# Aspirin contraindications??



## VirginiaEMT (Oct 22, 2010)

I am posting this in the ALS section even though I am an EMT-B because I realize that most B's don't have aspirin as part of their protocols.

As an EMT-B, I am authorized without medical direction to administer 324 mg of aspirin to someone who has cardiac related symptoms as well as administering the patients prescribed nitro, up to 3 every 3-5 minutes with out medical direction.

I realize that some of the contraindications of aspirin usage include NSAID usage, aspirin allergy, and blood thinners.

I remember reading somewhere that asthma is also a contraindication but I am finding it difficult to find any information on the subject. Could someone please enlighten me on the the subject as well as other contrindications that I should be aware of?


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## TacoMEDIC (Oct 22, 2010)

Aspirin is not absolutely contraindicated for pts with Asthma. It is  just a consideration. Bronchiospasm could be induced or worsened by  NSAIDs in some Asthmatics.

Another Contraindication is Peptic Ulcers.


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## LucidResq (Oct 22, 2010)

VirginiaEMT said:


> I am posting this in the ALS section even though I am an EMT-B because I realize that most B's don't have aspirin as part of their protocols.



Really? I thought this was a relatively common drug for EMT-Bs... we have it out here in CO... 




VirginiaEMT said:


> I remember reading somewhere that asthma is also a contraindication but I am finding it difficult to find any information on the subject. Could someone please enlighten me on the the subject as well as other contrindications that I should be aware of?


It is my understanding that some individuals with asthma are sensitive to aspirin, but I don't believe a hx of asthma is an absolute contraindication... especially when your pt has no such history. 


Aspirin is probably not a good idea when your pt has symptoms of stroke, despite what Linuss' genius partner might think XD


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## TransportJockey (Oct 22, 2010)

I've never been in a place where EMT-Bs didn't have ASA either. But as for other NSAIDs... I've never seen that as a contraindication for giving it in a CP pt. Peptic ulcers, bleeding disorders are both CIs. Caution in using it with pts already on blood thinners.


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## 18G (Oct 22, 2010)

Asthma is considered a relative contraindication for asthma. Some asthma patients develop bronchoconstriction/wheezing and dyspnea when they take aspirin. 

The aspirin can cause release of chemical mediators (leukotrienes) that cause the bronchoconstriction. Again, not all asthma patients will have this reaction but it is important to know in case your patient starts to wheeze after giving them aspirin. 

I wanna say the percentage of asthma patients that have sensitivity to ASA is 5-10%? I'll have to look it up to be sure of that percentage but I know its right around there.


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## 18G (Oct 22, 2010)

EMT-B's in Pennsylvania do not carry or administer ASA.


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## Smash (Oct 22, 2010)

True allergy/anaphylaxis is the only real contra-indication to aspirin in ACS.


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## VirginiaEMT (Oct 22, 2010)

Smash said:


> True allergy/anaphylaxis is the only real contra-indication to aspirin in ACS.



Thanks....


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## Cawolf86 (Oct 22, 2010)

In the LA County protocols - ASA is contraindicated by hypersensitivity, active GI bleed/ulcer, and hemorragic stroke.


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## skivail (Oct 22, 2010)

To receive ASA Pt must:
-be = or >40kg
-be alert and responsive
-NOT have an allergy to ASA or other NSAID
-NOT have current active bleeding (GI or other)
-have no evidence of CVA or head injury in the past 24 hours
-have a history of prior ASA with no adverse reaction if an asthmatic 

That is from Ontario, Canada


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## CAO (Oct 23, 2010)

Never heard of that until now.  Triple checking my copy of Mosby's, asthma isn't listed.

Looking online, it does show around 5% of the population with asthma to be sensitive, but it looks like the attacks it brings on can happen several hours later.

Gotta choose between something killing him now and something killing him later.  Hopefully you'll have him in the hospital by that time.


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## Shishkabob (Oct 23, 2010)

LucidResq said:


> Aspirin is probably not a good idea when your pt has symptoms of stroke, despite what Linuss' genius partner might think XD



Oh no, not just my partner, but the intermediate that was there as well.   




I swear I worry about patients welfare when they aren't with me or the couple of medics at my company that I actually trust.


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## Melclin (Oct 23, 2010)

Chest pain secondary to psychostimulants in the presence of high blood pressures is something to consider.

The issue is probably demand ischaemia so aspirin is not the answer. To add to that, should they haemorrhage in some way from high BP, you worsen their outcomes. 

Its not a contraindication.. more of a situation in which it isn't indicated and may possibly do some damage. 

On the topic of guidelines, our Aspirin contras are:
-Hypersensitivity/allergy. 
-Actively bleeding peptic ulcer. 
-Bleeding disorders.
-dissecting AAA.
-Chest pain in psychostimulant OD with BP > 160.

The last two are just areas where it wouldn't be indicated and their identification is a matter of diagnostics not drug contraindications. It bothers me when protocols or people say something is contraindicated simply because it would be a detrimental to give it in that situation. It would be detrimental to give a person aspirin in uncontrolled haemorrhage too, doesn't mean its contraindicated because it wasn't indicated in the first place.


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## LucidResq (Oct 23, 2010)

Melclin said:


> Chest pain secondary to psychostimulants in the presence of high blood pressures is something to consider.
> 
> The issue is probably demand ischaemia so aspirin is not the answer. To add to that, should they haemorrhage in some way from high BP, you worsen their outcomes.



This is a good point... now I know this is a bit of a tangent but can you tell me specifically what psychostimulants are likely to cause HTN and chest pain and such in the field? I know drugs of choice on the street in Australia might vary a little bit from out here, but still, has anyone seen this in the field and what was the presentation like? I'm just curious really.

We had an 18 yo male pt once who came in complaining of a bad HA, he was relatively healthy with no medical hx although a bit obese. I took his blood pressure as the medic was talking to him and my eyes nearly popped out of my head as it was something around 200/100, which he was able to confirm was not normal. I believe his heart rate was also a little elevated around 90-110 or so. The medic was able to confirm the high bp and if I remember correctly 12-lead showed nothing abnormal. We tried our damnedest to get him to go in (I was working at the amusement park, this was an employee) but he refused and said he'd go to the doctor later. I remember the medic mentioning cocaine or another stimulant as a possible cause. 

I don't mean to hijack the thread (ok, yes I do) but since we're on the subject.... can anyone talk about what drugs and presentation one might see on the street?


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## Shishkabob (Oct 23, 2010)

Cocaine, Amphetemines, Ectasy, PCP

Agitated, sometimes combative, elevated (extremely so sometimes) HR and BP, diaphoretic, tachynpnea.  



We give Valium, along with Morphine, to those experiencing chest pain after taking an illicit stimulant.


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## Outbac1 (Oct 23, 2010)

ASA From our Medical Oversight Medications list. http://www.gov.ns.ca/health/ehs/documents.asp

2.0 *Classification*
2.1 Analgesic.
2.2 Antipyretic.
2.3 Platelet inhibitor.

3.0 *Mechanism of Action*
3.1 Reduces platelet stickiness.
3.2 Prolongs bleeding time.
3.3 Onset 30 minutes.
3.4 Duration 24 - 48 hours.

4.0 *Indications*
4.1 All patients experiencing possible ischemic chest pain.
4.2 AMI.
4.3 Unstable angina.

5.0 *Contraindications*
5.1 GI bleeding.
5.2 Allergy.
5.3 Asthmatics sensitive to ASA.

6.0 *Dosage*
6.1 Chew two 80 mg tablets.

7.0 *Supplied*
7.1 80 mg tablets.

8.0 *May Be Given By*
8.1 All paramedics.

9.0 *Precautions*
9.1 Patients already on ASA or another platelet inhibitor such as Ticlid do not require ASA.

10.0* Side Effects*
10.1 Indigestion, epigastric distress.
10.2 Nausea and vomiting.
10.3 Gastric bleeding.
10.4 Urticaria or anaphylaxis (allergy).

I always ask pts if they have had it before and if it caused any problems or had adverse effects, in addition to asking them if they have any allergies before giving any med.


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## Melclin (Oct 23, 2010)

LucidResq said:


> This is a good point... now I know this is a bit of a tangent but can you tell me specifically what psychostimulants are likely to cause HTN and chest pain and such in the field? I know drugs of choice on the street in Australia might vary a little bit from out here, but still, has anyone seen this in the field and what was the presentation like? I'm just curious really.



I haven't had much experience with psychostimulants on the road. So I couldn't tell you for sure presentation wise. In my limited experience, they come straight out and say, "I've taken all this speed and now my chest hurts and I'm just really anxious and I was worried I might be overdosing. Am I ganna be alright?". They're 17, been at [INSERT TRENDY NIGHTCLUB NAME] and slammed 2 red bulls because they didn't have anything for dinner. Not exactly screaming acute coronary syndrome. They're generally responsive to PO fluids, 15 minutes of sitting down and anti-anxiety techniques like removing excessive stimuli and breath coaching. But I've never seen someone properly OD needing midaz etc.  

Methamphetamine is very very popular here amongst the lower class "junkie" type users - there was a bit of a heroin drought and ice took over. 

In the party scene, there is an increasing popularity of technically legal drug analogues and various strange chemicals, on account of increasingly internet savy youngsters who feel the need for speed.


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## Smash (Oct 24, 2010)

VirginiaEMT said:


> Thanks....



I presume from you artful use of the ellipsis (although strictly speaking it should have only three little dots...) that my answer may be somewhat less useful than you had wanted.  I am, however, taking my answer directly from the AHA.  The benefits of aspirin in ACS is so great and the potential harm so small, that if you suspect that your patient is having some kind of coronary event, the best thing you can do is give aspirin.



Melclin said:


> Chest pain secondary to psychostimulants in the presence of high blood pressures is something to consider.
> 
> The issue is probably demand ischaemia so aspirin is not the answer. To add to that, should they haemorrhage in some way from high BP, you worsen their outcomes.
> 
> ...



Meh... so aspirin isn't great for someone with a bleeding ulcer... Risk/Benefit (assuming the patient is indeed having an ACS) is still soundly in the "give aspirin" field.  Bleeding disorders are a varied and wonderful bunch of disorders that stem from problems with many and varied factors.  Just because they have some kind of disorder doesn't mean they won't benefit from inhibition of platelet aggregation during the cardiac event.

The last two I agree are strange.  I find it odd when things are contra-indicated for conditions that no sane person would consider them indicated for.  It's like saying that chest tube insertion is contra-indicated in someone with an isolated extremity fracture.  No-one puts that in their protocol because it would never occur to a normal, mostly sane person to do it.


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## Melbourne MICA (Oct 24, 2010)

*Sidetrack*

Just a little historical footnote but Aspirin was apparently first identified by an English priest in the 1700's who observed local villagers making a kind of slurry from willow leaves. The villagers claimed the drink was used for any number of problems the priest describing this administration to treat "general malaise". This very observant fellow made a point of documenting his observations and largely thanks to him this quite extraordinarily versatile drug has been used ever since.

As for how Aspirin is used by EMS my view would be it is only used to prevent clot formation in occluded coronary arteries - ie to reduce the risk of infarct.
We have much better analgesics, better anti-inflammatories and better anti-pyretics. In the psycho-stimulant pt I can't see it serving any purpose whatsoever even in the infarcting cocaine overdose pt where coronary artery spasm and widespread vaso constriction are the culprits not fissured coronary artery plaques with clots forming.

As for precautions and contraindications, active bleeding disorders is a gimme and sensitivities the other. I'll take your word about the asthmatics.

MM

MM


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## Melclin (Oct 24, 2010)

Smash said:


> The benefits of aspirin in ACS is so great and the potential harm so small, that if you suspect that your patient is having some kind of coronary event, the best thing you can do is give aspirin.
> 
> Meh... so aspirin isn't great for someone with a bleeding ulcer... Risk/Benefit (assuming the patient is indeed having an ACS) is still soundly in the "give aspirin" field.  Bleeding disorders are a varied and wonderful bunch of disorders that stem from problems with many and varied factors.  Just because they have some kind of disorder doesn't mean they won't benefit from inhibition of platelet aggregation during the cardiac event.



I certainly agree. Their disorder may be nothing to do with platelet aggregation nor may it matter in the setting of ACS. But for the time being I feel I should defer to my guidelines given my relatively poor knowledge of bleeding disorders. If I can't directly back it up, I shouldn't do it. But I'm working on it. 



Smash said:


> The last two I agree are strange.  I find it odd when things are contra-indicated for conditions that no sane person would consider them indicated for.  It's like saying that chest tube insertion is contra-indicated in someone with an isolated extremity fracture.  No-one puts that in their protocol because it would never occur to a normal, mostly sane person to do it.



To me a contraindication means it _was_ indicated but due to additional reason ________ , you _absolutely_ can't do it. Situations where it is not useful or even detrimental, but not indicated in the first place, s**t me to tears. We have a few things like that floating around in guidelines. Especially about fluid. Modifyin factors they're called. Don't give fluid to a pt with poor perfusion 2ndry to a tension pneumo - what the bloody hell would I?


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## MrBrown (Oct 24, 2010)

We are cautioned against using it for asthmatics and have recently removed GI bleeding as a contraindication.


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## emtchick171 (Oct 27, 2010)

As far as contraindications for Aspirin (ASA); only true allergic reactions. 

However, precautions are: GI Bleed, upset stomach, and because Aspirin is a platelet inhibitor it is not recommended for PTs taking blood thinners, but just because they are precautions/not recommended does not mean these things are "set in stone". Use proper judgment, and if need be...ask your ALS provider/partner if you work with an ALS service.


- -information comes from North Carolina Protocols.


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## the_negro_puppy (Oct 28, 2010)

CVA/Head trauma

Peptic ulcers/hx of GI Bleeds

Bleeding disorders

known severe adverse reaction to aspirion or other NSAIDS

Children under 18


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## emt_irl (Oct 28, 2010)

in ireland our contra-indications for asprin are:

under 16

active g.i ulcer or bleed

bleeding disorder( e.g hemophila)

and a known severe adverse reaction.


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## firetender (Oct 28, 2010)

VirginiaEMT said:


> As an EMT-B, I am authorized without medical direction to administer 324 mg of aspirin to someone who has cardiac related symptoms... QUOTE]
> 
> What I'm curious about is how do you manage to knock off that extra mg. from the standard 325 mg ASA tablet?


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## emtchick171 (Oct 28, 2010)

firetender said:


> VirginiaEMT said:
> 
> 
> > As an EMT-B, I am authorized without medical direction to administer 324 mg of aspirin to someone who has cardiac related symptoms... QUOTE]
> ...


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## firetender (Oct 28, 2010)

emtchick171 said:


> If their standards are like North Carolina's standards...we only carry 81mg tablets of ASA on our trucks...so administration of 4 tablets will give you the 324mg. There has been a large debate within the past year or so about the 324mg (4 tablets) versus the 325mg (1 tablet).


 
I really ought to look inside one of these trucks again!


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