# Administering nitroglycerin for cardiac patient



## redbull (Jul 6, 2010)

If a patient has cardiac chest pain, how would you administer nitroglycerin? 

Via tablets or spray? Does it matter?


----------



## TransportJockey (Jul 6, 2010)

Depends. Are you allowed to? I know in NM I could as an EMT-B if the pt has a script for it and had their own (we would actually tend to use the NTG spray or tabs on the bus since a lot of peoples NTG is not as potent as it should be due to improper storage). Really there's no difference in which I would pick. Both deliver usually .03-0.4mg NTG per tab/spray. That being said, if a basic decides to give it they damn well better monitor vitals VERY carefully


----------



## MrBrown (Jul 6, 2010)

We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn

I haven't seen GTN tablets here


----------



## TransportJockey (Jul 6, 2010)

MrBrown said:


> We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn
> 
> I haven't seen GTN tablets here



The NTG tabs I'm talking about ARE SL tabs... Were you thinking like a PO tab?


----------



## abckidsmom (Jul 6, 2010)

MrBrown said:


> We have always used sublingual GTN like since, forever and its good because you can alter dosage 0.4=0.8 prn
> 
> I haven't seen GTN tablets here





Do you mean you've used spray forever?

We've used SL Tabs since the beginning of time, and have never even tried spray.  And I laugh every single time you spell NTG backwards.


----------



## WolfmanHarris (Jul 6, 2010)

Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.

In terms of protocol ours 

Conditions
- HR between 60 and 160 bpm
- Systolic BP >100 mmHg
- No drop in systolic drop of greater than one third from prior BP
- Hx of previous NTG use or IV established
- No medications containing sildenafil (ED meds, revatio)

Administer 0.4mg q 5 min to a maximum of 8 doses.


----------



## Sassafras (Jul 6, 2010)

I would administer whatever form their doctor prescribed since EMT-Bs can not give nitro here, merely assist with their own prescription.  Protocols FTW.


----------



## MrBrown (Jul 6, 2010)

Yes I am meaning like a PO GTN tablet, apparently they do exist.

We have always used the aerosol SL spray


----------



## the_negro_puppy (Jul 6, 2010)

WolfmanHarris said:


> Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.
> 
> In terms of protocol ours
> 
> ...



Our protocol is pretty similar except

HR 50-150
Systolic bp greater than 100
No current CVA or suspected ehad injury
Precaution for inferior MI


----------



## WolfmanHarris (Jul 6, 2010)

the_negro_puppy said:


> Our protocol is pretty similar except
> Precaution for inferior MI



This is covered in the language. All of our medical directives say "The Paramedic may..." rather than "The Paramedic will..." so I do have discretion to withold, provided I document it and can justify it.


----------



## mar7967 (Jul 7, 2010)

WolfmanHarris said:


> Not even sure if you can get tablets around these parts. Only see spray both on the trucks and prescribed to patients.
> 
> In terms of protocol ours
> 
> ...




In NY, the patient must be prescribed NTG...

Out contraindications are:
(1) Blood pressure below 120 mmHg systolic
(2) Heart rate less than 60 bpm
(3) Medication not prescribed for the patient
(4) Pediatric patient
(5) Any patient having taken medication for erectile dysfunction (e.g., Viagra™, Levitra™, or Cialis™) within the
past 72 hours. Medical consultation is required to override this contraindication.

We can give up to 3 doses of 0.4mg SL tablet, including what the pt took PTA. (so if they took 2 doses before we got there, we can only give one more.)


----------



## redbull (Jul 7, 2010)

This is in regards to a quiz question last night. I read in the Brady text it didn't say anything about preference. But both were options on the quiz. :glare:


----------



## abckidsmom (Jul 7, 2010)

redbull said:


> This is in regards to a quiz question last night. I read in the Brady text it didn't say anything about preference. But both were options on the quiz. :glare:





In that case, I bet they were looking for a local protocol answer.


----------



## jjesusfreak01 (Jul 7, 2010)

My instructor states that the sublingual spray is unsanitary, since you are holding it right in front of someones mouth. Of course, that makes pretty much everything else used in pt care unsanitary too.


----------



## WolfmanHarris (Jul 7, 2010)

jjesusfreak01 said:


> My instructor states that the sublingual spray is unsanitary, since you are holding it right in front of someones mouth. Of course, that makes pretty much everything else used in pt care unsanitary too.



Your instructor may not be entirely competent.

Suggest he look up the enteral route of medication administration.


----------



## vquintessence (Jul 8, 2010)

WolfmanHarris said:


> Your instructor may not be entirely competent.
> 
> Suggest he look up the enteral route of medication administration.



I'm assuming he [instructor] is referring to the pt breathing on the NTG spraying device, and all the contagions being able to indefinitely survive in the outside environment, ready to spring upon the unsuspecting cardio/pulmonary pts.

But yeah, I'm with your determination.


----------



## Shishkabob (Jul 8, 2010)

Sassafras said:


> I would administer whatever form their doctor prescribed since EMT-Bs can not give nitro here, merely assist with their own prescription.  Protocols FTW.



Eh, I do my own loophole for my EMT when giving nitro.  Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.


I'm going to give it anyhow, so it's really of no difference.


----------



## vquintessence (Jul 8, 2010)

Linuss said:


> Eh, I do my own loophole for my EMT when giving nitro.  Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.
> 
> 
> I'm going to give it anyhow, so it's really of no difference.



While I think your heart is in the right place, you're putting their license/cert at serious risk.  Hopefully you're not also documenting them being the ones to administer.

Just a grump peeping in from the outside


----------



## Shishkabob (Jul 8, 2010)

vquintessence said:


> While I think your heart is in the right place, you're putting their license/cert at serious risk.  Hopefully you're not also documenting them being the ones to administer.
> 
> Just a grump peeping in from the outside



Eh, that's the gray area.  State of Texas allows EMTs to give nitro, regardless of whether it's the patients own or not.   The EMT section of the company protocols state "Administer prescribed nitro".


But of course I put down that it's me giving it, because it technically is, even if not physically as I'm the one making the decision.  


But that is also where I draw the line:  Allowing an EMT to give a medication that is already within his scope that he's allowed to give.  He doesn't do any Intermediate/Paramedic drugs, no IV drugs, etc etc.


----------



## WolfmanHarris (Jul 8, 2010)

In Ontario medical directives have been interpreted to allow a BLS provider to perform to ALS protocols when the skill is within their scope. 

For example: When treating acute cardiogenic pulmonary edema, my directives as a PCP allow a dosage of 0.4mg NTG SL. An ACP may give 0.8mg. If I am on scene with an ACP I may spray the NTG twice per dose for 0.8mg since the delivery of SL meds is within my skill set, even though that dosage is outside my directives since the ACP is saying, "Hey, give them two sprays for me."

This also goes for hitting the shock button on a manual defib setting. While I operate in semi-auto mode, the ACP is the one interpreting the monitor and saying, "Okay charge to this for me and hit shock please." The pushing of the button isn't of any concern to Medical Direction, the decision making is.


----------



## WolfmanHarris (Jul 8, 2010)

vquintessence said:


> I'm assuming he [instructor] is referring to the pt breathing on the NTG spraying device, and all the contagions being able to indefinitely survive in the outside environment, ready to spring upon the unsuspecting cardio/pulmonary pts.
> 
> But yeah, I'm with your determination.



Perhaps, but for us NTG spray is one time use. After the few shots it goes with the Pt. or into the garbage. No cross contimination. I sure as heck hope there's not areas where the meds are being used for multiple patients.


----------



## TransportJockey (Jul 8, 2010)

WolfmanHarris said:


> Perhaps, but for us NTG spray is one time use. After the few shots it goes with the Pt. or into the garbage. No cross contimination. I sure as heck hope there's not areas where the meds are being used for multiple patients.



That is a hell of a lot of waste of medications...


----------



## WolfmanHarris (Jul 8, 2010)

jtpaintball70 said:


> That is a hell of a lot of waste of medications...




Unit cost for the service is $0.17 per NTG spray.
Can't remember for the salbutamol. I don't work in management, I was just told that figure once by a Superintendent during a chat.

Better waste than cross contamination. Though I find working in health care does run headlong into my eco-friendly side. Especially when I don my fourth or fifth pair of gloves for the call.


----------



## reaper (Jul 8, 2010)

NTG spray here is around $100 a bottle. No way that is going to be wasted. The tip should never come in contact with the pt and it should be cleaned after each use.


----------



## octoparrot (Jul 8, 2010)

Mass BLS protocol

BP greater than 100 mmHG, Assist PT 0.3 - 0.4 mg SL; q 3-5 minutes prn to maximum of 3 doses. NTG spray: 0.4 mg under the tongue; 1-2 sprays.


----------



## Stew (Jul 8, 2010)

the_negro_puppy said:


> Our protocol is pretty similar except
> 
> HR 50-150
> Systolic bp greater than 100
> ...


Puppy, you're missing one contraindication... (on my skim through I don't think it's been mentioned anywhere else).


----------



## exodus (Jul 8, 2010)

Lack of viagra


----------



## Sassafras (Jul 8, 2010)

Linuss said:


> Eh, I do my own loophole for my EMT when giving nitro.  Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.
> 
> 
> I'm going to give it anyhow, so it's really of no difference.



Ahh yes, but we are a bls unit, so unless we dispatch the medics there's no other nitro around...given, we do always dispatch them for chest pain, but sometimes you have to wait a wee bit for them to get there so it's your own nitro and a non rebreather till they get there...and if you need another before they do, I have to call medical command...still gets me off the hook...until the medic gets there and throws his tackle box at me.  Eeesh.  Why are all the caps gray in that thing.  I'm totally going to hand him the wrong "one with the gray cap" one of these days.


----------



## Sassafras (Jul 8, 2010)

exodus said:


> Lack of viagra



Or ciallis 

And ask the ladies too since apparently they are experimenting with it now.


----------



## WolfmanHarris (Jul 9, 2010)

Sassafras said:


> Or ciallis
> 
> And ask the ladies too since apparently they are experimenting with it now.



More likely is that they were taking it for an off label usage for pulmonary hypertension of reynaud'. Hence the repackaging and remarketing of Revatio for that purpose.


----------



## the_negro_puppy (Jul 11, 2010)

Stew said:


> Puppy, you're missing one contraindication... (on my skim through I don't think it's been mentioned anywhere else).



erectile dysfunction medication in previous 24 hours


----------



## Melclin (Jul 11, 2010)

Anyone else have VT as a a C/I?

I don't hear much talk about RVI/Inferior STEMI either. Maybe not as a CI but precautions...reduced doses.


----------



## TransportJockey (Jul 11, 2010)

Melclin said:


> Anyone else have VT as a a C/I?
> 
> I don't hear much talk about RVI/Inferior STEMI either. Maybe not as a CI but precautions...reduced doses.



V/T is a CI in NM for medics giving the drug as well. And might be for NM EMT-Is as well


----------



## clibb (Jul 11, 2010)

the_negro_puppy said:


> erectile dysfunction medication in previous 24 hours



For some medications it's 36 hours now.


----------



## Shishkabob (Jul 11, 2010)

clibb said:


> For some medications it's 36 hours now.



Depends on your protocols.


----------



## clibb (Jul 11, 2010)

Linuss said:


> Depends on your protocols.



Here we were taught that if the patient has taken Viagra within 36 hours we should not administer Nitro... But yeah, that might just be our protocols. I don't know.


----------



## 18G (Jul 11, 2010)

As for the original OP's question.... generally spray or tablet it doesn't really matter which is used. They are both nitro of the same dose just different delivery methods. They will have the same effect. 

Absorption can be considered a factor in which type an EMS service carries. The sub-lingual tablet needs to dissolve under the tongue before it can start to work. The spray (being in a liquid form) does not need to undergo the same transformation process prior to absorption. So the spray should start to work sooner then a SL tablet. I've not seen any study that say's one has a better efficacy then the other but its makes perfect sense how a spray would work faster. Also, if a patient has dry mouth the SL nitro tablet will have a hard time dissolving. In this case you can squirt some normal saline under the tongue to aid the tablet in dissolving.

I had a priority patient once we were treating with SL captropril... we got to the ED and the captopril was still in solid form with very little dissolving due to the patient having really dry mucus membranes...

All nitro spray I have seen used on an EMS unit is multi-patient use. The bottle does not come into contact with the patient. To me it seems really wasteful to ditch a full bottle of perfectly good nitro spray. 

The SL tablets are much cheaper than the nitro spray. I personally prefer the spray.


----------



## mcdonl (Jul 11, 2010)

Linuss said:


> Eh, I do my own loophole for my EMT when giving nitro.  Our protocols state that EMTs can only give prescribed nitro... technically every drug a Paramedic gives to a patient is prescribed for that patient at that time by standing orders, therefor I allow my EMT to give the trucks nitro.
> 
> 
> I'm going to give it anyhow, so it's really of no difference.



I had a patient this morning which chest pain and PMHX of cardiac problems, I called OLMC for permission to assist with the patients nitro... received permission, and then said.... oh... by the way the patients SL tablets are expired. Med Control said use what we have on board. Pt got the spray...

I Should also mention ALS was en-route, and in radio communications and knew what was going on.


----------



## Sassafras (Jul 11, 2010)

clibb said:


> Here we were taught that if the patient has taken Viagra within 36 hours we should not administer Nitro... But yeah, that might just be our protocols. I don't know.



We have...
Viagra 24
Cialis 36


----------



## clibb (Jul 12, 2010)

Sassafras said:


> We have...
> Viagra 24
> Cialis 36



I totally just mixed those two up. You're right, sorry h34r:


----------

