# Nitro for BLS



## Wrar (Oct 26, 2016)

Long story short.. We responded to a home. Pt. had a chest pain every time he breathes. Vitals are stable, my partner was going to give Nitro but then he said we can't because in our protocol book, after giving nitro Pt. needed to be IV. since we were all basics and cant IV. We ended up giving Aspirin instead. The question is, why does the patient needed to be in IV after giving Nitro? i didn't learn "IV after giving nitro" in emt class as far as i can remember. Any help would greatly be appreciated


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## Flying (Oct 26, 2016)

Protocols may or may not be sound, and they often include a clause that places them before a caretaker's discretion.
Now that's out of the way, why consider nitro in a stable patient?

Also, if you are allowed to have nitro on a BLS ambulance, I find it hard to believe that your medical director made a clause that was intended to stop you from providing relief to patients.

If your guidelines actually say that nitro administration MUST be followed by IV access, then that section was probably written with higher-level providers in mind and you ought to ask a higher up to clarify that for you.


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## CALEMT (Oct 26, 2016)

Flying said:


> Also, if you are allowed to have nitro on a BLS ambulance, I find it hard to believe that your medical director made a clause that was intended to stop you from providing relief to patients.



This. I find it hard to believe your medical director wants IV fluid after Nitroglycerine administration if you're allowed to carry/administer it on a BLS rig. Perhaps reread the protocol, this could be a simple misinterpretation of it and you can ask your supervisor. Or this could just be one of those completely whacko protocols.


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## WolfmanHarris (Oct 26, 2016)

Here have to have IV access prior to admin if the Pt hasn't taken NTG before AND regardless of previous use we must have a 12/15 to r/o RVI. When possible for the cath lab access should be left side, AC preferred as our PCI lab uses groin primarily and R-arm as their secondary site. 

If I'm concerned about a large drop in BP though I'm not going to admin until I have my line. I'm not going to risk not be able to get access after the fact.


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## DesertMedic66 (Oct 26, 2016)

We have no such protocol for ALS here. Can give NTG and NTG paste with out an IV if needed.


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## Qulevrius (Oct 27, 2016)

Same, assist with pt's prescribed NTG. I don't believe I've ever heard of any of the ALS rigs stocking it. Plus, why would you give NTG to a patient just for 'chest pain' ? Did you consider other factors, such as quality of pain, site, referral, possible SOB, skin, Hx etc ?


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## StCEMT (Oct 27, 2016)

The IV is just to help bump pressures up if they drop too low. I don't get why you would carry it and not be allowed to use it though.


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## SpecialK (Oct 27, 2016)

What a load of rubbish, honestly.

Do patients need an IV before they take their own GTN? No.

We've been giving out GTN to people with no IV in situ for probably close to twenty years and never had a problem; so has the UK and Australia.

If you are that worried about your patient's BP then either don't give it to them (provided they meet the criteria - the local cutoff is BP 100 mmHg systolic and a HR between 50 and 150) or give them a single spray (0.4 mg SL instead of 0.8 mg) and see how they go.


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## StCEMT (Oct 27, 2016)

I have never seen it be an issue. Little sub set of my protocol just calls for fluid in cases like inferior STEMI if they become hypotensive. But what I have read shows no significant difference in giving nitro to any STEMI, so I am not much concerned with it. I would just have one established on this person regardless.


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## Gurby (Oct 27, 2016)

So...... Is the whole "giving nitro to people having a right ventricular MI will tank their BP" thing a myth?

Or is it that people with right sided involvement will usually have soft pressures to begin with, and so don't meet the criteria for nitro anyways?


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## Qulevrius (Oct 27, 2016)

Gurby said:


> So...... Is the whole "giving nitro to people having a right ventricular MI will tank their BP" thing a myth?
> 
> Or is it that people with right sided involvement will usually have soft pressures to begin with, and so don't meet the criteria for nitro anyways?



It's a 'let's dumb it down for the reaper chasers' thing. Same as giving people O2 'for comfort'.


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## Summit (Oct 27, 2016)

Gurby said:


> So...... Is the whole "giving nitro to people having a right ventricular MI will tank their BP" thing a myth?
> 
> Or is it that people with right sided involvement will usually have soft pressures to begin with, and so don't meet the criteria for nitro anyways?


Relevant paper... https://www.ncbi.nlm.nih.gov/pubmed/2502902 Full text here

Gurby the rest isn't directed at you, but more to the topic. 

Most RV MI are hypotensive already... but not all... so we can't assume no RV involvement if normotensive
RV MI are typically preload dependent. Nitro will drop your preload. Will it drop it enough to tank the pressure of a normotensive RV involved patient? 

Sometimes. So do they have RV involvement?

Many RV involved MI are going to have bradycardia... maybe extra n/v... but that is not sensitive/specific...
Bad RV MI may have appreciable JVD, but that is hardly sensitive/specific to RV involvement...
Basically we cannot form a reliable diagnosis or exclusion of RV involvement from vitals and physical findings, just suspicion.

We need a _good _EKG which can tell us about inferior wall, which is sensitive to RV involved STEMI but maybe 40% specific. 

But absent that, a patient who meets criteria for nitro is unlikely to have RV involvement. Unlikely is far from a rule out. So do you withhold the nitro for BLS? It's a gamble, isn't it! Is an EKG equipped unit right around the corner or we are 2 minutes out from the ED? No... well then we stack our odds with an IV before giving the nitro so we can fluid bolus to restore preload...

And if we have none of that, is the benefit for the patients who aren't preload dependent outweighed by the negative effects of tanking the few that are? I guess we still think yes, but I don't have that answer from the data. Hopefully someone more familiar with the data will come along.

Paging cardiology...


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## Tigger (Oct 27, 2016)

Ivangell said:


> Long story short.. We responded to a home. Pt. had a chest pain every time he breathes. Vitals are stable, my partner was going to give Nitro but then he said we can't because in our protocol book, after giving nitro Pt. needed to be IV. since we were all basics and cant IV. We ended up giving Aspirin instead. The question is, why does the patient needed to be in IV after giving Nitro? i didn't learn "IV after giving nitro" in emt class as far as i can remember. Any help would greatly be appreciated


ASA instead? It's not really a one or the other type thing. If you suspect someone is having cardiac chest pain and they have no contraindications to aspirin, give it.


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## Handsome Robb (Oct 27, 2016)

Tigger said:


> ASA instead? It's not really a one or the other type thing. If you suspect someone is having cardiac chest pain and they have no contraindications to aspirin, give it.



This. 

Aspirin is the only thing EMS does that's proven to help outcomes at all. NTG is primarily a patient comfort medication. 

I'm trying to find it but I read a study a while back that showed hypotension was just as common in any STEMI as it is with RVI with NTG administration. 


Sent from my iPhone using Tapatalk


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## EpiEMS (Oct 27, 2016)

Handsome Robb said:


> I'm trying to find it but I read a study a while back that showed hypotension was just as common in any STEMI as it is with RVI with NTG administration.



I've seen this too - I think it may be this one from PHEC? 
"Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction" 

Key findings: "Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. A drop in systolic blood pressure ≥ 30 mmHg post NTG occurred in 23.4% of inferior STEMIs and 23.9% of non-inferior STEMIs, p = 0.87."

Based on this, I would worry about causing hypotension in STEMIs and NSTEMIs with NTG administration about the same amount - not so much, assuming you're starting off with an acceptable BP.


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## Summit (Oct 27, 2016)

EpiEMS said:


> I've seen this too - I think it may be this one from PHEC?
> "Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction"
> 
> Key findings: "Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. A drop in systolic blood pressure ≥ 30 mmHg post NTG occurred in 23.4% of inferior STEMIs and 23.9% of non-inferior STEMIs, p = 0.87."
> ...



Good retrospective study! Full Text here



> We retrospectively reviewed prehospital medical records from Urgences-santé, the sole emergency medical services (EMS) provider for the cities of Montreal and Laval in the province of Quebec, Canada...The majority (99%) of providers at Urgences-santé are trained to the BLS-D level.
> ...
> Another potential limitation is that paramedics may have been more reluctant to give NTG to patients with inferior STEMI and elected to do so only in patients who were stable in their opinion, leading to a selection bias. However, since our paramedics are not trained in ECG interpretation, this is unlikely to have occurred.
> ...
> ...


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## Handsome Robb (Oct 27, 2016)

EpiEMS said:


> I've seen this too - I think it may be this one from PHEC?
> "Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction"
> 
> Key findings: "Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. A drop in systolic blood pressure ≥ 30 mmHg post NTG occurred in 23.4% of inferior STEMIs and 23.9% of non-inferior STEMIs, p = 0.87."
> ...



Yep that's it. 

Sorry got distracted by the pup and her wanting to go to the bark park. 


Sent from my iPhone using Tapatalk


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## Underoath87 (Oct 27, 2016)

Was this your nitro, or were you "assisting" him with his own nitro?


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## StCEMT (Oct 27, 2016)

EpiEMS said:


> I've seen this too - I think it may be this one from PHEC?
> "Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction"
> 
> Key findings: "Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. A drop in systolic blood pressure ≥ 30 mmHg post NTG occurred in 23.4% of inferior STEMIs and 23.9% of non-inferior STEMIs, p = 0.87."
> ...


This was the study I was trying to find again.


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## EpiEMS (Oct 28, 2016)

I'd be curious to hear if any BLS folks can administer service/ambulance-stocked nitroglycerin in the U.S. (not patient-assist/patient's own). I would imagine in some rural areas this is a possibility?


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## Tigger (Oct 28, 2016)

EpiEMS said:


> I'd be curious to hear if any BLS folks can administer service/ambulance-stocked nitroglycerin in the U.S. (not patient-assist/patient's own). I would imagine in some rural areas this is a possibility?


Not in Colorado (where EMTs can also start IVs).


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