient R on T'ing, and going into VF/VT.  



> Generally speaking though, it's the second or third dose you have to watch out for in those right ventricular infarcts.



Disagree strongly.  While you're ultimately constrained by the medical advisory committee of whatever organisation you work for, there's an increasing number of services that defer NTG until you have a 12-lead and IV access.  There's also an increasing number that have an absolute, "no NTG in RVI" standard of practice, and a fair number that will require IV access for any SL NTG.


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## KellyBracket (May 3, 2012)

TheLocalMedic said:


> Our protocols give precedence to NTG over an IV for treating ACS.  Granted, you want to get that IV in case they crump on you, but with a strong pressure, I wouldn't worry too much about it, even if they were having an inferior wall or right ventricular infarct.
> 
> In fact, our protocols state to start with a double dose of 0.8 mg if the pressure is over 150 systolic.



Is the "double dose" being given to treat the blood pressure alone, or in the context of acute CHF?


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## ZootownMedic (May 13, 2012)

I'm just getting my feet wet in the ALS game but I prefer to have the line. As others have said there is no reason the nitro has to go in that fast that I can't get access first. Obviously if the 12-lead is showing a inferior wall MI I am going to be VERY cautious about giving it AT ALL. Just out of curiosity how often do you experienced guys do right-sided EKG's to get the full skinny on inferior wall MI's? In class we were taught to get a right-sided EKG to check for right sided involvement and if no then NTG could still be a good option. Just wondering how it works in practice vs a scenario.


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## epipusher (May 14, 2012)

As stated earlier, patients self administer their own ntg all the time without first checking a set of vitals, performing an initial 12 lead, or placing an i.v.


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## the_negro_puppy (May 14, 2012)

epipusher said:


> As stated earlier, patients self administer their own ntg all the time without first checking a set of vitals, performing an initial 12 lead, or placing an i.v.



Yep they certainly do.

We almost always give nitro here before IV access. In this order-

HX / Vitals (including 6 lead ECG...1-3+augmented)
Nitro x 1 (if pain symptoms present, HR > 50 < 150 , BP above 100 systolic
Aspirin
IV + lead usually done at the same time
then nitro after 5 minutes from last dose whilst still indicated.

I have never had a pt crash after nitro/GTN however- If the 6 lead ECG revealed changes pointing to an inferior infarct and their heart rate/ BP was on the lower end of normally I would get 12 lead + V4R and IV access first before giving nitro.


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## systemet (May 14, 2012)

epipusher said:


> As stated earlier, patients self administer their own ntg all the time without first checking a set of vitals, performing an initial 12 lead, or placing an i.v.



Yes.  But why is your patient taking NTG?  Probably because a physician has diagnosed them with exertional angina.  A chronic problem, due to coronary insufficiency that prevents oxygen delivery from meeting oxygen demand when the demand increases.

Now you're evaluating a patient you suspect may be have an acute STEMI.  They may now have had an acute blockade of one of the vessels supplying their myocardium.  They may have acute ventricular dysfunction.  Their entire physiology has changed from the time their physician saw them, and evaluated them for their *angina*!

What may once have been a benign intervention may now have become very dangerous, depending on which regions of the heart are infarcting, their current cardiac reserve, and how preload dependent they currently are.

Besides which, the argument that we should do something because a lay person does it all the time is hardly logically sound in of itself.


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## systemet (May 14, 2012)

the_negro_puppy said:


> Yep they certainly do.
> I have never had a pt crash after nitro/GTN



Just bear in mind that just because it hasn't happened to you personally, yet, doesn't mean it might not happen in the future.  Or that it hasn't happened to someone else.  

I've had a fair number of STEMIs just up and code on me.  Sudden arrhythmic death is a major killer in the first 24 hours.  

Some of those patients have coded a couple of minutes after NTG administration, in several cases after someone else has given NTG without bothering to evaluate for a RVMI.  Causality or correlation?  Not sure, but I don't see the rush to get NTG in as soon as possible.  Often these patients have waited a couple of hours to access the medical system after the onset of pain.  Yet there's no real evidence to suggest that NTG improves long term outcome, so how time-dependent is an event that we can't measure?



> however- If the 6 lead ECG revealed changes pointing to an inferior infarct and their heart rate/ BP was on the lower end of normally I would get 12 lead + V4R and IV access first before giving nitro.



This isn't what I do, or would recommend, but it seems like you're making a decision on a balance of risks.  Most of your inferior / RVIs are going to be bradycardic and hypotensive or borderline hypotensive.  Deciding that these patients are a high-risk group, and choosing to evaluate them further before NTG would seem prudent and reasonable.

But you're relying on a 6-lead, presumably in monitoring frequency to resolve ST changes, which isn't that reliable.

There's also an argument to be made that there's a number of case reports whereby ST elevation was seen in an initial ECG and then resolved in a subsequent ECG following O2 and nitrates.  While this is obviously a good thing, these patients should probably be followed up much more aggressively than someone with simple angina.  Capturing the ECG first makes sure we don't miss these patients.


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## mycrofft (May 14, 2012)

I admit I'm not reading the forest of comments before posting this:
1. Was the EKG specifically indicative of a condition nitro was called for under your protocols or common teaching? (not "rule of thumb", but classroom teaching).
2. Was musculoskeletal pain assessed for? Intermittent chest pain without other cardio-like signs and symptoms, especially in the elderly, by my experience, can be due to bad backs, consto-chondritis, or even referred pain.
3. Does your protocol call for emergent tx/Rx of BP's like hers? Was her BP usually like that (per vital signs from the facility)?
4. Second thing to assess elderly patients for, especially in a nursing facility, is *polypharmacy* or drug-food interactions (e.g., caffeine). Could this pt be experiencing a drug-drug interaction? This is also more likely in the elderly, not only because of being treated for so much, but also because they/we don't necessarily clear medications from the body as fast or the same as others expect; this goes double for meds that need a pass through the liver to produce active metabolites.

The usual and cautious admin of oral nitroglycerine is allowed to be "assisted" by Am Red Cross basic first-aid-ers, certainly without an IV lines. But it must be prudent, appropriate and cautious as with any drug; cowboy "rules of thumb" should never dictate medicating anyone, especially the fragile elderly.


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## epipusher (May 14, 2012)

that is very similar how it is done around here as well.


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## RocketMedic (May 14, 2012)

Plus there's always the question of "what's their normal pressure, and is this angina normal or ???"


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## systemet (May 15, 2012)

mycrofft said:


> 2. Was musculoskeletal pain assessed for? Intermittent chest pain without other cardio-like signs and symptoms, especially in the elderly, by my experience, can be due to bad backs, consto-chondritis, or even referred pain.



This is a valid point, but it's also worth remembering that somewhere around 5-10% of patients experiencing an acute MI may have point tenderness that's reproducible upon palpation.  So point tenderness on physical examination alone can't be considered a rule-out.

Swap CJ, Nagurney JT. Value and limitations of chest pain history
in the evaluation of patients with suspected acute coronary
syndromes. J Am Med Assoc 2005; 294:2623–9.



> The usual and cautious admin of oral nitroglycerine is allowed to be "assisted" by Am Red Cross basic first-aid-ers, certainly without an IV lines.
> But it must be prudent, appropriate and cautious as with any drug; cowboy "rules of thumb" should never dictate medicating anyone, especially the fragile elderly.



But of course, this is comparing apples and oranges.  A paramedic has a greater scope of practice, more diagnostic tools at their disposal, and a duty to act.  If the various first aid organisations advise NTG assist for a lay person acting as a Good Samaritan, that shouldn't be inferred to be the standard of practice for a "professional", such as a paramedic.

I agree with many people who've said that the risk of a particular patient being preload-sensitive is very low.  And that's correct.  But why expose the patient to this risk when there's a tool that will allow us to identify some high risk patients (12/15-lead ECG), and an intervention (IV therapy) that will allow us to rapidly treat potential complications of a medication (NTG) that is known to be dangerous to some patients?  

I just don't see a benefit that's outweighing that risk.  What are we hoping to achieve by giving NTG five minutes earlier?  Hey, maybe I'm a dangerous idiot, but it just seems wise to get that IV and 12-lead before giving the NTG.  These (along with ASA), are interventions that are far more important.  They cut down the time to reperfusion therapy, they allow us to identify patients that may benefit from thrombolytics, and enable us to administer them.  Why prioritise NTG over a 12-lead or IV, especially when having these is going to (1) allow us to avoid giving NTG to high-risk patients and (2) make giving NTG to the remaining population safer?


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## Hunter (May 15, 2012)

Wouldn't you also wanna consider other things than bp, such as allergic reaction, wether the patient is taking any medication that might doubler the effect of nitro. I'd really want a line befor giving ANY medication, in this case I would've at least attempted it first,  the patient doesn't understand the pain scale so there's no way to determine wether or not the nitro is helping anyways.


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## mycrofft (May 15, 2012)

Good points.
Chest wall/thoracic spine/referrred pain do not necessarily present as point tenderness unless it was from a hockey game or such.  However, nothing to say you can't have CWP AND coronary artery disease at the same time.

The phrase by the OP that bothers me is this:

"As soon as I get into the rig both of the other medics are racing for the nitro and shoving it down my pt's throat"

That led me to believe the med was given in an extreme and hasty dose with a paucity of evidence for its prudent use.

The ARC and AHA nitro deal for lay persons is a red herring anyway, there is no realistic situation where, unless the pt's hands are somehow impaired, a layperson would not be essentially giving the medicine at the pt's request alone...a "bozo no-no" for professionals as well.


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## ZootownMedic (May 15, 2012)

I still haven't heard too many people mention a inferior wall MI with right sided involvement. If I have a patient that is complaining of chest pain and presents as a MI I am darn sure gonna check a 12 lead before I go throwing the NTG at them. I HAVE seen NTG dump a persons pressure that was having an inferior wall MI with right sided involvement and I am not trying to be that guy that explains that one to my medical director. Just sayin........


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## epipusher (May 17, 2012)

Here we go with the whole "inferior/right side mi" argument. Again, pt's are administering their own ntg to themselves without an iv in place. Prescribed for angina or previous mi aside.


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## systemet (May 18, 2012)

epipusher said:


> Here we go with the whole "inferior/right side mi" argument. Again, pt's are administering their own ntg to themselves without an iv in place. Prescribed for angina or previous mi aside.



And, again, the fact that a physician is prescribing a patient NTG to relieve their angina is irrelevant to the question of whether it's a good idea for a paramedic to administer nitroglycerin to someone having a STEMI! 
_
"*Nitrates in all forms are contraindicated in patients with initial systoloic blood pressure <90 mm Hg or ≥30 mm Hg below baseline and in patients with right ventricular infarction*.40,–,42 Caution is advised in patients with known inferior wall STEMI, and a right-sided ECG should be performed to evaluate RV infarction. Administer nitrates with extreme caution, if at all, to patients with inferior STEMI and suspected right ventricular (RV) involvement because these patients require adequate RV preload."_ 

ACLS 2010.

_"The treatment benefits of nitroglycerin are limited, however, and* no conclusive evidence has been shown to support the routine use of IV, oral, or topical nitrate therapy in patients with AMI*.183 With this in mind, these agents should be carefully considered, especially in the patient with low blood pressure and when their use would preclude the use of other agents known to be beneficial, such as angiotensin-converting enzyme (ACE) inhibitors." _

ACLS 2010


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## epipusher (May 21, 2012)

Everyone is an outside the box medic on an ems forum.


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## Melclin (May 22, 2012)

systemet said:


> So we're giving a medication that theoretically should reduce infarct extension by reducing preload and hence wall tension / oxygen demand; and may have some secondary effects like reducing pain / anxiety / sympathetic outflow, etc.
> 
> But we can't wait the seconds or minute(s) to get an IV first, and we're willing to accept the definite risks of infarct extension if we bottom coronary oxygen delivery by sewering arterial pressure?  And the very real risk of a sudden arrhythmia and/or cardiac arrest?  Let alone the compensatory tachycardia we may see if we reduce the pressure too far, which is probably going to increase the oxygen demand we were seeking to reduce in the first place?  (Assuming they're physiologically capable of increasing their rate, in which case something worse is going to happen?)
> 
> Exactly what benefit is there to giving NTG a minute earlier?  Or five minutes earlier?  Especially if the patient has been having chest pain for an hour and a half before calling 911?



This is my theory and my practice. I don't see that this is outside the box. Thankfully we have discretion about things like the exact order of every single one of our actions 

1) GTN isn't proven to improve outcomes. 
2) You could significantly bugger up their outcome by giving it to the wrong person. I've seen a relative bucket of pt's go arse up directly after GTN administration (generally not pts who should have got GTN in the first place in my opinion, but thats another story).

As such, I don't have a problem waiting for a line or simply not giving it at all if I don't believe the pt is suffering from a problem with preload/afterload. Unless I think they're going to go arse up, I'll generally trial 300mcg, if there is not improvement, I generally won't go for another one. Other times, I’ll give it straight up if I think its safe and its something that will help. 

When I asked a very astute intensive care medic recently why he waited 15 mins, 10mgs of morphine and 2 x 12 leads before the first tentative (and only) 300mcg dose of GTN to a STEMI pt, he replied in his typically colourful manner, “Well you don’t f**k with perfusion. He seemed well perfused and I didn’t wanna f**king kill the c**t”.  

Also, I don't understand why people are so keen to give GTN to RVIs with an added, so give them fluid as well. Why take their preload away only to give it back, with perhaps a nasty dip in perfusion along the way? That’s not rhetoric, I’m actually interested in their rationale.


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