# Nitro before IV



## FFMedic1911

Whats everyone's take on the question.When dealing with chest pain,Do you always start a line before giving nitro SL.I've seen it both ways.I prefer to start one but would like to hear some other schools of thought.


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## KEVD18

line and ekg prior to ntg.


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## Sasha

I check the bp, give ntg if its high enough. If its skirting the line, Id start a line first


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## BossyCow

You do run the risk of losing the juicy veins with the decrease in BP. Not impossible to get but definitely can be more difficult.


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## Ridryder911

Nothing like bottoming out the patient and increasing the infarct size because of a zealous provider. 

A twelve lead and IV should be performed *before* any NTG is administered. Administering NTG before knowing it is not a right sided AMI is only asking for troubles the same as if administering NTG without a line. 

R/r 911


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## KEVD18

Ridryder911 said:


> Nothing like bottoming out the patient and increasing the infarct size because of a zealous provider.
> 
> A twelve lead and IV should be performed *before* any NTG is administered. Administering NTG before knowing it is not a right sided AMI is only asking for troubles the same as if administering NTG without a line.
> 
> R/r 911



as usual, you're more eloquent in your response.....


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## NESDMEDIC

12 lead ekg and line before nitro, the cath lab in my area also likes a second line prior to arrival and the lines to be with an 18 gauge.


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## FF-EMT Diver

Definitley a line first,


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## Hastings

The ABSOLUTE ONLY situation in which I would consider Nitro before an IV is if the patient is prescribed and/or regularly takes Nitro already. But even in that case, it takes what - 45 seconds? - to start an IV. 

Just start the IV first. Lose the pressure without a lifeline and you just made an emergency a...well...bigger emergency.


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## reaper

I love seeing the ones that say "their BP was high enough". These are the ones that have never seen a pt with a bp of 170/100 drop to 70/40, after one NTG dose. You have now made the heart work twice as hard, while it is infarcting.

There is a reason why they teach IV first. As Rid stated, you also want a 12 lead before any meds. That way, if the NTG resolved the problem the Dr. can see what was going 
on.

If a pt takes their own NTG, they know the risks. We are there to help,not harm.


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## Hastings

reaper said:


> I love seeing the ones that say "their BP was high enough". These are the ones that have never seen a pt with a bp of 170/100 drop to 70/40, after one NTG dose. You have now made the heart work twice as hard, while it is infarcting.
> 
> There is a reason why they teach IV first. As Rid stated, you also want a 12 lead before any meds. That way, if the NTG resolved the problem the Dr. can see what was going
> on.
> 
> If a pt takes their own NTG, they know the risks. We are there to help,not harm.



220/90 -> 80/? with dizziness and temporary loss of consciousness after one Nitro.

Learned the hard way. Thankfully, had a large IV ready. It's really vital.


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## rjz

*get the nitro on board*

Gotta say that I give nitro before the IV on an very regular basis (read almost always). If someone has chest pain I ask the basic PQRST questions, ask about allergies and sexual enhancing drugs, grab a BP and then the ASA and nitro is started. In the system I work in we strive to have nitro on board within 3 minutes of pt. contact and a 12 lead done within 5 mintues. The basis of everything that we do is to relieve pain and reduce the size of the infarct so get the nitro going, and don't wait around for the IV.


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## KEVD18

rjz said:


> Gotta say that I give nitro before the IV on an very regular basis (read almost always). If someone has chest pain I ask the basic PQRST questions, ask about allergies and sexual enhancing drugs, grab a BP and then the ASA and nitro is started. In the system I work in we strive to have nitro on board within 3 minutes of pt. contact and a 12 lead done within 5 mintues. The basis of everything that we do is to relieve pain and reduce the size of the infarct so get the nitro going, and don't wait around for the IV.



i seriously hope your service reconsiders this policy after one of your medics kills a pt with a right sided mi.


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## Hastings

rjz said:


> Gotta say that I give nitro before the IV on an very regular basis (read almost always). If someone has chest pain I ask the basic PQRST questions, ask about allergies and sexual enhancing drugs, grab a BP and then the ASA and nitro is started. In the system I work in we strive to have nitro on board within 3 minutes of pt. contact and a 12 lead done within 5 mintues. The basis of everything that we do is to relieve pain and reduce the size of the infarct so get the nitro going, and don't wait around for the IV.



You can start the IV first and still be well within the 3 minutes.

Should take no more than 45 seconds. You can give the Nitro as soon as IV placement is confirmed. Have someone pop the Nitro in, secure the IV. Together, should be no more than 2 minutes.


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## marineman

Odd question to me, our local protocols say 12 lead and an IV must be in place prior to administering any nitro. So that will be the answer I go with but what's everyone's take on the basics that have nitro and can't do a line?

I know locally the pt must either be prescribed nitro or have an order from med. direction stating to give it (have to check with them even if it's prescribed) for basics so they're not out there just spraying people on a whim but it still seems like a potentially dangerous practice. Especially dangerous considering the systolic pressure only needs to be above 100 mm Hg it wouldn't take much of a drop to really create a Charlie Foxtrot (military people know)


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## KEVD18

people with their own nitro usually have it for a chronic condition(angina pectoris etc).

bls carrying our own nitro and administering it without iv and ekg findings is reckless and i dont agree with it.


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## Hastings

marineman said:


> Odd question to me, our local protocols say 12 lead and an IV must be in place prior to administering any nitro. So that will be the answer I go with but what's everyone's take on the basics that have nitro and can't do a line?
> 
> I know locally the pt must either be prescribed nitro or have an order from med. direction stating to give it (have to check with them even if it's prescribed) for basics so they're not out there just spraying people on a whim but it still seems like a potentially dangerous practice. Especially dangerous considering the systolic pressure only needs to be above 100 mm Hg it wouldn't take much of a drop to really create a Charlie Foxtrot (military people know)



It has the same dangers as usual, and it makes me uneasy. It is well controlled though. As you stated, BLS usually needs an order from Med Control (which will rarely come). And again, if someone is prescribed Nitro, the patient is usually able to tolerate it well. Can't rely on that though. Should always have a lifeline.


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## volparamedic

It's not just the blood pressure its self but how much of a change happens. A blood pressure drop of 30mmHg can make anyone dizzy/near syncope when getting up from laying.  I promise you will have a difficult time establishing an IV then. Other times it's not a problem but you can never really tell unless you see right side involvement. Then you can guarentee a drop.  Otherwise, use trendelenburg and fluid bolus to get to a safe level to be able to give the nitro.

When you look at leads 2 and 3 and see Inferior MI you should always suspect right side involvement. To check for this, place the red lead at right V4 and other leads as normal then check in lead 3 for ST changes. If you see changes then you have right side involvement. That is when you have the highest probability of a big drop in blood pressure with a nitro. I usually have them chew baby asa while I start the IV (at least an 18GA).  It is not uncommon to give 500cc fluid bolus prior to administration of nitro with right side involvement. Check breath sounds if clear give 250cc, recheck breath sounds...if clear give the other 250cc. When you do give the nitro you will then be ahead of the game.

Hope this helps ya!


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## Ridryder911

Again many do not understand that NTG itself is not primarily used for AMI's, rather for Angina (the old ruling out Angina vs. AMI technique). Patients are prescribed NTG for angina, NOT an AMI. 

Thus the reason so many are against Basic level administering NTG is the potential problems. 

R/r911


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## KEVD18

volparamedic said:


> , use trendelenburg



here we go again.......................


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## JPINFV

Trendelenburg? I guess we could try some magic beads as well.


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## FFMedic1911

Thanks for the replys.In medic school I was taught to always start a line.I would like to add this for discusion.When you have a pt. with right sided Mi do you give nitro or hold off.Once again this seems to be a debate among medics I have talked too.I give it but am ready if there is problems.


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## MSDeltaFlt

Here's the deal with NTG admin on CP: It's not a ''see this, do that'' type of scenario.  It depends on the clinical condition of your pt.  ''Clinical condition'', people requires ''thorough assessment''.  You need to know what's going on, where it is, how bad it is, where you are in reference to the hospital, what you have to do until you get to the hospital, where you are in your protocols, where and if your pt falls outside of your protocols, and knowing the difference in order to better care for your pt.  

That's how your treat your pt.  That's what's got to go through your mind when you do this.  That's why I said all of that in order to say this: When it comes to NTG admin and sarting a line or not or whatever, either for Angina, AMI (Rt or Lt), it depends on the situation.


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## volparamedic

Ridryder911 said:


> Again many do not understand that NTG itself is not primarily used for AMI's, rather for Angina (the old ruling out Angina vs. AMI technique). Patients are prescribed NTG for angina, NOT an AMI.
> 
> R/r911



Good point Nitro is used for angina and CHF but also an adjunct treatment in AMI. Nitro increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas. Thus, reduces myocardical oxygen consumption and reduction of damage to the heart. Then again, there is also stable angina and unstable angina...leading to AMI.


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## Ridryder911

You will never see a well documented article of saying_.."withold NTG on ride sided  or inferior wall AMI's"...._ Why? Because, it can be given... with extreme caution. 

I have given it and seen the patient get better and I have seen it and the patient get extremely worse. 

Alike what was said, it depends upon your patient. Evaluate their baseline, look at the MAP as well if they are as well hemodynamic compromised with such as bradycardia also. Personally, I like Fentanyl for pain for such AMI's and do not even like Morphine (especially if they have a Hemiblock). Again treat accordingly and cautiously, as well as be prepared for the feces to strike the oscillating rotary device... 

R/r 911


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## rhan101277

As far as basics go we can help pts. with their nitro, as long as no contraindications exist.  Systolic BP has to bee above 100mmHg.  When dialating someone's arteries it causes lower BP which is supposed to take the workload off the heart.  But how come the heart doesn't just think you are bleeding out and try to re-constrict to bring BP back up.  Is it because the nitro stops that effect?


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## daedalus

volparamedic said:


> Good point Nitro is used for angina and CHF but also an adjunct treatment in AMI. Nitro increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas. Thus, reduces myocardical oxygen consumption and reduction of damage to the heart. Then again, there is also stable angina and unstable angina...leading to AMI.



I think that is no longer the school of thought with nitrates. Rid or Vent might chime in here, but it is my understanding that the new line of thinking is that nitro reduces afterload, therefore reducing the work and oxygen demand of the myocardium.


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## newbie

OK my answer to the initial question is that I want a line first but I really really want a 12-lead.  If I have an inferior infarct then I need a right sided 12-lead and with RVI then I need to be really careful with that ntg.  I will almost certainly be preloading my pt. w/ fluids prior to ntg irrespective of my protocol.




Ridryder911 said:


> You will never see a well documented article of saying_.."withold NTG on ride sided  or inferior wall AMI's"...._ Why? Because, it can be given... with extreme caution.
> 
> 
> R/r 911



Now in response to this can anyone produce any literature that ntg reduces the m/m of MI pt's?  I have a friend who is a cardiology PA who swears, and I believe him, that ntg for MI is simply empirical medicine and no one can show that it is of clinical benefit.  Can anyone point to contrary literature?  Now I still give them ntg 
J


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## rjz

*try the AHA website*

Anytime that I have questions regarding cardiac care and why we do something I look in the AHA website. The entire 2005 guidlines are online and provide some great insight into why we do things the way we do.

http://circ.ahajournals.org/content/vol112/24_suppl/


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## Melbourne MICA

*Gtn s/l*

Treating angina is bread and butter ambo work for BLS or ALS. Take a thorough history, do a thorough exam, exclude allergies and contra-indications, do your ECG, check their meds then treat with aspirin, GTN +- Nitro patch. Inform patient of likely side effects - if they get a headache or feel faint tell them to spit out the pill and lay down (they should be sitting in the first place). nset of GTN is fast so if its going to drop a BP to near fainting level it will ahppen quick. More often than not it will be the first time user who goes flat or the operator giving it with a marginal BP/fast HR  - signs that should make you suspicious to begin with

Do your IV, give some Morph down the track if 2 or 3 GTN's have no effect on pain. History is the key. Pts know their condition and have their own meds so they are more often than not reliable historians on their own angina.

9/10 AMI is a catastrophic event. If you note the pt looks very crook you can bet your tools will verify it. If this is the case you have a new ball game.

Otherwise if its angina, chill. Put the IV in along the way. It doesn't necessarily have to go in before, during or after. Whatever your preference. Just watch the patient, don't do silly things and understand the process. Besides what happens if you like to start with a line but don't get the line in? Have five goes whilst not treating the angina? Or not give the GTN at all because you fear you might trash the BP but have no line?

There *are * many papers on GTN in R sided infarcts by the way. Our guys here researched it and had our guideline changed as a result. Not a good idea unloading the right side when its not filling the left in the first place. Besides a pt with a good BP in infarct is a bonus - the idea is to hang on to it. The fastest way to kill an infarcting pt is to lose it.

Treat the sympathetics, fill the right side with fluid boluses and always have atropine and Adrenaline ready and drawn up. Brady and flat - thats typical for inferiors/R infarcts.  

Chest pain is about 40% of our routine work here. Similar over in US?

Melbourne MICA


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## Zippo1969

newbie said:


> ...I have a friend who is a cardiology PA who swears, and I believe him, that ntg for MI is simply empirical medicine and no one can show that it is of clinical benefit.  Can anyone point to contrary literature?  Now I still give them ntg
> J



MI = ischemic tissue
ischemic tissue = irritable tissue
irritable tissue = arhythmias

...and while ntg may only help perfuse an ischemic area of the heart 'temporarily' (in AMI), it is absolutely necessary to maintain function of the affected cells until they can be surgically corrected.  I don't see how one could reasonably make the claim that nitro is of no benefit to AMI (or angina, for that matter), as we've all seen it work...if it didn't then what have I been titrating ntg drips to?


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## Outbac1

Well here PCP's give nitro for cardiac c/p without a line. I agree that a line and 12 lead should be done first if possible. However while nitro can cause a catastrophic drop in b/p, how often does it actually happen? I think our medical director is looking at the benifits to the many vs the detriment of the few. 

  Does anyone know how often nitro causes a major drop to an unsafe b/p? Is it 1 in 5, 1 in 100 or 1 in 1000?


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## Hastings

Outbac1 said:


> Well here PCP's give nitro for cardiac c/p without a line. I agree that a line and 12 lead should be done first if possible. However while nitro can cause a catastrophic drop in b/p, how often does it actually happen? I think our medical director is looking at the benifits to the many vs the detriment of the few.
> 
> Does anyone know how often nitro causes a major drop to an unsafe b/p? Is it 1 in 5, 1 in 100 or 1 in 1000?



It's caused a significant drop in about 1 in 100 for me.

Not a lot. But when it has happened, it's been a dangerous drop.


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## newbie

Zippo1969 said:


> MI = ischemic tissue
> ischemic tissue = irritable tissue
> irritable tissue = arhythmias
> 
> ...and while ntg may only help perfuse an ischemic area of the heart 'temporarily' (in AMI), it is absolutely necessary to maintain function of the affected cells until they can be surgically corrected.  I don't see how one could reasonably make the claim that nitro is of no benefit to AMI (or angina, for that matter), as we've all seen it work...if it didn't then what have I been titrating ntg drips to?



I don't disagree that empirically we have all seen Pt's cp pain scale drop w/ Ntg.  The gauntlet thrown was a published peer reviewed study in a journal showing ntg decreasing m and m.  Anyone?
J


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## newbie

Zippo1969 said:


> I don't see how one could reasonably make the claim that nitro is of no benefit to AMI (or angina, for that matter), as we've all seen it work...if it didn't then what have I been titrating ntg drips to?



And the more I think about this quote the more I think it correlates well to fluids and PASGs in trauma.  Now there was great theory out there that "I don't see how one could reasonably make the claim" that fluids and PASGs is of no benefit to hypotensive Pt.'s with penetrating chest trauma as we've all seen BP's coming back up.  In the short term, in the back of the unit.  The problem is when the research was done, and I can't quote the paper but Dr. Paul Pepe published the results based on a study in Houston, the theory didn't play out to Pt.'s walking out of the hospital any better off.  Now I understand that there are very accomplished physicians that argue with some of the concussions drawn from that study but we have definitively trended away from there two ideas, PASGs and fluid boluses, in trauma based on research.  I don't think the research exists to show that Ntg. works, and when I say work I mean that more Pt.'s walk out of the hospital alive and w/ less cardiac deficit then Pt.'s that do not get Ntg.


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## Zippo1969

Well I definately agree with your point on PASGs.

And thanks for clarifying (long-term outcome vs. pain control).  

I think the difference here is with PASGs these patients almost always ended up in surgery, where research and studies have a lot more consistency and reliability; where a comprehensive study on nitro use would have to encompass so many different units, it would be very difficult to track.  

It is funny how some of the things we're taught to be life-savers one day turn out to be life-takers or time-wasters the next day... PASG, bicarb, LR, wide-open fluids, intracardiac drugs, lidocaine uses, all the changes in CPR...


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## Hastings

I second Lidocaine.

Was stressed heavily in Medic school as the drug of choice for PVCs, Cardiac Arrest, so on, so on.

Get out in the real world and find out no services in the area even carry it, and using Lidocaine for PVCs is unheard of.


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## Medexpresso

*nitro first...?*

what do your local or state protocols say? that's the safest way to go...


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## Melbourne MICA

*Nitro*

Nitro has been used for about a hundred years for "Angina". What the Cardio types have moved to now is to standardise approach across the board with two aims. To identify those developing an ominous coronary artery disease instability for early CAGS and to intercept the infarct before it either kills the pt or leaves them a cardiac cripple for life.

The methodology is of course aimed at one goal - prevention. This is why the pt is educated as well - take two or three GTN s and call for help when they don't work. It's also why we all have pretty much the same guidelines. Even the questions we ask our pts are probably the same. It's also why pts use pretty much the same types of meds all aimed at risk factor management - you know, anti - cholesterol, platelet antagonist, beta blocker, clopridogrel etc etc before and after infarct or CAGS.

This is of course because there are rarely singular events in the natural progression of IHD. The pt had an infarct twenty years ago and now has angina and will end up with CAGS - the whole thing never stops, we just intercept the nasty bits as best we can and give the pt a lifestyle and an ongoing life because of it.

The latest guidelines for our cardiologist community come from discussions and recommendations from the American and European HA. They have been adopted throughout the wetern medical world.

At least in cardiac medicine we EMS types do have a well quantified and important role even though I have found myself saying when the next call comes in ".......geeze - not another Nanna with Chest pain!!!!"


A last point on the IV before GTN debate - Pts use them all the time at home don't they? Without any IV being involved?

On the other point - Maddox and Pepe 1994 - fluid resuscitation in penetrating truncal trauma was the paper wasn't it?

Lot's of ifs if medicine - And schools of thought and practice. Evidenced based is the way to go now.

MMICA


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## chodyb

I think that there should be an IV and vitals before any NTG is given.  Especially if the pt isnt prescribed it and doen't know their reaction to it.  I would hate to give it to someone who is sensitive to it. Also,I've heard on rare occasions when someones having a Rt Sided MI NTG can bottom them out.


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## medic_chick87

reaper said:


> I love seeing the ones that say "their BP was high enough". These are the ones that have never seen a pt with a bp of 170/100 drop to 70/40, after one NTG dose. You have now made the heart work twice as hard, while it is infarcting.
> 
> There is a reason why they teach IV first. As Rid stated, you also want a 12 lead before any meds. That way, if the NTG resolved the problem the Dr. can see what was going
> on.
> 
> If a pt takes their own NTG, they know the risks. We are there to help,not harm.



Well Reaper, you wouldn’t like me too much I'm afraid 'cause I'm one of those who will give the nitro if there BP is high enough. Have yet to have one bottom out on me. But I'm still a newbie.^_^

This is how I usually run it. Thorough assessment (r/o anxiety cp'er). Check BP and other vitals including basic ekg, if high enough one spray nitro. Depending on how severe pt presenting start line on scene or on-route (if fire hasnt already done it for me). Again, depending on pt presentation 12-lead on scene or on route. Continuing care of nitro every 5 and possible morphine if no pain relief if I havnt arrived at the hospital yet.


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## Ridryder911

medic_chick87 said:


> Well Reaper, you wouldn’t like me too much I'm afraid 'cause I'm one of those who will give the nitro if there BP is high enough. Have yet to have one bottom out on me. But I'm still a newbie.^_^
> 
> This is how I usually run it. Thorough assessment (r/o anxiety cp'er). Check BP and other vitals including basic ekg, if high enough one spray nitro. Depending on how severe pt presenting start line on scene or on-route (if fire hasnt already done it for me). Again, depending on pt presentation 12-lead on scene or on route. Continuing care of nitro every 5 and possible morphine if no pain relief if I havnt arrived at the hospital yet.



Just because your a newbie is *NO* excuse. Go back and learn cardiology! Good grief NTG before a twelve lead and maybe an IV?  How good are the 12 leads, while enroute? Are you really serious? Like increasing your patients infarct size or just watching them die as they attempt to increase the preload? 

I bet you probably give NTG for those in BBB as well? Did you know that if the BBB is wider than 170ms, the patient probably has a poor left ventricular effectiveness? The ejection fraction is going to be reduced and administering NTG can be dangerous? 

A patient with a bifascicular block (LBB or RBB w/hemiblock) drugs such as Morphine, lidocaine, procainamide will slow conduction through the ventricles resulting in drug induced heart block, or possibly, ventricular asystole. 

Your new.. read more than the initial text. Yes, what and how we do it matters!


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## TNemt975

The protocols where I work say 1 NTG allowed prior to IV access, however most of the people here have IV access prior to NTG.  In 4 years of working on a truck I have had one pt code on me because no line was established.  Granted that was within the first six months of working on a truck and the pt is alive and doing well (4 MIs later), but that is a pretty crappy feeling that can easily be avoided.


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## ILemt

Protocol in my area:
BLS 
- Oral dose of Asprin (81mg tab)
- Oxygen (6lpm via n/c or 12lpm via NRB )
- If pt has nitro, may assist pt with administration 
 If pt does NOT have nitro:
 - EMT may contact ER to request 1 nitro tab via EMS supply 
 taking vitals before and after


I/ALS
- Asprin -as above
- Oxygen - as above
 -Start line 18/20 gauge to 500ml bag of NS
 - Hook up pt to EKG (also does o2 sat and B/P )
 - One nitro _tablet_
 - If no change @ 5 minutes administer 2nd nitro
 - Contact ER for further


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## Ridryder911

Personally, I prefer to treat my patients *not* my protocols or even the monitor. One of the reasons I will never will work for a "cook book" type of treatment service. Hence, a more detailed assessment and having the knowledge of what is good and bad for the patient. Discussing with the medical director the problems of the written protocols and how they should be changed if wrong. 


Just because they have M.D. after their name does not mean they know what is best. As in protocols some may not realize exactly what each step was or how it is performed. Many will review and with a little research will change them to current standards. 

R/r 911


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## EMT-P633

Ridryder911 said:


> Personally, I prefer to treat my patients *not* my protocols or even the monitor. One of the reasons I will never will work for a "cook book" type of treatment service. Hence, a more detailed assessment and having the knowledge of what is good and bad for the patient. Discussing with the medical director the problems of the written protocols and how they should be changed if wrong.
> 
> 
> Just because they have M.D. after their name does not mean they know what is best. As in protocols some may not realize exactly what each step was or how it is performed. Many will review and with a little research will change them to current standards.
> 
> R/r 911



Hey R/r, was wondering if you would be willing to come to my service and give us a REAL ACLS / cardiology inservice?  We seam to have just that problem. too many are treating protocols / monitors, and not the patients.


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## knxemt1983

FFMedic1911 said:


> Whats everyone's take on the question.When dealing with chest pain,Do you always start a line before giving nitro SL.I've seen it both ways.I prefer to start one but would like to hear some other schools of thought.



depends on teh situation, our protocols allow us to admin 1 NTG prior to an IV, but I do my best to have a line in place just in case it bottoms the B/P. Many times I will have my partner getting it ready while I start the line or vice versa. Of course 12 lead first, and the b/p must be of adequate level


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## EMT-P633

in all seriousness, I agree with R/r 12-lead, IV and complete assessment prior to nitro.  However in my neck of the woods. my particular service does not have 12-lead capabilities.  Our director feels that performing 12-leads in the field is a complete waiste of time.  Says that since the MD's wont even look at them so why have them on the monitors?  We have the E series Zoll monitors, fully capable of the 12-lead, but ours are set up for a 3 lead / defib pads only. (yes BP and SaO2 is there as well).


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## el Murpharino

By director do you mean your medical director doesn't want you performing 12-leads?  Are you still authorized to use them for your own benefit, even though, according to your director, the doctors won't look at the 12-leads and is a waste of time?   Your director is truly doing a disservice to the EMS providers and their patients by having this attitude.


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## Ridryder911

EMT-P633 said:


> in all seriousness, I agree with R/r 12-lead, IV and complete assessment prior to nitro.  However in my neck of the woods. my particular service does not have 12-lead capabilities.  Our director feels that performing 12-leads in the field is a complete waiste of time.  Says that since the MD's wont even look at them so why have them on the monitors?  We have the E series Zoll monitors, fully capable of the 12-lead, but ours are set up for a 3 lead / defib pads only. (yes BP and SaO2 is there as well).





Might want to suggest not performing them increases liability for litigation. It is the National Standard and has been for a while. It does not not matter if your M.D.'s look at them or not, yes it matters the treatment is NOT always the same! 

My EMS Director had the same opinion until we had a 25 year old with a STEMI that could not be seen in the three leads. I also added the final statement...:_ I would continue to argue that we need twelve leads, but it is obvious you know nothing about cardiology, or we would not be having this discussion"....._

You might go to Physio site, they have testimonies as well as references form AHA, etc.. 

Good luck, 

R/r911


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## Melbourne MICA

Ridryder911 said:


> Just because your a newbie is *NO* Good grief NTG before a twelve lead and maybe an IV?  How good are the 12 leads, while enroute? Are you really serious? Like increasing your patients infarct size or just watching them die as they attempt to increase the preload?



Are you advocating that nobody gets nitrates from EMS unless you have a 12lead at hand or if they present with a BBB even those already prescribed them by their cardiologist?

MM


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## Melbourne MICA

Ridryder911 said:


> My EMS Director had the same opinion until we had a 25 year old with a STEMI that could not be seen in the three leads. IR/r911




Are you saying that you cannot identify any ckincial ECG markers of STEMI in a 3lead? And what was the clinical presentation of the patient?

A 25yo infarct would have statistical odds of what? - about 1 in 250000?

MM


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## Melbourne MICA

In practical terms and used in accordance with protocols nitrates have proven efficacy. I haven't seen a guideline yet nor any drug manufacturers explanatory notes or PPGuide that lists BBB or 12lead analysis as either a precaution or contraindication for the admin of GTN to the angina?ACS/chest pain pt with ischaemic pain?

MM


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## Jon

Melbourne MICA said:


> Are you saying that you cannot identify any ckincial ECG markers of STEMI in a 3lead? And what was the clinical presentation of the patient?
> 
> A 25yo infarct would have statistical odds of what? - about 1 in 250000?
> 
> MM


Can you?

Sometimes you can see ST elevation in 3 leads... sometimes you can't, right? Remember how Dubin characterizes a 3 lead vs. a 12 lead? Like looking at 3 sides of a car, rather than walking all around it? Can you perhaps not see small amounts of damage with just 3 views?

12 lead has really become the accepted standard. And the cardiology folks WANT STEMI door-to-balloon time to drop. There are many factors that make that happen... but diagnosis of STEMI prior to ED arrival is a HUGE factor to decrease the time.

The only factor, nationally, that decreases average times more is to have a cardiac surgeon onsite 24x7 - which doesn't happen at anything other than huge teaching hospitals.


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## Melbourne MICA

*STEMI on 3 lead*



Jon said:


> Can you?
> 
> Sometimes you can see ST elevation in 3 leads... sometimes you can't, right? Remember how Dubin characterizes a 3 lead vs. a 12 lead? Like looking at 3 sides of a car, rather than walking all around it? Can you perhaps not see small amounts of damage with just 3 views?
> 
> 12 lead has really become the accepted standard. And the cardiology folks WANT STEMI door-to-balloon time to drop. There are many factors that make that happen... but diagnosis of STEMI prior to ED arrival is a HUGE factor to decrease the time.
> 
> The only factor, nationally, that decreases average times more is to have a cardiac surgeon onsite 24x7 - which doesn't happen at anything other than huge teaching hospitals.



Your'e right to a certain extent - 3lead gives us only partial view of the picture. Sometimes the changes are apparent straight up.

The most obvious example of suspected AMI on 3 lead analysis being ST elevation in leads two and three - the inferior. Most Paramedics would have come across this in at one time or another. Alternatively clinically significant ST depression (reciprocal ischaemia) in any of the limb leads should lead you to include an anterior infarct in your suspicions. Thus noting ST elevation is not the only way to to arrive at a differential diagnosis of infarct.

Lets not forget that "diagnosis" of infarct is made on the basis on three elements and requires at least two of those three to confirm diagnosis and invoke treatment protocols in the ED along those lines. (Though biomarkers now dominate diagnosis with Troponin rises being very sensitive and specific to demonstrating an acute event). 

They are: 1. clinical history/presentation i.e. the pts story with S&S attached
2. 12 lead ECG changes. 3. abnormal Bio-chemical markers eg Troponin rises.

Now you could argue technically that with clinical history plus a twelve lead in the filed you can "diagnose" AMI. Having a 12lead in the field is definately a plus - provided the following don't mitigate its effectiveness in the process.

1. The operator is skilled at interpretation. Training, experience etc come in here. It's a pretty good idea to know, for example, the effect a LBBB or anterior hemi block will have your interpretation of AMI.
2. There is the time and practical circumstances to do a thorough analysis -  try and do a good 12lead when the pt is throwing up big time as is common in the hypotensive inferior pt.
3. The patient isn't crashing in front of you necessitating a focus on treatment. Inferiors are classically unstable in the field with brady arrhythmia's, hypotension, severe pain etc. Anterior infarcts may cause PO as the LV fails requiring respiratory support. 

Typically our most effective tool is clinically suggestive S&S. AMI is more often than not a catastrphic event with profound symptomology. We've all seen them - diaphoretic+++, acute pain++, rhythm disturbance, perfusion changes, anxiety++, SOB etc. (Of course they can also be subtle).

(And lets not forget about non STEMI's - 12lead useful in that?)

In the end the trick is to join up all the dots and recognise that even a singular piece of the pts story may alert you to AMI. For the ALS operator experience is definately a plus. As we all know S&S can be tricky, subtle or confusing.

For example, only recently I had an elderly man with no prior cardiac HX, who presented with severe, sudden onset central chest pain at rest whilst showering. He stated he felt particularly unwell, was frightened by the event and now felt nauseated. The pain apparently changed with deep inspiration.

His 3lead showed a mild sinus tachy. BP was normal. He was pale and "sweaty".

The BLS crew didn't join the dots. They were misdirected because his pain changed with breathing. 15% of AMI pts present to the ED with pain variability on inspiration. But the crew didn't know this, saw a normal ECG and differentiated the wrong way. They also assumed he was "sweaty" because he had just come out of the shower! Oops!!

For me the clue was the sudden onset at rest, the pts sense of impending doom and his description of the pain.

We did just 2 MCL's using our 3lead - 1 and 2 (V1&V2) - tombstones.

The point is I guess that the clinical assessment was useful in and of itself. The ECG tool was another dot joined (a very necessary one no doubt).

I'm not advocating that 12lead is superfluous -indeed it is not. But like so many things we do in the field components of any event create an index of suspicion that we must act upon. Spinal is another example - you know mechanism of the accident etc.

We don't have the time, the tools or the luxury of ED level analysis. !2 lead is an effective tool absolutely. But its also being adopted in the field for very specific reasons. Not just to diagnose AMI but to alert the cathlab/cardiologist to the type. This enables services to be used efficiently and maximally. Throbolysis or plasty. This is also why telemetry is also being added in the truck. With confirmation from both ends we can then introduce treatment even faster - say like throbolysing the pt in the ambulance.

Monitorisis is the way one of my old lecturers called it. Getting transfixed by the screen. I personally think we need to be very careful about getting preoccupied with electronic tools to the detriment of our skills as clinicians.

3lead - works for most pts - MCL's a nice little extra. 12 lead - even better but needs great care. 

12lead will be the accepted standard I have no doubt -for equipment that is. But we operators need to be up to scratch to make it trully effective. 

Incidentally MICA in Melbourne started out in 1973 as in field cardiac care. We are only just getting 12 leads. (hey -  its aussie land - things go a bit slower here because of the gravity). Our time to balloon is worlds best practice.

(You have let us brag about something because we've only ever beaten you at the Americas cup and Michael Phelps didn't share very well with all those gold medals now did he?).

Cheers
MM


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## FFMedic1911

Thanks for all that replied.I would like to add one more question to the mix.I've noticed some have replied that sometimes they would and sometimes would not give nitro to a right side MI.So to those that have stated this if you have two pts. both with right sided MI what would be the deciding factor on who would get it and who would not.If you say clinical finding what are they.
PS sorry if this isnt typed properly am tired and goin to bed.Good night


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## JPINFV

Now I'll admit that I'm not a paramedic and that I don't have all that fancy applied education, but I have been trolling a few EMS forums for a few years and have picked up a few things. Wouldn't one of the problems with using a 3 lead to infer ECG abnormalities be that a 3-lead isn't as sensitive as a 12 lead and will show exagerated differences? (Can I get CMEs for reading EMTlife and EMTcity?)


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## Melbourne MICA

JPINFV said:


> Now I'll admit that I'm not a paramedic and that I don't have all that fancy applied education, but I have been trolling a few EMS forums for a few years and have picked up a few things. Wouldn't one of the problems with using a 3 lead to infer ECG abnormalities be that a 3-lead isn't as sensitive as a 12 lead and will show exagerated differences? (Can I get CMEs for reading EMTlife and EMTcity?)




It's a good point and it would depend on the monitor. Low voltage monitors are notorious for lack of senitivity. 2 or more squares of ST elevation is clinically significant and this may be misrepresented on some monitors whether with 3 lead capacity or twelve lead. 

Our old HP's, the Zoll's and even our newer Philips MRX's can give false displays of elevation. Readings may or may not also be affected by dot placment. All electronic tools have their idiosyncracies.

Its the *combination* of history, clinical findings, S&S and pattern recognition (of the segment rises and other ECG indicators) that matters. For example, if your pt is fit as a fiddle with no symptoms but has gross ST rises its likely to be either a relatively benign dysrhythmmia like anterior hemi block or a monitor testing you out.

In the way of treatment, planning and your sense of urgency not much will change (with the exception of giving GTN and fluids) whether you analyse inferior, anterior, antero-septal, antero- lateral MI or whatever.

You end up managing perfusion, rhythm disturbance and respiratory state like you would with any other patient.

Then you direct your aim at the appropriate receiving facility with a cathlab or good cardiac unit. And what's on the 12lead will matter to them more than us.

Now when we get pre-hospital thrombolysis this will be a different story!

MM


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## Melbourne MICA

FFMedic1911 said:


> Thanks for all that replied.I would like to add one more question to the mix.I've noticed some have replied that sometimes they would and sometimes would not give nitro to a right side MI.So to those that have stated this if you have two pts. both with right sided MI what would be the deciding factor on who would get it and who would not.If you say clinical finding what are they.
> PS sorry if this isnt typed properly am tired and goin to bed.Good night




Any pt with RV or RA wall MI (R coronary artery structures incl posterior) will likely lose preload and/ or have significant rhythm disturbance such as brady arrhythmias. If you're lucky enough to have a good BP protect it. Don't dump it with GTN. Filling the R side of the heart with fluids or using inotropes to bolster BP and improve CO (and hence coronary artery filling pressures) is now the standard thinking. 

GTN's benfits on collateral circulation and reducing injury spread are too marginal and limited and the side effects too potentially destructive to treat a R sided MI with it. Like trauma the *definitive* care for our infarct patients is in the hospital not the ambulance.  

Having said this some cardiologists will try to exploit any benefits from any drugs including giving GTN if available but typically they want a healthy BP before even they drop it. The difference for them is that the pt is just minutes away from the table and they have far more tools to manage cardiac problems than we do. 

MM


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## EMT-P633

Thanks R/r for the ammo and the advice, I will keep trying to do my best to get our service up to speed. it will be a long row to hoe so to speak........


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## medic_chick87

Melbourne MICA said:


> Are you advocating that nobody gets nitrates from EMS unless you have a 12lead at hand or if they present with a BBB even those already prescribed them by their cardiologist?
> 
> MM



^_^  Thanks Melbourne. That's my line of thinking. That and I wonder what medics did for how many years before 12-lead? Hmm... maybe some Nitro.  Didn’t really want to say anything though because I didn’t want to start anything. After all, I'm just a lowly medic, not a cardiologist.


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## Ridryder911

Melbourne MICA said:


> Are you advocating that nobody gets nitrates from EMS unless you have a 12lead at hand or if they present with a BBB even those already prescribed them by their cardiologist?
> 
> MM



YES! Again NTG is prescribed for angina *NOT* an AMI. Cardiologist will (or should be) the first to recognize that the NTG was NEVER prescribed for an AMI or potential AMI. Patients are placed upon NTG at home again for angina not an AMI hence the reason of teaching the patient if NTG does not work notify EMS.

We for some reason presume that NTG is always "good thing" for all chest pain. Why would one want to administer a medication that could produce severe effects and even potential death, when obtaining a 12 lead should take less than 45 seconds to one minute? 

As well one should NEVER blanket treatment any complaint solely based upon s/s alone, especially when one has diagnostic tools to aid to differentiate. Again, the old adage of if NTG works in a chest pain, it is probably not an AMI since most reperfussions are not corrected by NTG alone. Yes, it may allow or increase some blood flow but not enough alone to correct the problem. 



R/r911


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## Ridryder911

medic_chick87 said:


> ^_^  Thanks Melbourne. That's my line of thinking. That and I wonder what medics did for how many years before 12-lead? Hmm... maybe some Nitro.  Didn’t really want to say anything though because I didn’t want to start anything. After all, I'm just a lowly medic, not a cardiologist.



Unfortunately, many were ignorant of the problems as is it still prevalent. I used to perform multi-leads to rule out an inferior by moving my leads around. (Yes, it can be done on a three lead). Ignorance should *NOT * be tolerable. 

After you have seen a patient go into cardiac arrest because a "lowly medic" administered NTG; I would believe your opinion would change. It happened and unfortunately continues to do so as we still encourage EMT's to administer NTG before a detailed exam can be performed. 

R/r 911


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## Melbourne MICA

*12lead*

Absolutely we should always use our tools at hand. All meds have both effects and side effects - its a double edged sword. Monitoring is important, even vital, but its not 100% reliable. Sometimes it shows nothing when something exists. It's all up to the skill and "street smarts" of the user to join the dots.

GTN is no blanket therapy - never has been. Its reliable, proven and consistent. And its supposed to be used as part of a careful process of evaluation and Mx that now includes 12lead.

I would never give any type of medication without utilising all the assessment tools first.

Its all about "ACS" now, even for us, Whether you have angina or an acute MI the process is the same, lumen obstruction, its just a matter of degree and risk. We are now expected and trained (some might have a sly grin about that one), to make an attempt to subdivide our pts for direction to services.

Our role in EMS now is certainly more than just symptomatic management and I agree Rider, there is no "blanket" therapy approach that is appropriate. Its about directing the pt to the correct management services - basic pharmacological interventions and GP/cardiologist follow up, CAGS or infarct Mx. Some of our "angina" pts are even OK to stay at home. But their are limits, costs, bed availability, cath lab services availability, staffing issues etc tied into the process as well.

But in the end the EMS guy still has an obligation to treat (with care and prudence). Giving GTN is a standard adopted by all EMS services around the world and before services could afford EKG's or train grunts to work them it still had its place and a certain level of effectiveness without compromising too many pts. But we understand more now and the whole thing is coming together right from the pointy end of EMS to the cathlab table.

BLS types need to always be conservative and ready to bring in ALS types but one thing follows on from the other. They're not separate.

If you give GTN without having monitored the pt its just as bad as not having taken a BP, asked about contraindications/allergies or gotten a decent history. (or if you haven't bothered to look at your books for 3 years!)

Expect side effects to see you in the supervisors office fast if you adopt this approach!!!

MM


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## Ridryder911

Melbourne MICA said:


> Expect side effects to see you in the supervisors office fast if you adopt this approach!!!
> 
> MM



That's what I do.....

The point I am attempting to make is that patients are not nor should ever be blanketed treatment. Each case is as individual as the person. When we start educating (instead of training) medics, then and only then we will see a medical diagnosis should be made upon history, variable assessments and of course the tools that aid our assessments. 

Unfortunately, the EMT (in the U.S.) does not have the required education nor even the training to go into differential diagnosis as only based upon s/s and tx. In which the system has used the "best of the two evils" instead of correctly resolving the problem. Especially in areas where the nearest ED maybe 1-2 hours away per ground or nearest cath lab is 3 hours. Even in some of our larger suburbs 24 hour cath is only a dream, as it is a costly adventure and if "they can make through the night"; we will attempt to cath in the morning!. 

There is a far cry though of an AMI or even Prinz Metals Angina and the classic standard Angina caused by coronary occlusion, by which in all rights can and should be treated with standard NTG, even possibility of long lasting, high dose (aka: Nitrobid). 

I do believe we agree, possibly miscommunication though on the system we have here. Basics blindly administering NTG as long as the patient is not hypotensive and yes no ACLS follow up for who knows when? 

As a Acute Care Nurse Practitioner student, that makes rounds with Cardiologist, I can assure you that NO medicine is routinely blindly given. Would they agree, again if faced between the two evils..? 

R/r 911


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## Melbourne MICA

Ridryder911 said:


> That's what I do.....
> Basics blindly administering NTG as long as the patient is not hypotensive and yes no ACLS follow up for who knows when? R/r 911



I get where you are coming from. Is it an issue of a perception - the imperative to provide some level of treatment in the public's mind? Perhaps a lack of technological tools. More likely as you say, it's a matter of available definitive services and cost/benefit issues plus practicalities  like distance to ED.

But cardiac disease is so rampant. So you may end up needing a basketful of drugs and a hundred assessment toys to treat Pt's on a case by case basis. Facilitating that kind of approach - It's tough one. 

Still we all must act with duty of care and empathy for our pt. It's someone else's husband, mother, grandfather we're sticking dangerous drugs in after all.

MM


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## mycrofft

*Nurse Thumbfingers here. Yo?*

As much as I have been learning and nodding at in these highpowered exchanges, (and I am getting some material I need at work, thanks very much), allow me to mention some stuff:

1. Over 70% of MI pt's _present_ with sudden clinical death. ("Sudden" usually means the signs were not recognized by the pt or others). Pt hx then is nonextant. A lot of your "zebras" are going to be dead ones in the field situation, period, sorry, claim yor prize and hit the egress. Old saying: "In house: treat. Out-house: sheet". 

2. Project the time needed to perform the evaluations and treatments on the spot,  versus on the go, and the relative benefits as considered against transport time to a hospital. I have to frequently get my doctors to cut to the chase and get transport coming to us instead of becoming target fixated and holding off on initiating transport until the pt is "better", when in any event that pt will need a hospital. Multi-task, but get your intel (eval) first and ongoing. I think everyone does this, but in the heat of the forum it gets spun out.

3. In metropolitan areas ALS is available on most responses for this sort of call, no? But in rural areas, or in settings where medical personnel are present and expected to act but are not ALS (for instance, nursing homes or physical rehab facilities) in the immediate case you have to fall back on protocols based on the local realities. This is definitely a tiered situation and as long as one is not violating basic tenets of their level of eduation and practice they are doing "right". The answer is "competent ALS everywhere", but it is not going to happen and eventually still requires hospitalization.

Here's some chum for the scrum. What do you NOT like to see having been done for these pts before you get them at the ALS level? (Maybe that deserves its own thread....watch for it).


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## MedicPrincess

I guess my question for those that give the Nitro if the BP is "high enough" is What do you consider "High Enough?"

140/90?  Even if they have a 25% drop they will still be at 105/...  Is that high enough?  

Where do you draw the line?  Do you ask your patients if they have had Nitro and what kind of effect it had on them?

I think back to a pt I had whose initial BP was well over 190/ and he refused his third Nitro (at that time his BP was still above 140) because the 3 of the past 5 times he had Nitro, after the third one he ended up in Cardiac Arrest.  Being one of our "Snow Birds" he had his medical records with him, and he wasn't mistaken.

So whats considered "High Enough" to give your nitro without a backup plan in place?


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## EMT-P633

MedicPrincess said:


> So whats considered "High Enough" to give your nitro without a backup plan in place?



In my opinion there is no "high enough" to admin nitro with out a back up in place.


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## mycrofft

*And of course MAP...*

Is 140/90 high enough with a pulse of 130/min, or 120/66 with 75/min?
This discussion (and thanks to everyone) has made me upset with my coworkers and medical director. This means (more) war.


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## marineman

Looking at it strictly as an EMT-B according to the registry anything over 90 is technically high enough. Now I'll be the first to admit that much of the information in this thread was miles over my head as we haven't hit on cardiology yet but from what I've understood it sounds like it's not the actual end number of the BP that's truely important it's how far it dropped. Say you had a patient go from 180 systolic to 110 systolic vs a patient at 90 systolic dropped to 75 systolic I think the first one is what we're worrying about. That second patient under our protocols wouldn't qualify for a second dose where the first patient technically would but I think I'd make use of the peddle on the right and let the doc give that second dose to either one.


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## mycrofft

*marineman, how they taught me in emt-Amb to remember it, as rule of thumb...*

(Ah, yes, Professor Quartz at old Bedrock U)...
Beware when the heart is working too hard for the BP you get (pulse rate higher than you would generally expect for a given BP). Something's gotta give. Especially so when the rate is irregular (and an irregular rate will throw off some automatic BP machines....did I mention those things? Sorry).


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## Melbourne MICA

marineman said:


> Looking at it strictly as an EMT-B according to the registry anything over 90 is technically high enough. Now I'll be the first to admit that much of the information in this thread was miles over my head as we haven't hit on cardiology yet but from what I've understood it sounds like it's not the actual end number of the BP that's truely important it's how far it dropped. Say you had a patient go from 180 systolic to 110 systolic vs a patient at 90 systolic dropped to 75 systolic I think the first one is what we're worrying about. That second patient under our protocols wouldn't qualify for a second dose where the first patient technically would but I think I'd make use of the peddle on the right and let the doc give that second dose to either one.



Don't get hung up on BP. The most important things to realise are these.

What is GTN and how does it work? How does GTN fit into the scheme of things for the cardiac pt? Where does GTN fit into your protocol for the management of cardiac chest pain/ACS?

Learn the drug sheet and follow the guidelines on its use. Realise it is a powerful, potentially dangerous drug but is versatile and effective as well.

Also realise that *ALL* drugs have effects (benefits or uses as a tool to achieve a specific goal) and side effects (concurrent undesireable or counter-productive effects). And on occasion we may exploit either of these things to achieve a goal.

But remember that these chemicals are tools we use, are usually very specific and have limited uses. They are also tested, checked for safety using many medical studies, and distributed for use to various health professsionals (including us) to be used after careful consideration of their benefits to the most number of people the maximum amount of times possible.

But they are neither foolproof nor 100% reliable because everybody is different. No two people have identical medical problems.

So when you pull out your nitro spray or tablet remember that it is a dumb chemical and once it's in, it's in. There is no Naloxone for GTN.

So gather information - as much as you can given the circumstances - use your 12lead, check contraindications AND precautions. Know the onset times and duration of effect. And above all talk to the patient - they know their own condition better than anyone.

If you do all these things but still have doubts or uncertainties you still have several options. Give less than the prescribed dose. Give none and look for alternatives - if its pain and GTN is a worry and you can give Morph then think about it. Check your partner, check your medical controller. If in doubt -transport is still treatment. Give the O2, give the aspirin, rest the patient.
If they are sick call for backup.

Nobody expects you to be a cardiologist but you must still act prudently and with judgement and common sense.

If you are giving an 80yo woman with a Hx of IHD AMI/angina, hypertension etc and she has cardiac pain with a BP of 105sys and a HR of 120/min, (marginal perfusion numbers), a drug that works by dropping preload and after load - blood pressure going in and going out, what do you think will happen and what must you do?

Work the problem - respect the patient.

It all about the margin for error that you have before you. Thats right - its a numbers game. Always stack the odds in favour of the patient.

MM


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## Ridryder911

Hence, the problem. You make very important point however; majority of the EMS in U.S. are not nor have the capabilities of performing 12 lead. Even ALS units that provide ACLS care still may not perform twelve lead assessment. 

You mentioned the assessment of the patient in lieu of the numbers of the blood pressure, which I totally agree but unfortunately you are discussing an assessment technique to a level that is taught four hours of assessment techniques including trauma and medical. Also the terms or understanding of "preload, after load and even stroke volume" are rarely or never mentioned or even discussed in the basic curriculum, yet we still allow and expect them to administer and decide "which patients" it is safe to administer NTG to. Again, a course that the total cardiac segment is less than four clock hours in length.  

In regards to treating the patient that will cause acute hypotension, other than laying the patient in a supine and administering oxygen there is NOTHING they can do. Remember, our national level Basics are not able to cardiac monitor nor establish IV for fluid challenge. As well, myself and many other cardiac educators emphasis is recognizing the damage that might occur if this happens. Having the patient to compensate the sudden drop is the emphasis of worry. Again, causing an increase in heart rate, increasing workload, increasing the oxygen demand upon an already damaged myocardium is never good, as one knows would do nothing more than increase the infarct size. 

I am definitely not against NTG. In fact, it is not used enough in the prehospital phase as most Paramedics do not administer it properly as in the dosage or most effective route. Personally, IV NTG should be administered upon those that inferior wall AMI has been ruled out but again most providers do not have IV pumps to ensure the administration to be safe. Even making sure all ALS providers can perform twelve lead ECG's. Again another part of the failing portion of providing adequate care. You may believe costs is the prohibitive factor but in comparison of hazmat, WMD and other trinkets and toys that will never be used it should be a priority, something that would be used. Unfortunately, providing definitive patient care usually makes it on the lower priority list. 

R/r 911


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## MedicMonty

*No 12 Lead, now what?*

Another tip for those of us that don't always have 12-Lead available:  it IS possible to run Modified Chest Leads, which give similar views of the heart as the precordial leads.  Therefore it is also possible to run RIGHT-sided precordial leads (if you're in a hurry, MCL4R is the most useful), which should tip you off to a Right Ventricular Infarct.  You should use a machine capable of diagnostic-quality tracings, if available, but any machine capable of a 3 lead tracing can give you these views.  It's actually not that difficult, just be sure you know what you're looking at.

To do this, place the positive and ground electrodes (white and black) in their usual positions for lead II, and set the monitor to Lead III.  Then, you can quickly place the positive (red) lead in position to view any left- or right-sided precordial lead you like, MCL1-MCL6 or the same leads on the right side.  

Again, the disclaimer here is that you know the limitations of what you're looking at:
-it will NOT be as accurate as a true 12-Lead.  You cannot call these tracings "V1" - they should be labelled as MCL1
-unless you're using a machine that's capable of diagnostic quality tracings, you will miss some subtle things.  You may only see ST elevation when it's huge, or you may miss small q waves, etc.  In that case, it may be possible to rule "in" and RVI, but it is even more difficult to rule it "out"

For a better discussion (and instructions on how to get a LP10 into "diagnostic" quality mode), see: 
http://www.flightweb.com/forums/index.php?showtopic=1973&st=0

Hope this helps.  Be safe!

NJM


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## rhan101277

This is difficult for me to understand.  Why won't they give us what equipment/training we need to save lives?  If its money related get some tax dollars.  I mean this doesn't make since.  It is like you know what needs to be done but your hands are tied.  The 3-lead that is on our ambulance, the resolution is low the paper that it prints out on, I don't see how folks interpret it.  Seems like the 3-lead is a simple, do I have any electrical activity.  I don't think you could tell whether the pt. was having a STEMI or a non-STEMI with those.  Almost every pt. I saw rolled into the emergency room with SOB or chest pain had their blood sent up for testing.  How come not have medics ready with some blood from the pt. for testing when they roll in w/ them.  I mean medics can start a IV already, how hard is it to get a vial of blood?  It just boggles my mind to see what EMS could be doing in regards to training/equipment.

It seems to me like the 3 leads we use on our ambulance are from the 80's, they are so clunky.


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## JPINFV

rhan101277 said:


> Why won't they give us what equipment/training we need to save lives?



... because you can't simply increase a 110 hour course by a few hours to justify more diagnostic and intervention tools.


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## MedicPrincess

rhan101277 said:


> This is difficult for me to understand. Why won't they give us what equipment/training we need to save lives? If its money related get some tax dollars.


 
It's not as simple as just getting some tax dollars.  You have to put a proposal out.  Try to educate the voters that you really really need that money and why.  Counter act all the bad press because someone complains your crew is grabbing something to eat at some nast fast food place (Bk, McD, Wendys, etc) even though its 10 hours into their shift and they have hardly had time to pee let alone get something to et.  Continue to try to educate people who can't write their own name, or won't put down their beer long enough to read the literature.  Counteract some more bad press because one of your units was blocking up an intersection at 5pm rush hour while working a MVC with entrapment.  And if your lucky on election day and actually get your 1/2cent sales tax, you then have to wait until NEXT tax year to get your money.  Getting tax dollars is not like going to an ATM.




rhan101277 said:


> Almost every pt. I saw rolled into the emergency room with SOB or chest pain had their blood sent up for testing. How come not have medics ready with some blood from the pt. for testing when they roll in w/ them. I mean medics can start a IV already, how hard is it to get a vial of blood?


 
Whats the point of drawing blood?  Hospitals in our area can't/won't/whatever use EMS blood.  They claim liability.  They can't be sure the blood isn't contaminated.  

Heck, there's is one hospital that unless we are going to be potentially giving meds or fluids, we don't start the IV in the field anymore.  No more courtesy IV's to save the ER staff time.  That hosptial has a policy to pull ANY IV that is not started by one of their staff.




rhan101277 said:


> It seems to me like the 3 leads we use on our ambulance are from the 80's, they are so clunky.


 
What are you using?  LP 10?



rhan101277 said:


> It just boggles my mind to see what EMS could be doing in regards to training/equipment.


 
 Statement of the year, right there.


----------



## rhan101277

JPINFV said:


> ... because you can't simply increase a 110 hour course by a few hours to justify more diagnostic and intervention tools.



Maybe make the training more stringent for basics, make the course a two semester program.  Mine is only one semester, Tuesdays and Thursday from 6-9.

I read the jems article where they are nationalizing the basics, going update the SOP where we can use pulse oximeter.  Who knows how long this will take to happen.


----------



## JPINFV

Well, requiring a semester of anatomy, semester of physiology, semester of biochem and a year of chemsitry would be a great start (the first two should be required, but I can always wish about the second two). My concern over adding things like pulse oximetry to the EMT-B SOP is that I have my doubts that most EMT-Bs have a solid understanding of cardiopulmonary A/P that should be required before they use it. I foresee a lot of providers looking at it as a "stick probe on finger. read results, write down results" with no real understanding on what the device is telling them, but thinking that their patient is all honkey dorey because the number is above 92.


----------



## rhan101277

JPINFV said:


> Well, requiring a semester of anatomy, semester of physiology, semester of biochem and a year of chemsitry would be a great start (the first two should be required, but I can always wish about the second two). My concern over adding things like pulse oximetry to the EMT-B SOP is that I have my doubts that most EMT-Bs have a solid understanding of cardiopulmonary A/P that should be required before they use it. I foresee a lot of providers looking at it as a "stick probe on finger. read results, write down results" with no real understanding on what the device is telling them, but thinking that their patient is all honkey dorey because the number is above 92.



yeah I am in A and P now I like it.  You can still have good Sp02 but poor perfusion, I saw over the weekend with some woman who tried to commit suicide by taking a overdose.  Her oxygen level was great, but blood pressure was not it was 60/40, MAP was 40'ish, minimum is supposed to be 60 for good perfusion.

I have a strange feeling that some people don't want us basics to know more.  They are scared maybe we could save more people, I don't know.  What is more important than getting a education to learn to use proper equipment/training to save a life.


----------



## Ridryder911

Now really consider what you just wrote... 

If one obtains a formal education and more education in EMS and medicine, then... one would not be a basic would they? 


R/r 911


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## JPINFV

Ridryder911 said:


> Now really consider what you just wrote...
> 
> If one obtains a formal education and more education in EMS and medicine, then... one would not be a basic would they?
> 
> 
> R/r 911


Until there becomes an EMT-JPINFV level, unfortunately an EMT-B with an educational foundation is still an EMT-B. Just as there will still be paramedics that act like technicians once the EMT is dropped from EMT-Paramedic.


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## Melbourne MICA

Ridryder911 said:


> Hence, the problem. You make very important point however; majority of the EMS in U.S. are not nor have the capabilities of performing 12 lead. Even ALS units that provide ACLS care still may not perform twelve lead assessment.
> 
> You mentioned the assessment of the patient in lieu of the numbers of the blood pressure, which I totally agree but unfortunately you are discussing an assessment technique to a level that is taught four hours of assessment techniques including trauma and medical. Also the terms or understanding of "preload, after load and even stroke volume" are rarely or never mentioned or even discussed in the basic curriculum, yet we still allow and expect them to administer and decide "which patients" it is safe to administer NTG to. Again, a course that the total cardiac segment is less than four clock hours in length.
> 
> In regards to treating the patient that will cause acute hypotension, other than laying the patient in a supine and administering oxygen there is NOTHING they can do. Remember, our national level Basics are not able to cardiac monitor nor establish IV for fluid challenge. As well, myself and many other cardiac educators emphasis is recognizing the damage that might occur if this happens. Having the patient to compensate the sudden drop is the emphasis of worry. Again, causing an increase in heart rate, increasing workload, increasing the oxygen demand upon an already damaged myocardium is never good, as one knows would do nothing more than increase the infarct size.
> 
> I am definitely not against NTG. In fact, it is not used enough in the prehospital phase as most Paramedics do not administer it properly as in the dosage or most effective route. Personally, IV NTG should be administered upon those that inferior wall AMI has been ruled out but again most providers do not have IV pumps to ensure the administration to be safe. Even making sure all ALS providers can perform twelve lead ECG's. Again another part of the failing portion of providing adequate care. You may believe costs is the prohibitive factor but in comparison of hazmat, WMD and other trinkets and toys that will never be used it should be a priority, something that would be used. Unfortunately, providing definitive patient care usually makes it on the lower priority list.
> 
> R/r 911



I guess Marinemans message reminded of me of myself years ago to some extent when it seemed "enlightenment" on some clincial issues was simply a matter of getting to grips with a couple of numbers or ideas like BP drop versus starting BP. It's a recipe for confusion without an understanding of the larger picture. If Marineman is reading I hope I didn't sound pompous or condescending like I'm some expert - which I am not.

I just wanted to get across the idea that its not matter of one number or another but rather a complex mix of information we must interpret for the best outcome for our patients.

There are always options and things we can do no matter what our level of expertise that are safe, practical and benefit the patient. If all your service does is give you a drug and say "give it under circumstance "X", you can still think things through and take account of each pts situation so when you are about to give it, you give it as a thinking person not a drone. By definition, the more basic your level of training, the more conservative you should be in how you approach your pt management.

On GTN, the great thing about the tablet admin route is if side effects present themselves you can get the pt to spit out the pill. You can' t do that IV. (though IV would be good for well trained ALS types for sure). You can also give a half or even a quarter if you have doubts, are in the ballpark of treatment guidelines and will get your but kicked by your boss if you didn't give it.

The miedical standards committees of all our services must look long and hard at the treatment freedoms they give to EMS staff and I can assure you they do. At the same time they must follow the current medical practices, borne out by research, that provide the most value to the most number of people for the least risk to all stakeholders, in whatever form that may come.

I think you ALS guys need to make clear to EMT-B's who read and post here that they must act with care and take on board only as much information as they can understand within their own limits or can research or discuss with their clinical superiors.

MM


----------



## bonedog

At one time NTG was contraindicated for MI's. 

Now it is recognized for pain relief, not treating MI's, unlike ASA, which reduces M&M more than any other treatment...

Line first unless they have used their own NTG prior to arrival.

Great for angina and CHF.


----------



## erik412

*Nitro*

I prefer to have my line and on a monitor before NTG.  Unfortunately, I only have 3 Lead capabilities but it can at least give me some insight as to what is going on.

Erik


----------



## tydek07

12 lead, nitro, line

That is the way I was taught, and have never had a problem doing it that way.


----------



## NRCCEMTP26

Ridryder911 said:


> Nothing like bottoming out the patient and increasing the infarct size because of a zealous provider.
> 
> A twelve lead and IV should be performed *before* any NTG is administered. Administering NTG before knowing it is not a right sided AMI is only asking for troubles the same as if administering NTG without a line.
> 
> R/r 911



Amen to Ridryer911. I also strongly believe that a 12lead and a line should be started. Knowledge of a right side vs left side is uber critical! For any BLS unit dispatched to a cp should wait until ALS arrives before giving nitro.


----------



## Outbac1

Here is an ECG of one I did the other night.
 55y/o m, supine on floor. pale, cool, clammy, weak. Had been sitting in a chair talking with his friend when he had a sudden onset of c/p and sob.
He said it came in waves and the pain was severe. His friend helped him lay down on the floor.
 HR 80 - 90
 B/P 108/80
 RR 20 - 24
 B/S clear bilaterly
 Allergies to rubbing alcohol, bees and shellfish
 No previous cardiac hx
 only chronic back pain
 Hernia operation a month ago for which he takes tylenol 3s with codeine
 Pt given O2 via n/c @ 4L/min, ASA160mg PO, 4 lead ECG obtained then 12 lead.
 Somewhere in there ALS backup was called
 Its a 20 min drive to the hosp. and we had to put him into a stair chair to get him out of the 2nd floor apt. 

 I'm not yet allowed to start a line,(until I finish ACP school), I am allowed to give nitro. ALS will take at least 15 min to get to me. 
 So to give or not. Should I make this pt wait for ALS? Your thoughts please.


----------



## Outbac1

Maybe it will post now.


----------



## Outbac1




----------



## Ridryder911

*NO!*

Couple of reasons

First, you did not describe if the patient was complaining of any chest pain at the current time. 

Very prominent Inferior and Lateral wall involvement with reciprical changes, verifying such. The patient as well is demonstrating normotensive and even slightly possibly hemodynamically challenged if placed with dilating properties. 


Why wait, why not rendezvous with the ALS Unit?  Meet them, this will cut down transport time and at the same time the patient will receive the required ALS. 

Truthfully, one of the best interventional therapy might be fluids, as Right Sided Infarcts respond to fluid therapy. 

R/r911


----------



## KEVD18

Outbac1 said:


> Here is an ECG of one I did the other night.
> ****************55y/o m, supine on floor. pale, cool, clammy, weak. Had been sitting in a chair talking with his friend when he had a sudden onset of c/p and sob.************
> He said it came in waves and the pain was severe. His friend helped him lay down on the floor.
> HR 80 - 90
> B/P 108/80
> RR 20 - 24
> B/S clear bilaterly
> Allergies to rubbing alcohol, bees and shellfish
> No previous cardiac hx
> only chronic back pain
> Hernia operation a month ago for which he takes tylenol 3s with codeine
> Pt given O2 via n/c @ 4L/min, ASA160mg PO, 4 lead ECG obtained then 12 lead.
> Somewhere in there ALS backup was called
> Its a 20 min drive to the hosp. and we had to put him into a stair chair to get him out of the 2nd floor apt.
> 
> I'm not yet allowed to start a line,(until I finish ACP school), I am allowed to give nitro. ALS will take at least 15 min to get to me.
> So to give or not. Should I make this pt wait for ALS? Your thoughts please.



i would hope the "somewhere in there als was called" took place between the stars.....


----------



## bonedog

Nitro is a relative if not absolute contra-indication with this pt. Rid is bang on....

It is good to realize that nitro is purely for pain relief for these patients and the vasoactive properties make it extremely dangerous especially with RMI.

Personally I don't prescribe to protocols that lead to more protocols.... especially ones that may end with the patient going in the coroner's wagon.


----------



## Outbac1

I called for ALS early in my assessment. 

  The pt was having pain that came and went in "waves". Waves were his description. Every time one came it was described as severe. He wouldn't or couldn't give me a number on a scale. 

  I didn't wait. I finished  my assessment and we moved him to a stair chair and headed for the truck. While moving him he had another "wave" of pain. So I took the chance and gave him 1 x 0.4mg nitro SL. The pain went away, but maybe it would have left anyway. When I checked his pressure a minute or so later it was actually up to 118/88. As we got out of the apt. bldg. our ALS arrived. We quickly got him in the truck and headed for the hosp. A line was started and NS hung. Enroute he was given 2 more nitro sprays and morphine was drawn up but not given. 15 minutes after arrival at the ER he was given TNK and moved up to the ICU. Our nearest cath lab is 2 hours away. 

 His door to drug time was about two hrs. Not too bad considering he waited to call for 45 min and there was 40 mins of travel time involved, and a prolonged extrication. 

 Next year we are supposed to have TNK on the trucks for this type of call. It will be given in the field  by ACPs with online consultation.
Part of me is excited as I should have my ACP tag by then, and part of me wants to stock up on diapers.

 As of yesterday pm he was still in ICU and has had no more pain. 

 Just looking for your thoughts and input on this call. I know everyone would probably run the call a little differently, and everyone has different protocols to live by. I feel by sharing some of our calls everyone has a chance to learn something from each other. Thus the purpose of the forum.
 Thanks to all for your input.


----------



## Melbourne MICA

*Nasty*

Nasty

Inferior with antero-septal ischaemia, maybe posterior and q's and small ST rise in laterals suggestive they might be suffering as well. Nitro aint gonna do much for this man except screw around with his coronary artery/myocardial perfusion. 

Morph, fluid, aspirin, Ts - expect arrhythmias esp bradys, a BP dump > CG Shock, have some Epi and Atropine ready and be nice to the man.

Early Ts was a good option.
MM


----------



## FLAEMT22

*always IV*

You need an IV before you give nitro. I don't care how high the B/P is. You don't want to have that one patient that has a reaction to the nitro and bottoms out on you. Better to be prepared for the worst.


----------



## remote_medic

IV first, then nitro. No ifs/ands/or butts.

Now I'm going to contradict myself...If IV access is not available I would consider giving Nitro if the patient has been perscribed it and uses it on a semi-regular basis. If my patient crumps I can quickly gain central access using the IO drill.

My opinion and my opinion only


----------



## rhan101277

Sorry to drudge up, but didn't want to create a new one.

I am starting at a service that only had 3 lead capability.  I can use modified chest lead to get a better picture.  Even if I had 12 lead capability an inferior infarct can still be right or left involved or both.  I will always start an IV even if pressure is within limits.  We were always taught that you can kill a pt. by giving them nitro if its right sided, due to decreased preload, which is going to effect how much blood the heart receives for itself.

Every area except lateral can include right ventricle correct?


----------



## MrBrown

Our BLS Officers can give GTN without an IV and have done so for years

Do patients cannulate themselves before they take a squirt of thier nitro?


----------



## rhan101277

MrBrown said:


> Our BLS Officers can give GTN without an IV and have done so for years
> 
> Do patients cannulate themselves before they take a squirt of thier nitro?



No they don't, but I guess physicians think this is better than nothing.  But 50% of MI's are right ventricular involved according to some studies.


----------



## Shishkabob

Just because you don't see ST changes denoting an inferior infarct doesn't mean it's not there.


Having said that, just it being an inferior infarct would never stop me, and shouldn't stop you, from giving nitro.  Just have an IV and be prepared to give a bolus.  IMO, the benefit of giving nitro outweighs the small possibility of the substantial drop in BP.  Just more infarct happening.


(Bring on the replies about the "no proven decrease in morbidity/mortality")


----------



## rhan101277

Linuss said:


> Just because you don't see ST changes denoting an inferior infarct doesn't mean it's not there.
> 
> 
> Having said that, just it being an inferior infarct would never stop me, and shouldn't stop you, from giving nitro.  Just have an IV and be prepared to give a bolus.  IMO, the benefit of giving nitro outweighs the small possibility of the substantial drop in BP.  Just more infarct happening.
> 
> 
> (Bring on the replies about the "no proven decrease in morbidity/mortality")



Yeah I would give it of course, because you never can know for sure.  I'm just saying that that its like you said, if it is RV then you are creating a bigger infarct w/ giving nitro, even though we all have to give it because of protocols unless contraindications exist.


----------



## FLEMTP

Im going to jump in here and give ya'll my .02 cents. The ONLY medication I give in a suspected cardiac event or chest pain WITHOUT an IV is Aspirin. I get a set of vitals, a 12 lead EKG, and if its a chest pain I always put in 2 IV lines. I give a dose of sublingual NTG mainly as a diagnostic indicator. I say this because if the NTG shows a change in the chest pain, or a decrease in the elevation or an improvement in the 12 lead EKG, then I start an IV Nitro drip. I have the second line as a RULE because I will NOT piggy back NTG into a Normal saline line.

Why? Simple. It would be too easy for someone to decide the patient needed an IV medication (fentanyl is a good example) so you draw it up, and plug it into your IV port, and push it. Good.. now you've given your fentanyl.. AND ALL of the IV nitroglycerin thats present in the line between the patient and your Nitro piggy back.

So, always 2 lines, and always BEFORE i give nitroglycerin. If the 2 minutes it takes to put in 2 lines causes the patient to code, then I'd bet the nitro before the line vs after wouldn't have made the difference. 

Id also like to point out like anything else we check, a 12 lead is a diagnostic indicator only. it is NOT the final word. Ive had patients in the past with completely not related complaints (cellulitis) and out of sheer boredom i performed a 12 lead. The EKG is screaming ***ACUTE MI SUSPECTED***
but there was, in fact, no STEMI present. The patient stated that EKG machines ALWAYS do that with her EKG. 

Most paramedics would have called the STEMI or cardiac alert, and taken the patient to the ER with an "MI" because the machine says so. 

The EKG is just a tool to assist in your diagnosis of the patient. 

Look at your patient!!

Last friday I had a patient that called us for chest pain. She was obese, a 30 pack year history of smoking, was being treated for hypertension, hyperlipidemia, Non insulin dependant diabetes, and had a cardiac cath with stent placement one month prior. She was pale, cool, diaphoretic, nauseated with 10/10 pressure and squeezing pain in her chest. She was also mildly short of breath. 

We placed her on a NRB mask, obtained a set of vital signs (slightly hypertensive and sinus tach at 110/min) and a 12 lead EKG. 12 lead showed no ST segment depression, no wide complex anything, no ectopy of any kind. 

Based on her presentation, and my exam, i opted to treat her for an acute coronary syndrome/unstable angina. 

I did serial 12 lead EKG's to look for anything in the way of ischemia, or infarct. Nothing

NTG sublingual helped her pain MARGINALLY but after the Nitroglycerin at 10mcg/min her pain did improve slightly. Her blood pressure hovered around 110/systolic. She also got fentanyl for additional pain management. 

She was admitted, and I am waiting on final follow up.

The point to all of this? Treat your patient, NOT the monitor...and DONT administer ANY cardiac medication without at least a SINGLE IV line... including NTG. I would consider PO ASA to be the ONLY exception.


Hope this helps!


----------



## Veneficus

rhan101277 said:


> Yeah I would give it of course, because you never can know for sure.  I'm just saying that that its like you said, if it is RV then you are creating a bigger infarct w/ giving nitro, even though we all have to give it because of protocols unless contraindications exist.



In right sided MIs I have always observed the systolic pressure to quite low, don't ever recall seing it over 80. That would be a contradiction to giving nitro.

FLEMTP:

I understand your reasoning, and it certainly is a reasonable practice decision, but I am a little more fast on the trigger with the nitro. The only thing I want to see before I give it is some indication for it in a patient that clinically could possibly be havings some type of ACS and a bp ~100, though once a line is placed ~90 sys. 

My reasoning is that if it is angina, (of any sort) something that can help is administered. In the event it is an MI, it can be useful info even prior to a 12 lead. Finally, in unstable angina, insult has a couple of mechanisms that can cause a plaque rupture which can result in thrombotic event.

As i understand, it is bad practice to piggyback nitro in any case. 

But I would mention the action of the NTG (GTN) in spray or tablet has a rather short half life, acts locally instead of centrally, and most providers in the field have paste as maintenence instead of a drip.

Again, my way is not the "right" or "more right way" just a different way. See... "practicing."


----------



## FLEMTP

Veneficus said:


> In right sided MIs I have always observed the systolic pressure to quite low, don't ever recall seing it over 80. That would be a contradiction to giving nitro.
> 
> FLEMTP:
> 
> I understand your reasoning, and it certainly is a reasonable practice decision, but I am a little more fast on the trigger with the nitro. The only thing I want to see before I give it is some indication for it in a patient that clinically could possibly be havings some type of ACS and a bp ~100, though once a line is placed ~90 sys.
> 
> My reasoning is that if it is angina, (of any sort) something that can help is administered. In the event it is an MI, it can be useful info even prior to a 12 lead. Finally, in unstable angina, insult has a couple of mechanisms that can cause a plaque rupture which can result in thrombotic event.
> 
> As i understand, it is bad practice to piggyback nitro in any case.
> 
> But I would mention the action of the NTG (GTN) in spray or tablet has a rather short half life, acts locally instead of centrally, and most providers in the field have paste as maintenence instead of a drip.
> 
> Again, my way is not the "right" or "more right way" just a different way. See... "practicing."



I generally prefer to make sure that the nitro wont be detrimental to a patient because their chest pain and symptoms are due to a dissecting aortic aneurysm or a perforated ulcer, or other conditions from the list that would cause  similar symptoms. it doesn't take me but a few minutes to do a fairly thorough history, physical and exam and make a clinical decision regarding a course of treatment. I can however appreciate your being "fast on the trigger" as you put it. Every one is different. Im just a bit more cautious considering how potent IV nitroglycerin is. I find that one can be aggressive with treatment, but still be cautious in that treatment.


----------



## Jon

For those concerned about right-sided MI's... Who does a V4R? Who does a 15-lead?

I do the "Bob Page" 15 Lead - V4r, V8, V9 (As opposed to the Tim Phalen 15 Lead of V7, V8, V9).

Doesn't take that much more time, and there is no reason not to do it.


----------



## FLEMTP

Jon said:


> For those concerned about right-sided MI's... Who does a V4R? Who does a 15-lead?
> 
> I do the "Bob Page" 15 Lead - V4r, V8, V9 (As opposed to the Tim Phalen 15 Lead of V7, V8, V9).
> 
> Doesn't take that much more time, and there is no reason not to do it.



Personally, on any inferior wall MI I assume there IS right ventricular involvement, and treat accordingly. 

Hows this for a reason not to do it? you're more concerned with playing with the monitor to do a right sided 12 lead.. but who really is going to pay attention? How will that actually change your patient's outcome? will their MI magically resolve as soon as you do one? 

NO

You should be spending the minute or so talking to your patient, reassuring them, and explaining their condition to them, as well as what can be expected once they roll through the ER doors. That will do more for them as a patient than a right sided 12 lead will. 

Cardiologists always assume an inferior wall MI has right sided involvement, and they treat accordingly. the patient still gets nitrates for chest pain, along with a healthy dose of fluid to help keep the preload up and help prevent hypotension with nitroglycerin administration.


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## Coco

I'd never give Nitro without having an IV. I've seen many doctors doing it, and almost every time the patient collapsed. So, with an IV I'm prepared for this situation.
But however, why you give Nitro? For ruling out angina pectoris? Or for lower the blood pressure?


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## MasterIntubator

Guten Abend Deutschland, ich denke, die meisten von uns geben nitro zur schmerzbehandlung, via pharmakologische Physiologie Gründen sollten wir alle wissen.  Ich würde Blutdruck Kontrolle in Gegenwart von Herzinsuffizienz/lungenödem, sonst ist normalerweise nicht meine Priorität.
 Sorry... could not resist, Coco.... I miss Germany! 

Our area has protocols set, if the pt is already prescribed NTG, then the BLS providers and ALS can give NTG prior to an IV ( assessment based decision ).
Now to blindly give it without an IV.... as a general rule, I have taught folks not to.  1 - IV starting does not and should not take that long.  2 - you have a little time.  3 - One day.... you will have that pt get hypotensive, and then you will wish you had an IV... as now it will be a bit more difficult with extra stress to deal with.  
I have had my share of folks ( mostly have been female ), where after a single NTG ( with an IV in place ), they have dropped 30-40 systolic points, became pale, diaphoretic and ALOC.   Lying them flat and raising thier legs a bit along with fluid caused them to rebound to about 100 systolic.  I can not remember what thier cardiac story was... or if they were just nitrate sensitive... never the less... it will happen. So don't do half the job to save time.
If I do suspect right sided, and the leads suggest it, we typically give fluids first, then NTG.


----------



## Tal

KEVD18 said:


> line and ekg prior to ntg.



and relevant history...Contra indication etc.
Line before ntg allways, some pts dont hadle it so good as others.


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## socalmedic

let me pose this question to you, a decision I had to make last night. 

you have a 87 yo female with unexplained syncope. 12 lead shows st elevation V1 and V2. you are unable to get an IV, and dont expect to get one. BP 160/80, P80. do you give nitro?


----------



## Shishkabob

Elevation on V1 and V2... any reciprocal changes in other leads?  What sort of S/S does she have going on?  What kind of history?


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## socalmedic

no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.


----------



## FLEMTP

socalmedic said:


> no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.



This is whats wrong with EMS today. COOK BOOK MEDICINE = FAIL!!!!!!


I am just so damn sick of the ignorance and lack of free thinking in EMS anymore. Makes me just want to hang it up and never look back!:excl:


----------



## TransportJockey

When I was a basic I could give a patient his own NTG w/out a line. Now that I'm an I (or BIV in CO) I make sure I've got a line at the very minimum. Too bad I can't interpret a 12lead by state protocols


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## socalmedic

JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.


----------



## MrBrown

socalmedic said:


> JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.



that would make the IAFF and Medicfighters (you know, the Firefighters who fight being a Paramedic every day) unhappy


----------



## Outbac1

socalmedic said:


> you have a 87 yo female with unexplained syncope. 12 lead shows st elevation V1 and V2. you are unable to get an IV, and dont expect to get one. BP 160/80, P80. do you give nitro?
> no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.
> JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.



Probably a vagal episode.  I probably wouldn't have given nitro as I don't think it was warranted. (But I wasn't there) Any idea as to her troponins?


----------



## socalmedic

outback- I have no idea what her blood work was, I did not make a return trip to that hospital.

Brown- I ride big red at my main job. unfortunately it is a BLS department and I enjoy ALS.


----------



## medicRob

FLEMTP said:


> This is whats wrong with EMS today. COOK BOOK MEDICINE = FAIL!!!!!!
> 
> 
> I am just so damn sick of the ignorance and lack of free thinking in EMS anymore. Makes me just want to hang it up and never look back!:excl:


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## Leonidas1

RMC, chewable aspirin at least 162mg (if no hx of allergies, or GI problems) NTG.04 mg/sl if systolic B/P is 100mm/hg or above.


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## TransportJockey

This might be a dumb question, but what does RMC stand for? I don't recall ever hearing that one before


----------



## Veneficus

jtpaintball70 said:


> This might be a dumb question, but what does RMC stand for? I don't recall ever hearing that one before



Royal Marine Commando?


----------



## MrBrown

Veneficus said:


> Royal Marine Commando?



One of my professors was an ex Royal Marine Commando in the Falklands War when Prince Andrew landed on his ship to take a dump ... the boys bagged it up and sold it at the pub, needless to say that Prince Andrew never came back to thier ship!


----------



## Leonidas1

RMC (Routine Medical Care) for  ALS providers in the Chicago North EMS System consists of... IV, oxygen, cardiac monitor.


----------



## MrBrown

Leonidas1 said:


> RMC (Routine Medical Care) for  ALS providers in the Chicago North EMS System consists of... IV, oxygen, cardiac monitor.



If patients go to the hospital or his GP is an IV, oxygen and cardiac monitor routine care provided to them?

So why is it that in EMS it is acceptable?

*Brown once again yells loudly that not every patients needs a bloody IV or oxygen crammed down thier throat


----------



## medic417

MrBrown said:


> If patients go to the hospital or his GP is an IV, oxygen and cardiac monitor routine care provided to them?
> 
> So why is it that in EMS it is acceptable?
> 
> *Brown once again yells loudly that not every patients needs a bloody IV or oxygen crammed down thier throat



Well there's your problem, don't shove the O2 tank down their throat.  :wacko:


----------



## reaper

Leonidas1 said:


> RMC (Routine Medical Care) for  ALS providers in the Chicago North EMS System consists of... IV, oxygen, cardiac monitor.



Let point you back to post #115!  Read, take notes and practice!


----------



## socalmedic

FLEMTP said:


> This is whats wrong with EMS today. COOK BOOK MEDICINE = FAIL!!!!!!
> 
> 
> I am just so damn sick of the ignorance and lack of free thinking in EMS anymore. Makes me just want to hang it up and never look back!:excl:



I feel that the problem is not with the field level medics, we all come out of school wanting to learn more, expand our knowledge, so forth. I feel the problem is with management and Md's who do not want us to do anything more. 

It dosnt matter what my patient tells me or what I read in the 12 lead. if the machine says ***ACUTE MI SUSPECTED*** I am ordered to adhere to a particular algorithm. I know there are systems out there that allow medics to think, however Southern California is not one of those systems for any host of reasons, lets not get into the "its the Fire Departments fault" topic we already have one of those.


----------



## MrBrown

socalmedic said:


> Brown- I ride big red at my main job. unfortunately it is a BLS department and I enjoy ALS.



Which bar did you pick up "Big Red" at?


----------



## medicRob

MrBrown said:


> Which bar did you pick up "Big Red" at?


----------



## JPINFV

MrBrown said:


> Which bar did you pick up "Big Red" at?



[YOUTUBE]http://www.youtube.com/watch?v=56S81vVDufI&feature=related[/YOUTUBE]


----------



## socalmedic

you dont want to know, she is a bit of a rough ride. she sure does get my hose hard though.


----------



## MasterIntubator

FLEMTP said:


> I am just so damn sick of the ignorance and lack of free thinking.......



I will agree with this... but that is a double edged sword.... free thinking with ignorance gets folks in just as much trouble.  Some just free think too much, and without a good solid basic knowledge... it gets all hosed up.


----------



## Charmeck

haha trendelenburg.  I'd just as soon have a line.


----------



## YoungMedic

Ridryder911 said:


> Nothing like bottoming out the patient and increasing the infarct size because of a zealous provider.
> 
> A twelve lead and IV should be performed *before* any NTG is administered. Administering NTG before knowing it is not a right sided AMI is only asking for troubles the same as if administering NTG without a line.
> 
> R/r 911



Perfect, exactly what i would say/do.  This so happens to be my protocols as well, for good reason.


----------



## Handsome Robb

This is interesting. I just got done with my cardiology/ECG lab tonight and actually asked my instructor this exact question. I know I am in I school and not a Paramedic so I don't know if this may have something to do with it and she told me that its best to give the NTG first then secure a line...with the explanation that its better to let the NTG start doing its thing before worrying about starting a line, but it seemed to me and seems to be pretty unanimous on here that you would want a lifeline pre-NTG just in case sh*t hits the fan....
Just some food for thought.


----------



## slb862

I learned it as O2, IV, EKG (12 lead included),ASA, vitals were done by the first responder, and then the NTG.  ASA is thee only drug that is going to be of any medical benefit.  I have enough people working with me, if they are not starting the IV for me, then they are handing me what I need when I ask.  You don't ever want to see a pt. "crash" after giving NTG without IV fluids/IV ready.  Peace Out!!


----------



## usalsfyre

While I'm happy to see a healthy respect for NTG, y'all do realize you will probably recognize the majority of preload-dependent MIs with the first set of vital signs?


----------



## 18G

slb862 said:


> ASA is thee only drug that is going to be of any medical benefit.



How so?


----------



## Smash

18G said:


> How so?



ISIS-2 amongst others demonstrated that Aspirin is the only drug that we routinely give in the field that has any positive impact on mortality and morbidity from ACS.  

It is very cheap, extremely safe and tastes yummy.

Nothing else has been proven to have such a benefit, or indeed any benefit at all, and many of those wonderful routine ambulance driver things we do may actually cause harm (High concentration O2 anyone?)


----------



## 18G

I know that hyperoxia in ACS/MI is detrimental and can worsen ischemia... this finding goes back to research done in the 1950's. It was so nice to see it included in the new AHA guidelines. 

Nitro has not been shown to decrease mortallity per se, but it does have medical benefit as it relieves pain which decreases catacholamine release, improves the O2/demand ratio by reducing workload,  and can improve coronary blood flow. Is this not a medical benefit?

Pain meds don't fix a fracture but they are still of medical benefit.


----------



## swissmedic

In our new protocols we need an iv or io line before nitro application.
We only give nitro after 12 lead ECG and we sure that the patient have no Right Heart Failure !!
Here is a short overview from our ACS / thorax pain protocoll:

1. Oxygen + ECG, BP, SpO2, Glucosetest
2. Asperin iv or io
3. Morphin iv or io
4. Nitro po (if you have no right heart failure!! >>> if you have one you should give NaCl 0,9% 500ml as a bolus)
5. Contact cath labor to give plavix 600mg and Liquemin 5.000i.E. Only for STEMI 
6. Lasix iv or io if you have pulmonary edema

Matt


----------



## emtchick171

It is in our protocols that a patent IV MUST be established prior to the administration of Nitro. Also, systolic must be at least 100 or higher before the admin. of Nitro.


----------



## Boston.Tacmedic

If combat medicine has taught me anything it is unless it is a trauma code or your taking fire that's truly the only times to rush. As the prior posts stated abc IV, EKG then if still needed MONA. take your time and remember your training no need to rush to pharmacology just because we can.


----------



## Ridryder911

Amazing we dispense NTG to patients daily by the millions without an IV to those in clinic settings. The reason being is that they are diagnosed with angina, not having an AMI. This being, NTG is a medication and along with that is the responsibility of knowing when and why, it should be administered. 

I believe the question should be not having an IV but rather..."Is NTG appropriate to administer?"... Hence being, right ventricular infarct, poor preload factor, baseline blood pressure to handle vasodilation, chronic angina vs. acute AMI?. The old saying; it's not going to hurt to.. is simply a long standing myth and not accurate. 

With the advances and ease of the I/O, one can (or should be able to) always administer fluid bolus and allow compensation to occur. Best..? no but to withhold general treatment for the sake of ... "in case".. in not justifiable

R/r 911


----------



## MrBrown

Our Technicians have been giving GTN without an IV for oh gosh, ten years?


----------



## Melbourne MICA

Ridryder911 said:


> Amazing we dispense NTG to patients daily by the millions without an IV to those in clinic settings. The reason being is that they are diagnosed with angina, not having an AMI. This being, NTG is a medication and along with that is the responsibility of knowing when and why, it should be administered.
> 
> I believe the question should be not having an IV but rather..."Is NTG appropriate to administer?"... Hence being, right ventricular infarct, poor preload factor, baseline blood pressure to handle vasodilation, chronic angina vs. acute AMI?. The old saying; it's not going to hurt to.. is simply a long standing myth and not accurate.
> 
> With the advances and ease of the I/O, one can (or should be able to) always administer fluid bolus and allow compensation to occur. Best..? no but to withhold general treatment for the sake of ... "in case".. in not justifiable
> 
> R/r 911



Salient points as always ridders. I brought up the scenario (more than once) of pts with angina long standing or otherwise who use GTN for years without dropping in a screaming heap. But as you pointed out they are using it for angina not an infarct. If they call us its not working like it's supposed to and its then up to us to figure out whether their angina has become unstable (ACS) or an MI is underway - that's what they pay us for after all. It goes without saying an IV is pretty much standard fare for the cardiac pt but before every GTN admin? - unless obviously or  looking like they are getting crook no. If guys are thinking they are going to dump in fluids every time the BP gets a tickle hence the urgency on the IV they should have another think. If you can't feel comfortable giving GTN to a pt on the basis of a thorough history and clinical assessment  without plunging straight into an IV (and where is your plan of attack if you miss it? Now its IO "just in case" for every cardiac pt?) then maybe you shouldn't be doing it in the first place. Put the monitor on, give the aspirin, give the GTN, get your IV going and see where things stand. If its not angina you won't be going that path anyway. Of course if your service docs stipulate "IV - point 1" and your sphincter tone is directly proportional to your compliance with said stipulations then go for it. Whats the big hooha about all this anyway?

MM


----------



## Boston.Tacmedic

MrBrown said:


> Our Technicians have been giving GTN without an IV for oh gosh, ten years?



Just because something has been done for a long time does not imply it is being done well. I feel strongly on this as where I work I may be the only medical for 100's of miles and don't have the luxury of flying by the seat of my pants. I feel we do a discredit to out profession every time we take a short cut. If you just by looking at the Pt can assure there is ZERO chance of a Rt sided AMI then good on you, myself I am not that good hence I acquire a 12 lead. As for the argument of time slow is smooth and smooth is fast I can establish IV and 12 lead in under 3 min by myself or maybe with a willing lay rescuer. I am one who is not a cook book medic but do believe in fundamentals. Just my .02


----------



## usalsfyre

Boston.Tacmedic said:


> Just because something has been done for a long time does not imply it is being done well. I feel strongly on this as where I work I may be the only medical for 100's of miles and don't have the luxury of flying by the seat of my pants. I feel we do a discredit to out profession every time we take a short cut. If you just by looking at the Pt can assure there is ZERO chance of a Rt sided AMI then good on you, myself I am not that good hence I acquire a 12 lead. As for the argument of time slow is smooth and smooth is fast I can establish IV and 12 lead in under 3 min by myself or maybe with a willing lay rescuer. I am one who is not a cook book medic but do believe in fundamentals. Just my .02



Two shifts ago, I had a chest pain patient I could not canulate. She had finished a course of chemo recently, and four sticks later, I still didn't have a stinking IV. She had what based on my assesment was unstable angina. No inferior ST elevation was present, her pressure was not labile and no other signs indicating preload dependence were present.

What your saying is I shouldn't have provided this lady with relief from a painful but easily treatable condition because I couldn't start an IV?

For the record she got NTG prior to even attempting an IV.


----------



## Boston.Tacmedic

Your response to my stand point is not truly complete. You variable you left out is transport time, if you were close then yes I would have withheld. I also would ask myself how comfortable I am with my EKG. At this point if my transport is extended I would consider it however I would call my doc first I may skip the NTG and go with just morphine to calm said PT and help alleviate said discomfort. If my PT becomes so acute that nitro is clearly needed and I was not having an A game day then I would establish an IO 100mg lido for Pn at site and give fluid then NTG. Again just how I roll, all sizes may not fit all ;-)


----------



## usalsfyre

Boston.Tacmedic said:


> Your response to my stand point is not truly complete. You variable you left out is transport time, if you were close then yes I would have withheld. I also would ask myself how comfortable I am with my EKG. At this point if my transport is extended I would consider it however I would call my doc first I may skip the NTG and go with just morphine to calm said PT and help alleviate said discomfort. If my PT becomes so acute that nitro is clearly needed and I was not having an A game day then I would establish an IO 100mg lido for Pn at site and give fluid then NTG. Again just how I roll, all sizes may not fit all ;-)



So, you would rather do an IO (a painful and not necessarily benign procedure) "just in case"  to give nitro, than administer a medication that is given without a line literally _thousands_ of times a day world-wide?

Alternately, you would rather give a medication that the AHA now recommends be given with caution in NSTEMI and unstable angina because it may increase mortality, and in addition has a very unpredictable effect on blood pressure due to the side effect of histamine release. You would give it IM, which has 15-20min onset rather than a 5 minute absorption SL like NTG. 

Transport time does not play into my decision here. Whether it's 5 minutes or 50 minutes I'm going to try to relive the condition to the best of my ability.  If this is how you roll, you need to *seriously* think about if what your doing is best for your patients and not your comfort level.


----------



## Boston.Tacmedic

usalsfyre said:


> So, you would rather do an IO (a painful and not necessarily benign procedure) "just in case"  to give nitro, than administer a medication that is given without a line literally _thousands_ of times a day world-wide?
> 
> Alternately, you would rather give a medication that the AHA now recommends be given with caution in NSTEMI and unstable angina because it may increase mortality, and in addition has a very unpredictable effect on blood pressure due to the side effect of histamine release. You would give it IM, which has 15-20min onset rather than a 5 minute absorption SL like NTG.
> 
> Transport time does not play into my decision here. Whether it's 5 minutes or 50 minutes I'm going to try to relive the condition to the best of my ability.  If this is how you roll, you need to *seriously* think about if what your doing is best for your patients and not your comfort level.



I would thread cautiously in questioning my comfort level. I have done escharotomys in remote villages and treated ENT as well my comfort level is not in question nor is my personal skill set so before you continue you a personal attack I will stop you there. Topic at hand if your concerned with histamine release we carry drugs to handle that ( your system may differ) as to IO and Pn bones do not feel pn the change in pressure can cause discomfort hence why I said "lido .5-1mg/kg in an alert PT". The question of transport time is  pertinent because if the ER is 5 min transport time then all this what if is a mute point then, they will just goto ER were at worst case scenario is they get a central line. Our world is not black and white we work and live in the grey. This is my style your Millage may vary. 

~ Fin~


----------



## slb862

ASA is of great benefit, with little risk.  ASA also reduces blood clotting, (makes it slippery) and will help the blood flow through the narrowing artery caused by the heart attack.  Also remember, do not give ASA if there is an allergy, or taking a blood thinner, or if your doctor told you not to take.

Nitro is a vasodilator, and will reduce preload, consider the risks

Heparin has a mild benefit and you need to consider the risks


----------



## JPINFV

Err.... 

Could you clarify exactly what you mean by "blood thinners" as ASA (an anti-platelet) is commonly given with Clopidogrel (plavix) (a seperate anti-platelet) in patients with ACS. Similarly, warfarin (anti-coagulent) isn't a contraindication for even long term management per Up-To-Date (it's more of a caution for bleeding, but definitely not an absolute contraindication, plus what's the bigger risk, possibly increasing a bleed or an MI? This makes the decision significatly different from long term use to treatment of acute disease).

With heparin, I wonder why if system is using it in the field why they would choose heparin proper in light of low molecular weight heparin. LMW heparin carries significantly less risks and, unlike heparin, doens't require constant monitoring of aPTT.


----------



## 18G

An IO isn't really all that painful. I've seen several people get IO's while fully awake and they barely (if at all) flinched. The pain comes from the initial flush and flow of fluid into the medullary space which lido helps with. 

If the patient's pressure is high enough and the patient has prescribed NTG I don't see a problem with giving NTG prior to having an IV. If the patient becomes really hypotensive than start an IO. 

I think many people become scared at the idea of poking a needle into the bone and hesitate to go that route.


----------



## Boston.Tacmedic

18G said:


> An IO isn't really all that painful. I've seen several people get IO's while fully awake and they barely (if at all) flinched. The pain comes from the initial flush and flow of fluid into the medullary space which lido helps with.
> 
> If the patient's pressure is high enough and the patient has prescribed NTG I don't see a problem with giving NTG prior to having an IV. If the patient becomes really hypotensive than start an IO.
> 
> I think many people become scared at the idea of poking a needle into the bone and hesitate to go that route.



They are amazing, I have 2 styles in my IFAK kit. I also use combitubes more than traditional intubation (oh i know perish the thought) I guess it just depends on your service or environment, but yeah IO is a blessing.:wub:


----------



## usalsfyre

Boston.Tacmedic said:


> I would thread cautiously in questioning my comfort level. I have done escharotomys in remote villages and treated ENT as well my comfort level is not in question nor is my personal skill set so before you continue you a personal attack I will stop you there.


So please understand this is not a personal attack. However, what do ENT and escharotomies have to do with a cardiac patient? These treatments/procedures are not proof of education, experience or understanding of the subject at hand. Put another way, there are many military medics I would trust to cric someone but wouldn't let them transport a patient on multiple pressors between facilities. 


Boston.Tacmedic said:


> Topic at hand if your concerned with histamine release we carry drugs to handle that ( your system may differ)


We carry multiple anti-histamines, however most antihistamines are non-competitive antagonist which means they won't reverse exiting hypotension immediately, meaning you have to pre-treat. 


Boston.Tacmedic said:


> as to IO and Pn bones do not feel pn the change in pressure can cause discomfort hence why I said "lido .5-1mg/kg in an alert PT".


"Pain at the site" is a universally listed side effect.


Boston.Tacmedic said:


> The question of transport time is  pertinent because if the ER is 5 min transport time then all this what if is a mute point then, they will just goto ER were at worst case scenario is they get a central line. Our world is not black and white we work and live in the grey. This is my style your Millage may vary.


The world in far from black and white, which is why I can't imagine someone limiting themselves to only giving NTG if venous access is present regardless of clinical situation. If a patient is alert and oriented, is not tachycardic, does not have a labile pressure and shows no other signs of instability or preload dependence (including RVI) than why are we discarding it? Especially if there is a willingness to give other drugs which affect blood pressure such as morphine.To do so is simply being afraid of "the big bad NTG tablet" and is not grounded in clinical reality. 

I support having an I/O ready in case of profound hypotension, but can't see establishing it. If the patient grows unstable, by all means go for the bone. I doubt however, you will find a physician that establishes central lines or I/O just to give NTG. The will evaluate the patient and then go ahead and order it if the patient does not seem unstable.

Are people afraid of NTG or of their assessment ability?


----------



## EmtTravis

usalsfyre said:


> Two shifts ago, I had a chest pain patient I could not canulate. She had finished a course of chemo recently, and four sticks later, I still didn't have a stinking IV. She had what based on my assesment was unstable angina. No inferior ST elevation was present, her pressure was not labile and no other signs indicating preload dependence were present.
> 
> What your saying is I shouldn't have provided this lady with relief from a painful but easily treatable condition because I couldn't start an IV?
> 
> For the record she got NTG prior to even attempting an IV.



I was reading through this thread and yes im just a basic but did she not have a PICC or a Port since she was in chemo?


----------



## MrBrown

If you are that scared about giving a spray of GTN without an IV line perhaps you should not be trusted to give GTN.


----------



## Veneficus

slb862 said:


> ASA is of great benefit, with little risk.  ASA also reduces blood clotting, (makes it slippery) and will help the blood flow through the narrowing artery caused by the heart attack.  Also remember, do not give ASA if there is an allergy, or taking a blood thinner, or if your doctor told you not to take.
> 
> Nitro is a vasodilator, and will reduce preload, consider the risks
> 
> Heparin has a mild benefit and you need to consider the risks



I'm sorry, but this descrption defies belief.

Makes blood slippery?

Helps flow through the narrowing artery by being slippery?

ASA contraindicated with "blood thinner?" I think this is too simplistic to be true.

Heparin of minor benefit? Maybe not as aggresive as tpa or streptokinase, but minor?


----------



## Handsome Robb

Isn't ASA a 'platelet agitator'? Specifically classed as an Anticoagulant, NSAID, antipyretic, and analgesic... I could see how slippery could be used to define the action...but not really.


----------



## emtchick171

slb862 said:


> ASA is of great benefit, with little risk.  ASA also reduces blood clotting, (makes it slippery) and will help the blood flow through the narrowing artery caused by the heart attack.  Also remember, do not give ASA if there is an allergy, or taking a blood thinner, or if your doctor told you not to take.
> 
> Nitro is a vasodilator, and will reduce preload, consider the risks
> 
> Heparin has a mild benefit and you need to consider the risks



I'm slightly confused on this one. Nitro is a nitrate...thus being said the production of energy requires oxygen. Angina or "heart pain" is due to an inadequate flow of oxygenated blood to the muscle of the heart. It is believed that all nitrates, including nitroglycerin, correct the imbalance between the flow of blood and oxygen to the heart and the work that the heart must do by dilating the arteries & veins in the body. Dilation of the veins reduces the amount of blood returning to the heart so that the heart does less work and requires less blood and oxygen.

^^or at least that's what we have been taught in every class I've ever taken.


----------



## emtchick171

NVRob said:


> Isn't ASA a 'platelet agitator'? Specifically classed as an Anticoagulant, NSAID, antipyretic, and analgesic... I could see how slippery could be used to define the action...but not really.



I agree with you. It is a platelet aggregate, anticoagulant, analgesic...etc.

Also, I will occasionally give ASA as a first option for chest pains, however...I generally just go straight for the nitro, especially if they have a history of angina...providing that their blood pressure is high enough to administer Nitro.


----------



## JPINFV

emtchick171 said:


> I agree with you. It is a platelet aggregate, anticoagulant, analgesic...etc.
> 
> Also, I will occasionally give ASA as a first option for chest pains, however...I generally just go straight for the nitro, especially if they have a history of angina...providing that their blood pressure is high enough to administer Nitro.



Considering that the MOA and reason for giving ASA and nitro are completely different, why are you withholding ASA due to nitro? ASA is not given in ACS for pain control.


----------



## emtchick171

JPINFV said:


> Considering that the MOA and reason for giving ASA and nitro are completely different, why are you withholding ASA due to nitro? ASA is not given in ACS for pain control.



It is not that I am withholding ASA because of nitro...but in our county protocols...it is completely up to our discretion whether we administer 160-324mg of ASA and then give nitro, or we can just go straight for nitro. It all depends on the situation and how my patient is reacting to the drugs I administer, and the treatment given.


----------



## JPINFV

Just curious, then, if the chest pain responds to nitroglycern and the pain level decreases, do you not administer ASA because the patient responded positively?


----------



## emtchick171

JPINFV said:


> Just curious, then, if the chest pain responds to nitroglycern and the pain level decreases, do you not administer ASA because the patient responded positively?



It has a lot to do with the patient's history, and their current medical/physical condition.


----------



## vquintessence

emtchick171 said:


> It has a lot to do with the patient's history, and their current medical/physical condition.



You'd make a fine politician; you successfully dodged his question while providing an answer!


----------



## emtchick171

vquintessence said:


> You'd make a fine politician; you successfully dodged his question while providing an answer!



Am I supposed to take this as a compliment or an insult??? hahahaha


----------



## Handsome Robb

emtchick171 said:


> I agree with you. It is a platelet aggregate, anticoagulant, analgesic...etc.
> 
> Also, I will occasionally give ASA as a first option for chest pains, however...I generally just go straight for the nitro, especially if they have a history of angina...providing that their blood pressure is high enough to administer Nitro.



It makes sense to go straight to the nitro because of its fast action. I like to give the ASA then the nitro to give the ASA a head start on kicking in since by the time the nitro wears off the ASA will be kicking in.


----------



## emtchick171

NVRob said:


> It makes sense to go straight to the nitro because of its fast action. I like to give the ASA then the nitro to give the ASA a head start on kicking in since by the time the nitro wears off the ASA will be kicking in.



I'm glad to see that someone else agrees with me! My goal is to get my patient the best quality care, and to get the quickest pain relief.


----------



## JPINFV

NVRob said:


> It makes sense to go straight to the nitro because of its fast action. I like to give the ASA then the nitro to give the ASA a head start on kicking in since by the time the nitro wears off the ASA will be kicking in.



May I put forth that there's a difference between the order interventions are given and potentially withholding ASA because the patient responded to treatment with nitro?


----------



## Handsome Robb

True. But just as I said short action vs. long action. NTG lasts 4-5 minutes x 3 doses thats 12 minutes of relief whereas ASA lasts much longer, but takes longer to set in. 

I know medics that will push a little fent and then add some morphine on top because of the same reason, short action vs. long action.


----------



## 18G

> It is a platelet aggregate, anticoagulant, analgesic...etc.



It appears there is some misconception about the MOA and importance of timely administration of ASA in ACS/MI.

ASA is not a "platelet aggregate". Platelet aggregation is what we do NOT want to have happen as it will worsen the blockage. ASA prevents platelet aggregation by blocking the enzyme COX (cyclooxygenase) which in turn inhibits the synthesis of thromboxane A2 which is what stimulates platelet activity and their aggregation. Stating that ASA makes platelets slippery is somewhat accurate albeit an elementary description. 

ASA can also cause some arterial vasodilation through blockage of prostaglandins. 

The earlier the aspirin is administered the better for the patient. Some 911 centers through EMD instruct callers to admin ASA prior to EMS because of the importance of early administration.   

Aspirin is classified as an anti-platelet agent in addition to the several others.

I would give ASA as early as possible and before NTG... ASA has been shown to reduce patient death, NTG has not.


----------



## zmedic

18G said:


> I would give ASA as early as possible and before NTG... ASA has been shown to reduce patient death, NTG has not.



+1, I agree


----------



## the_negro_puppy

Our protocosl state to give GTN before aspirin h34r:


----------



## 18G

Our protocol has ASA before NTG


----------



## JPINFV

I highly doubt that it matters whether NTG or ASA goes first provided the patient gets ASA at some point early in the course.


----------



## Veneficus

18G said:


> Stating that ASA makes platelets slippery is somewhat accurate albeit an elementary description.


 
Not a description befit a haelthcare provider, nor to address one. 

Makes me want to let my medic card expire and disavow any knowledge or involvement in working in EMS.


----------



## Ridryder911

Geez, just how silly are we or is it ignorance is peeking its ugly head again? Really... we are debating squirting NTG and have someone chew some ASA? Really, does one really think the effect of ASA acts immediately and exactly how long does it take to administer either one?.. 

If you’re not administering ASA on any type of ACS and solely discreetly using a nitrate, you’re playing with fire. I would like to know exactly what differential diagnostic material you’re determining if it is an unstable/stable angina vs. an AMI? 

C'mon folks, surely if we are going to debate semantics and treatment modalities, let's pick our fights better. As well, I truly hope that other are not expecting the byproduct of analgesic effects of the ASA decreasing pain in an AMI or even angina taking effect soon.

R/r 911


----------



## JPINFV

Ridryder911 said:


> Geez, just how silly are we or is it ignorance is peeking its ugly head again? Really... we are debating squirting NTG and have someone chew some ASA? Really, does one really think the effect of ASA acts immediately and exactly how long does it take to administer either one?..



Well, as long as the dogma in EMS is "SECONDS COUNT!!!!111ONEONETWO12" then obviously the order of nitro vs ASA matters. What EMS needs to realize is that seconds, and even minutes, rarely matter, and those times that they do we're normally well behind the eight ball already.


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## Ridryder911

JPINFV said:


> Well, as long as the dogma in EMS is "SECONDS COUNT!!!!111ONEONETWO12" then obviously the order of nitro vs ASA matters. What EMS needs to realize is that seconds, and even minutes, rarely matter, and those times that they do we're normally well behind the eight ball already.



Exactly, we have lost all common sense! Seriously, expediting care and yes *not* delaying of care as in packaging in a timely manner, and preventing untimely delays. As mentioned, splitting hairs is only comical ... heck give them both at the same time!.. 

R/r 911


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## Melbourne MICA

*ASA GTN - issues*

Some extraordinary things being said here. 

Aspirin - an *anti *platelet aggregation agent - the opposite of what has been described by some. For a start, the wrong tense of aggregate was used - (semantics I know but speak English please). If you were describing it the way you are it would be platelet aggregator and that's wrong for starters. Aggregation means accumulation thus - "The aggregate effect of all these changes was to ......blah blah blah". Lets hope aspirin isn't causing platelets to aggregate in coronary arteries eh?

Reference for pharmacology of aspirin.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317722/pdf/jathtrain00031-0062.pdf

Its ant-platelet actions are precisely why we use it for ACS and AMI - to aid in reducing red thrombus formation at the fissured plaque site.  The antipyretic, anti-inflammatory and analgesic properties of aspirin are too mild to be of value in the acute setting of ACS/AMI - spot on about that Ridders if you're reading. (Though the anti-inflammatory properties are of value - prevents formation of prostaglandins). The inflammatory component of the disease process  has received significant attention from researchers as well as links between infection and acute coronary disease. Who knows - in the future the treatment for ACS by EMS may be early admin of antibiotics/antivirals and anti inflammatories.  

Onset times and half lives of GTN and aspirin - aspirins' antiplatelet properties last for days (8-10)  hence its value both in preventing thrombus formation in the acute phase of ACS/AMI and also down the track - makes a heck of a lot of sense doesn't it and why this drug is so valuable in the acute coronary pt.

Aspirin starts functioning pretty quickly but obviously with no discernible effect for the pt, except of course they may well not infarct. It lasts for the natural life of platelets.

GTN - tried and tested drug with an onset time of about 30secs - two minutes (buccal - quicker for IV) - reaches therapeutic range in about 10mins with a duration total of about 15-30mins. Whats this guff about 5mins of action - what bloody use would this drug be if lasted just 5mins?

What order to give these drugs? Who gives a rats bit? You see the pt during the acute phase of their clinical problem so the time frame for treatment is early anyway - hospital treatment is a good 30mins - an hour away so give both as early as possible (appropriate to the pts clinical problem and presentation and the CI/SE's/precautions of the drugs) and you've done the right thing. One is to treat the symptoms the other the causative factors at work - I'll let you guess which one does what.

I can't believe there has been 15 pages spent mostly on arguing which one goes first and whether you put an IV in before or after GTN. How many of these pts do we do every shift?

Next subject please.

MM


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## 18G

Great points... sometimes we have to keep the newbies entertained


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## Melbourne MICA

*Storm in a teacup*



18G said:


> Great points... sometimes we have to keep the newbies entertained



Appreciated. What concerns me some guys have no idea whatsoever about the drugs they are giving, why they give them and when to re-evaluate what you are doing based on sound logic and thorough assessment using all the tools and experince at your disposal. Coronary artery disease is _the _major killer in western countries and the preventitive and mitigation phases of its management starts with us. Do it right and we save thosuands of people from early death, from disability and take a healthy chunk out of health care budget costs while we are at it.

It's clearly time for all (some?) of us to hit the books, chat with the experts and catch up with the latest in cardiac management practices and research developments.

MM


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## iftmedic

Could you imagine all this chaos on scene of a chest pain?? When in dought, Vitals, O2, Monitor, IV, Transport . VOMIT. Lol!!!


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## JPINFV

^
Yea.. let's give the patient more free radicals and cause more reprofusion injury. Yea!


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## iftmedic

Increase free radicals and more reprofusion injury? ACS patients? By administration of NTG?


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## JPINFV

iftmedic said:


> Increase free radicals and more reprofusion injury? ACS patients? By administration of NTG?





iftmedic said:


> Could you imagine all this chaos on scene of a chest pain?? When in dought, Vitals, *O2,* Monitor, IV, Transport . VOMIT. Lol!!!


Emphasis added. No need for supplemental oxygen unless the patient is showing signs, symptoms, or monitor results of hypoxia, not just ischemia.


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## iftmedic

Your Paramedic VOMIT was a memory aid that would help you remember what to do in the event you were spinning your wheels on scene and uncertain on what to do, It would basically include the steps of what they sometimes call general ALS, in school it was used in a sarcastic way for medics that were clueless on scene.
It seemed appropriate to mentioned since we had some much disagreement in previous posts. Little humour that's all, but I think most paramedics heard that term in paramedic school.


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## MrBrown

When in doubt, by all means lets follow a standardised approach that covers our bum and eliminates a need for dexterious clinical application of cognitive knowledge (not that the firefighters and patch monkeys like that sort of thing anyway)


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## CAOX3

MrBrown said:


> When in doubt, by all means lets follow a standardised approach that covers our bum and eliminates a need for dexterious clinical application of cognitive knowledge (not that the firefighters and patch monkeys like that sort of thing anyway)



Stop talking sense. 

We have now replaced anatomy and physiology, with how not to get sued in the EMS training modules.

"dexterious clinical application of cognitive behavior"  I like it, Im stealing it.


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## EMSLaw

MrBrown said:


> When in doubt, by all means lets follow a standardised approach that covers our bum and eliminates a need for dexterious clinical application of cognitive knowledge (not that the firefighters and patch monkeys like that sort of thing anyway)



True, and I agree, but sometimes we do step into a scene where one asks oneself, "What the heck do they expect me to do now?"  Usually this involves a mobile home with narrow hallways and a 1000 pound patient, but... 



CAOX3 said:


> We have now replaced anatomy and physiology, with how not to get sued in the EMS training modules.



You know, I should write a paper on this.  For as lawsuit phobic as EMS types are (and I suspect all medical types, though doctors have some reason for their phobia other than paranoia arising out of reading too many online BBoard posts), the changes of an EMT or paramedic being sued are really quite small.  

However, if you're going to be sued, you're going to be sued.  If someone wants to file suit, they will, and so there's no reason to obsess about it.  Pay your (laughably small) malpractice premiums to HCPSO or whoever, and try not to do anything obviously stupid or intentionally harmful.


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## MrBrown

CAOX3 said:


> Stop talking sense.



Never! 



CAOX3 said:


> We have now replaced anatomy and physiology, with how not to get sued in the EMS training modules.



Brown thought you had one of those already? "Ethics and Legal" or something, no?



CAOX3 said:


> "dexterious clinical application of cognitive behavior"  I like it, Im stealing it.



Royalty fees are payable to Brown Inc 

Hey somebody has to pay for my "DOCTOR" jumpsuit .....


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## JPINFV

EMSLaw said:


> You know, I should write a paper on this.  For as lawsuit phobic as EMS types are (and I suspect all medical types, though doctors have some reason for their phobia other than paranoia arising out of reading too many online BBoard posts), the changes of an EMT or paramedic being sued are really quite small.
> 
> However, if you're going to be sued, you're going to be sued.  If someone wants to file suit, they will, and so there's no reason to obsess about it.  Pay your (laughably small) malpractice premiums to HCPSO or whoever, and try not to do anything obviously stupid or intentionally harmful.



Heck, we did medical jurisprudence earlier this year and the med-mal defense lawyers continually pointed out that, and this is against physicians, the vast majority of lawsuits never make it to a deposition or discovery, and the vast majority that make it that far are dropped before trial. Lawyers don't want to take on bad cases that they're likely to lose, thus costing them money.


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## MrBrown

.... just like Doctors dont want sick patients who are liable to die right?


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## Veneficus

EMSLaw said:


> However, if you're going to be sued, you're going to be sued.  If someone wants to file suit, they will, and so there's no reason to obsess about it.  Pay your (laughably small) malpractice premiums to HCPSO or whoever, and try not to do anything obviously stupid or intentionally harmful.




Seems kind of a waste to sue a paramedic, let's face it, they haven't much to take, and they are not really collectable. 

Better to sue a FD or a company I think. Better insurance payout and maybe even a worthwhile settlement.


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## EMSLaw

Veneficus said:


> Seems kind of a waste to sue a paramedic, let's face it, they haven't much to take, and they are not really collectable.
> 
> Better to sue a FD or a company I think. Better insurance payout and maybe even a worthwhile settlement.



Paramedics aren't definitive care, so they aren't expected to "fix it.".  Some of the people on this forum may want paramedics to be more than they are at present, but right now, for the most part, EMS is about treating symptoms in the short term to stabilize the patient and delivering the patient to the ER, as quickly and safely as possible.  Within those limited parameters, the actual risk of making things worse isn't that huge.  And the law also recognizes that what you're expected to do in 10 minutes on a street corner isn't the same as what's expected in a general hospital with lots of resources.  

Of course, Veneficus, you'll eventually be expected to "fix it."


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## jake_EMTI

EKG, IV, Nitro!! You need to know what you're dealing with before you start administering medications, Medical Control will not clear you otherwise.


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## TransportJockey

What do you mean medical control? They usually don't even know I've give ntg until I call my report into the receiving facility.





jake_EMTI said:


> EKG, IV, Nitro!! You need to know what you're dealing with before you start administering medications, Medical Control will not clear you otherwise.


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## Shishkabob

jake_EMTI said:


> EKG, IV, Nitro!! You need to know what you're dealing with before you start administering medications, Medical Control will not clear you otherwise.



Maybe you have some restrictive protocols as an Intermediate, but luckily as a Medic, there is VERY little I even have to notify med control about... and giving NTG to chest pain isn't one.


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## jake_EMTI

Paramedics out here have to notify medical control just the same as EMT-I's do. Our protocols are on the stiff side, but it makes great patient care and it only takes two seconds! No Biggy! I think it works great! Infact we got an award for patient care not to long ago for it, but that's great it works different for you fella's!


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## 18G

Ummm... calling "Mother May I" for something like nitro and everything else is not a good thing. Do you need to call med command to give aspirin and start an IV?


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## MrBrown

*Brown smashes his head on the desk 

You do not need an IV in place to give freaking GTN, if your patient is that shut down and crook you are worried some GTN is going to make them keel over maybe they shouldn't be getting GTN?

High flow oxygen helps everybody too right?


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## TransportJockey

MrBrown said:


> *Brown smashes his head on the desk
> 
> You do not need an IV in place to give freaking GTN, if your patient is that shut down and crook you are worried some GTN is going to make them keel over maybe they shouldn't be getting GTN?
> 
> High flow oxygen helps everybody too right?



But... the protocol book says we must and it's always right isn't it? And of course high con 02 helps everyone, there are no contraindications, so it must be the miracle drug, just like NS


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## MrBrown

Stop smoking crank its making you say embarrasing things 

jk


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## usalsfyre

jake_EMTI said:


> Paramedics out here have to notify medical control just the same as EMT-I's do. Our protocols are on the stiff side, but it makes great patient care and it only takes two seconds! No Biggy! I think it works great! Infact we got an award for patient care not to long ago for it, but that's great it works different for you fella's!



Calling for NTG...do you guys have th big orange box you plug into the patient's phone line to fax lead II as well?

While I do agree with having an idea of what's going on before treating calling for NTG is a moronic gesture. Get a 12 lead, then start treating. Do your medics ask for permission to have a BM as well?

We start NTG infusions without talking to a doc here, not to mention call our own STEMIs...


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## Scott33

MrBrown said:


> *Brown smashes his head on the desk
> 
> You do not need an IV in place to give freaking GTN, if your patient is that shut down and crook you are worried some GTN is going to make them keel over maybe they shouldn't be getting GTN?



More to do with ruling out an RVI in the presence of IWMI, where in about 90% of the population, blood supply to the AV node is fed by the RCA. A decrease in perfusion to a particular group of cells will ultimately decrease its function - not to mention the vasodilatory effects on preload the GTN will have - which in turn, could substantially decrease CO. 

I would say caution should be advised, and at least hook them up to the 12-lead first. Assess, then treat - in that order. Always.

Nothing we can't handle ourselves. Calling MC for GTN at the medic level is just embarrassing and it is not beneficial for the patient to see a so called professional having to ask permission for something so basic. The average Joe in the street could do the same.

You will usually find that counties which have such primitive restrictions are a result of previous f***k ups by providers in the past.


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## johnmedic

*Hmmm*

So, our policy as an als transporting agency is that a line before Nitro is highly advised. But not having a line isn't a contraindication to Nitro. So hi everyone, I'm new, got my registry coming up in a couple months and this thread got me thinking about how it's time to focus on localizing MI's, especially MI with suspected right ventricular involvement..

I've got Dubin's Orange book on EKG's, which helped told me to watch leads II III & AVF to indicate inferior MI, also that hypotension & JVD are often present, what else?


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