# Nitro or aspirin first......?



## Byekryam (Sep 12, 2014)

My question......potential MI, nitro or aspirin first?

Thought pattern.....give nitro first because can start working, then give pt aspirin to start chewing.  If you give aspirin first, you have to wait till they chew first till you can administer nitro (not really, but usually)

Other thought pattern....ASA gets absorbed slower then nitro through mucosal membranes, so get nitro on board so can open up vessels.

Other thought pattern.....give ASA to chew, then spray nitro on top of tongue (as per instructions on side of nitro box)

Other thought patterns..........?  (I'm open to thoughts)

I'm researching literature which suggests one is the proper route to administer these medications.  Does anyone know the proper sequence, and is there any documentation (literature) to back it up.

This may seem silly to argue over, but I would like to know.

Thanks


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## DesertMedic66 (Sep 12, 2014)

I've never seen it done one way over the other. In the time frame it takes for ASA to be chewed or NTG to dissolve I don't think it makes any difference.


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## teedubbyaw (Sep 12, 2014)

ASA has been shown to be one of the most important factors in treating ACS. Nitro, on the other hand, has mixed data on how beneficial it truly is.


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## STXmedic (Sep 12, 2014)

Who cares? Give both. 60 seconds isn't going to make a difference either way.


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## Byekryam (Sep 12, 2014)

I am a relatively new medic and have, in the past, been chastised for doing one over the other.  Trying to now help other "newer" medic students (and not chastising them), I am trying to guide them in the right ways to do things, but today was sternly disciplined for saying the wrong thing (the thing I was taught).  I just want to make sure I'm teaching the right procedure, that's all......


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## Akulahawk (Sep 12, 2014)

I usually give first whichever one is closest to grab. Usually it's NTG SL 0.4 mg (spray) and ASA 162-324 mg (per protocol) in that order. No real preference, just my bags were set up so the NTG was easiest to grab.


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## LACoGurneyjockey (Sep 12, 2014)

I'll do ASA first, get an IV and then give nitro, but my protocol requires access before nitro...


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## tpchristifulli (Sep 12, 2014)

I usually give the aspirin first and wait till after my 12 lead to give Nitro... Gotta watch for that hidden Right Sided involvement. Plus you should have a line before you give nitro. ASA first IMO.


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## azbrewcrew (Sep 12, 2014)

ASA first unless they are allergic of course. 12 lead before NTG


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## Byekryam (Sep 12, 2014)

Lots of great input, I appreciate it.  Yes, this is in light of the 12 lead, and is in the consideration of the pressure.  If someone was borderline, I would certainly go with the line first/nitro second mindset.  But this is in the pressence of an elevated BP where either the IV is already established or they are so hypertensive, that it's going to be rare that they are going to tank on one spray.


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## azbrewcrew (Sep 12, 2014)

Truthfully i dont think there's a right or wrong answer to your question. As long as you operate within your protocols and document your treatments you should be fine. Every medic has their own way of doing things. Some areas require iv access prior to admin nitro, some don't. If its a hypertensive crisis situation i dont see why giving nitro without an iv would be an issue


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## tpchristifulli (Sep 12, 2014)

Byekryam said:


> Lots of great input, I appreciate it.  Yes, this is in light of the 12 lead, and is in the consideration of the pressure.  If someone was borderline, I would certainly go with the line first/nitro second mindset.  But this is in the pressence of an elevated BP where either the IV is already established or they are so hypertensive, that it's going to be rare that they are going to tank on one spray.


What do you mean " In light of the 12 lead"?


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## avdrummerboy (Sep 12, 2014)

Realistically, it doesn't matter, you're going to give both pending any reason to withhold one or the other anyway, and you're going to administer both at the same time, what possible difference can it make, they will both be entering the body at the same time, sure PO can take a little longer to ingest, but you're not going to waste time waiting for it to take effect before admin of NTG. Unless there is a protocol explicitly stating to do it one way or the other, just give both in whatever order you please.


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## fma08 (Sep 12, 2014)

What was the reasoning of doing one over the other first? I'm calling bogus (without literature to back this up, don't judge). Two different drugs, two different MOAs acting on two different aspects of the disease process, there's no reason that one would need to be given first. If anything, give them aspirin to chew up so that they can work on that while you're getting your IV, and 12 lead, and BP, etc.


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## Burritomedic1127 (Sep 12, 2014)

ASA is the key. A great instructor told me a while back, ASA is like a bouncer its doesn't break up the party, it just stops more people from showing up


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## JPINFV (Sep 13, 2014)

People really care about which is given first? Where does oxygen play into this?


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## DesertMedic66 (Sep 13, 2014)

JPINFV said:


> People really care about which is given first? Where does oxygen play into this?


Clearly you put the pt on a NRB while they are chewing the ASA so the O2 pushes the powder into their lungs for a much faster response #don'tjudgeme


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## Akulahawk (Sep 13, 2014)

JPINFV said:


> People really care about which is given first? *Where does oxygen play into this?*


Hopefully the patient is still breathing?


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## Carlos Danger (Sep 13, 2014)

tpchristifulli said:


> I usually give the aspirin first and wait till after my 12 lead to give Nitro... Gotta watch for that hidden Right Sided involvement. Plus you should have a line before you give nitro. ASA first IMO.



People take NTG all the time without taking their VS first and when no one is around to start an IV. BLS also administers it in some places, without getting an EKG first.

Also, the evidence does not appear supportive of the idea that right-sided involvement tends to result in significantly greater rates of hypotension.


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## Byekryam (Sep 13, 2014)

"In light of the 12 lead" meaning being aware of a pre-load issue where it would be contra indicated.  

I did actually read one article from a cardiac institute which was written recently which did state that there is clear evidence that the ASA makes a difinitive difference, while it's only speculative on the actual benefits of the nitro.


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## Ewok Jerky (Sep 13, 2014)

In reality I don't think it matters which you do first because you will be administering both virtually "at the same time" so to speak...or at least <120 seconds.

In a theory though, I would say ASA first for a few reasons.  #1 because it is the only 100% to be effective prehospital intervention for ACS/MI.  #2 it has an onset of 30 minutes. #3 if you combine reasons 1 and 2 then logically ASA should be on board as soon as possible. #4 in general I think having a line before nitro is a good idea so why not get your ASA cranking while you start that line.  #5 unless allergic, isn't almost any chest pain of cardiac origin getting ASA in the field? Based on a good HPI you can admin ASA before/while hooking up your 12 lead.  Even with a clean 12 lead they are getting ASA anyways.


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## tpchristifulli (Sep 13, 2014)

JPINFV said:


> People really care about which is given first? Where does oxygen play into this?


Might not play into it at all if pulse ox is over 94%.


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## Handsome Robb (Sep 14, 2014)

Ummm...NTG has been studied and shown no positive effect other than patient comfort.

Aspirin. Especially since it has a long onset, get it onboard.

At the end of the day it really doesn't matter.


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## Handsome Robb (Sep 14, 2014)

+1 @beano.

On my phone so I can't "like" it.


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## Byekryam (Sep 14, 2014)

Thanks everyone for the input, I appreciate it!


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## ViolynEMT (Sep 14, 2014)

If you go by the registry exam, aspirin first because it works faster and is more reliable.  Immediately keeps the platelets from aggregating further.


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## teedubbyaw (Sep 14, 2014)

ViolynEMT said:


> aspirin first because it works faster



No it doesn't.


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## ViolynEMT (Sep 14, 2014)

teedubbyaw said:


> No it doesn't.


I was quoting the registry explanation.


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## teedubbyaw (Sep 14, 2014)

ViolynEMT said:


> I was quoting the registry explanation.



Where?


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## ViolynEMT (Sep 14, 2014)

teedubbyaw said:


> Where?


Ugh. Aspirin or nitro first is one of the test prep questions on J and B. In the explanation for the answer is where it says that.


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## DesertMedic66 (Sep 14, 2014)

ViolynEMT said:


> Ugh. Aspirin or nitro first is one of the test prep questions on J and B. In the explanation for the answer is where it says that.


Nitro has a very quick effect while aspirin can take ~30 minutes before it kicks in


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## ViolynEMT (Sep 14, 2014)

DesertEMT66 said:


> Nitro has a very quick effect while aspirin can take ~30 minutes before it kicks in


My bad. Trying to delete my post but don't know how. Bad first day on the site for me.


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## chaz90 (Sep 14, 2014)

ViolynEMT said:


> Ugh. Aspirin or nitro first is one of the test prep questions on J and B. In the explanation for the answer is where it says that.


Yeah, that's not correct.


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## chaz90 (Sep 14, 2014)

ViolynEMT said:


> My bad. Trying to delete my post but don't know how. Bad first day on the site for me.


Didn't mean to pile on. No worries! The purpose of the site is to help people learn.


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## teedubbyaw (Sep 14, 2014)

ViolynEMT said:


> My bad. Trying to delete my post but don't know how. Bad first day on the site for me.



Don't worry about it. Should have seen me the other night on here.


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## DesertMedic66 (Sep 14, 2014)

teedubbyaw said:


> Don't worry about it. Should have seen me the other night on here.


I have no clue what you're talking about...


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## BFDM2 (Oct 6, 2014)

Well me personally when faced with a patient that is complain of chest pain I go with asprin first. I would withhold nitro until I have ran a 12 lead. This being for a couple of reasons. One to see if there is any kind of elevation in any of the leads and to rule out any right sided MI. While the leads are being placed on the pt they can be chewing the aspirin. Once 12 lead is done I would check for elevation and give nitro. So if there was elevation prior to nitro I can see if it has gone back down to base line after the administration of nitro. If it has not gone down I know to watch a little more closer and possibly choose a little morphine to help with pain and some dilation as well.

I would hate to give nitro prior to any 12 lead and there be elevation and it goes unseen. This would not help the pt in any way. 

As far as oxygen I would with hold it if above 95%.I would choose a NC and tritrate it and keep it below 98-99%. It's hard to tell how much oxygen is actually in the blood once they reach the 100% mark. To much oxygen can cause vasocontriction of the blood vessels and cause more harm than good in the STEMI pt.


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## gronch (Oct 7, 2014)

BFDM2 said:


> Well me personally when faced with a patient that is complain of chest pain I go with asprin first. I would withhold nitro until I have ran a 12 lead. This being for a couple of reasons. One to see if there is any kind of elevation in any of the leads and to rule out any right sided MI. While the leads are being placed on the pt they can be chewing the aspirin. Once 12 lead is done I would check for elevation and give nitro. So if there was elevation prior to nitro I can see if it has gone back down to base line after the administration of nitro. If it has not gone down I know to watch a little more closer and possibly choose a little morphine to help with pain and some dilation as well.
> 
> I would hate to give nitro prior to any 12 lead and there be elevation and it goes unseen. This would not help the pt in any way.
> 
> As far as oxygen I would with hold it if above 95%.I would choose a NC and tritrate it and keep it below 98-99%. It's hard to tell how much oxygen is actually in the blood once they reach the 100% mark. To much oxygen can cause vasocontriction of the blood vessels and cause more harm than good in the STEMI pt.




I think this is the right answer for all levels of care.  For BLS, aspirin won't make your PT pass out, so put it first.


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## JPINFV (Oct 7, 2014)

BFDM2 said:


> As far as oxygen I would with hold it if above 95%.I would choose a NC and tritrate it and keep it below 98-99%. It's hard to tell how much oxygen is actually in the blood once they reach the 100% mark. To much oxygen can cause vasocontriction of the blood vessels and cause more harm than good in the STEMI pt.



Philosoraptor asks, "Is it possible to withhold something that isn't indicated?"


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## DesertMedic66 (Oct 7, 2014)

JPINFV said:


> Philosoraptor asks, "Is it possible to withhold something that isn't indicated?"


Didn't take the time to make the meme this time?


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## Shishkabob (Oct 7, 2014)

Remi said:


> People take NTG all the time without taking their VS first and when no one is around to start an IV. BLS also administers it in some places, without getting an EKG first.
> 
> Also, the evidence does not appear supportive of the idea that right-sided involvement tends to result in significantly greater rates of hypotension.



Although I do a 12lead before NTG, it's not for fear of an RVMI, it's due to the things that may disappear post-nitro, such as Prinzmetal's angina, that you really want proof of.


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## STXmedic (Oct 7, 2014)

Linuss said:


> Although I do a 12lead before NTG, it's not for fear of an RVMI, it's due to the things that may disappear post-nitro, such as Prinzmetal's angina, that you really want proof of.


Holy crap, Linuss is alive!


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## Carlos Danger (Oct 7, 2014)

Linuss said:


> Although I do a 12lead before NTG, it's not for fear of an RVMI, it's due to the things that may disappear post-nitro, such as Prinzmetal's angina, that you really want proof of.



My comments were more aimed at the statement "you really should have an IV before you give nitro".


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## JPINFV (Oct 8, 2014)

DesertEMT66 said:


> Didn't take the time to make the meme this time?



Nope... I'm too busy responding to BS rapid response calls (no... I'm not going to update a family on a patient I've never treated at 9:30 pm because... I know nothing about this patient) or BS calls (The patient admitted for sepsis today and on antibiotics had a fever when he came in... you don't say...") to make memes.


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## Nova1300 (Oct 8, 2014)

JPINFV said:


> Nope... I'm too busy responding to BS rapid response calls (no... I'm not going to update a family on a patient I've never treated at 9:30 pm because... I know nothing about this patient) or BS calls (The patient admitted for sepsis today and on antibiotics had a fever when he came in... you don't say...") to make memes.




Ahhhhh nightfloat.  Where you can be harassed all night and try to make the right decisions on patients you don't know, only to be scolded by the primary-team attending the next day for making the right decisions on patients you don't know.


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## Angel (Oct 9, 2014)

per protocol were supposed to get the 12 lead first BUT ive given nitro to a pt with a R sided MI and the decrease in BP was negligable. not saying thats always the case but we have the tools to treat it in case that happens. anyway, since we have nitro spray here, its a lot easier to spray then waiting for them to chew or dissolve the nitro/asa
if it was both tabs then ASA first for the same reason. IMO asa is a bit more important at first than nitro


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## JPINFV (Oct 9, 2014)

Nova1300 said:


> Ahhhhh nightfloat.  Where you can be harassed all night and try to make the right decisions on patients you don't know, only to be scolded by the primary-team attending the next day for making the right decisions on patients you don't know.



Technically call team. Interns on IM call go until 10 with night float going from 10pm-7am (and then doing floor work until 11am for their patients).


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## Ewok Jerky (Oct 9, 2014)

Angel said:


> per protocol were supposed to get the 12 lead first BUT ive given nitro to a pt with a R sided MI and the decrease in BP was negligable. not saying thats always the case but we have the tools to treat it in case that happens. anyway, since we have nitro spray here, its a lot easier to spray then waiting for them to chew or dissolve the nitro/asa
> if it was both tabs then ASA first for the same reason. IMO asa is a bit more important at first than nitro



I know you know this Angel, but just to clarify for those who might not:

Nitro can be a bad idea for RMI because of a drop in pre-load, not so  much BP (although they are related).  When nitro vasodilates, it not only drops after-load to give the L ventricle a break, but it also drops preload, giving the R ventricle less to work with leading the L ventricle to be less competent at perusing coronary arteries.


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