# high dose nitro



## Hunter (Jan 9, 2012)

Recent article I found, opinions?

http://ambulancedriverfiles.com/2011/11/03/just-so-were-clear-on-the-concept/


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## 46Young (Jan 9, 2012)

Hunter said:


> Recent article I found, opinions?
> 
> http://ambulancedriverfiles.com/2011/11/03/just-so-were-clear-on-the-concept/



I agree with the article. Also, in my system, we treat cardiac Acute Pulmonary Edema with double dose ntg (0.8 mg/dose) and CPAP until a therapeutic endpoint is reached, or adverse signs appear, on the ALS level.


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## STXmedic (Jan 9, 2012)

Agreed. Amen AD, good article. We use high dose nitro in conjunction with CPAP here on a very regular basis with no problems. IV Nitro was just added as well and should be arriving shortly


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## socalmedic (Jan 9, 2012)

We use it, 0.4mg every min with cpap. Untill relief then 0.4 every 3-5 min, or hypotension.


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## 18G (Jan 9, 2012)

In PA we use aggressive NTG dosing that is B/P dependent. 

Protocol states for CHF:
** dosed every 3-5mins**

SBP >180 = 1.2mg (3 sprays)
SBP 140-180 = 0.8mg (2 sprays)
SBP <140 - 0.4mg (1 spray)

We also have nitro paste. 

Considering that the primary goal in the acute management of CHF is pressure reduction, getting increased doses of NTG onboard is very important.


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## NYMedic828 (Jan 9, 2012)

NYC has unlimited standing order nitro Q3-5 for Chest Pain or APE. If a patient is hypertensive we usually hit them with a double dose before going to the ambulance.

Lasix was actually moved to a medical control option. The docs don't usually like to give it to us either unless the patient is already prescribed it.

Morphine was also removed as a medical control option for Chest pain but continues to be used for APE. We can still call for discretionary morphine of course.


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## 46Young (Jan 9, 2012)

NYMedic828 said:


> NYC has unlimited standing order nitro Q3-5 for Chest Pain or APE. If a patient is hypertensive we usually hit them with a double dose before going to the ambulance.
> 
> Lasix was actually moved to a medical control option. The docs don't usually like to give it to us either unless the patient is already prescribed it.
> 
> Morphine was also removed as a medical control option for Chest pain but continues to be used for APE. We can still call for discretionary morphine of course.



Where do you work?

I miss NYC EMS, and the fact that medics only get dispatched for ALS job types. In most of the country, medics run everything. What I don't miss is the restrictive protocols. It's understandable when you have FDNY, a bunch of hospitals, and a couple of privates. The quality of provider is inconsistent. In other systems, we have IV and IM Fent, EZ IO drills, CPAP w/ in line nebs, King LT airways, quantitative capnpography including the sidestream capnolines for conscious patients, and protocols where you can call for anything within your scope, not just what's featured as OLMC options.


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## R99 (Jan 9, 2012)

GTN here is 0.4-0.8mg with the vast majority of patients getting 0.8mg or two doses at once


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## NYMedic828 (Jan 9, 2012)

46Young said:


> Where do you work?
> 
> I miss NYC EMS, and the fact that medics only get dispatched for ALS job types. In most of the country, medics run everything. What I don't miss is the restrictive protocols. It's understandable when you have FDNY, a bunch of hospitals, and a couple of privates. The quality of provider is inconsistent. In other systems, we have IV and IM Fent, EZ IO drills, CPAP w/ in line nebs, King LT airways, quantitative capnpography including the sidestream capnolines for conscious patients, and protocols where you can call for anything within your scope, not just what's featured as OLMC options.



Im with FDNY.

Recently NYC has started moving towards the style of other systems. Currently we have

Theraputic hypothermia
EZ IO drills
CPAP is in protocol, but FDNY deemed it too expensive. Some privates carry.
Combitube is our only option outside of ET tubes.
Sidestream capno
We carry fentanyl, versed, valium, etomidate, morphine.
We can use any medication or skill in our scope for anything as long as it is approved as a discretionary decision through the medical director.
We just replaced EVERY monitor on all FDNY ambulances with Philips MRX units. I prefer the lifepak-15 but i wont complain about a color screen monitor.

The operating procedures actually have a nice line in them that states "These protocols are guidelines and are to be used in conjunction with good clinical judgement"

As a very new medic, I really am not in the place to comment on inconsistency of providers but I do know what you mean. It is hit or miss in these parts if you are getting the care you truly should be when you call 911.

The getting called only to jobs that are supposedly ALS is a nice perk for sure. Definitely allows me to learn as a medic much faster without having to deal with stubbed toes half my day.


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## 46Young (Jan 9, 2012)

NYMedic828 said:


> Im with FDNY.
> 
> Recently NYC has started moving towards the style of other systems. Currently we have
> 
> ...



Good, it sounds like your system is coming out of the dark ages, with the exception of the lack of CPAP. I left NS-LIJ in 2007 for a municipal EMS job out of state. 

As far as inconsistency, it's different when your service is the only one operating in your jurisdiction, save any mutual aid agreements. The hiring standards, training, QA/QI, and discipline are the same for everyone. As such, the providers can be given more trust and autonomy. No problems with pt steering, either. It's not exclusive to the hospitals and privates, certain volunteer departments will also refuse to txp out of their first due since it will take their unit out of service for too long.

We have the Phillips, only because the LP15 was cost prohibitive. I don't particularly care for it. It' subject to a lot of artifact, and only shows one lead at a time. The cables from the ECG to the SpO2 are way too short.


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## 325Medic (Jan 10, 2012)

18G said:


> In PA we use aggressive NTG dosing that is B/P dependent.
> 
> Protocol states for CHF:
> ** dosed every 3-5mins**
> ...



Took the words from my mouth. I have given at least x (3) doses of NTG (9 ntg's total) and the nurses go bonkers. "THATS TOO MUCH" they say. Doc says thats awesome that the S.O.P.'s are like that now.

325.


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## DrParasite (Jan 10, 2012)

18G said:


> Considering that the primary goal in the acute management of CHF is pressure reduction, getting increased doses of NTG onboard is very important.


we used to use lasix for CHF treatment (10+ years ago).  as an uneducated provider, I can say we now give NTG as long the pressure stays above 100 systolic, and than CPAP.

the NTG dilates the blood vessels, and the CPAP pushes the fluid out of the lungs and back into the vessels, which can handle the additional fluid because they have been dilated by the NTG.


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## Aprz (Jan 10, 2012)

Not exactly the same discussion, but makes me think of this post on SDN.

http://forums.studentdoctor.net/showthread.php?p=11945955#post11945955

Unfortunately, my county/system allows us only to administer 0.4 NTG SL q 3-5 minutes up to 5 doses. :\


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## systemet (Jan 10, 2012)

Hunter said:


> Recent article I found, opinions?
> 
> http://ambulancedriverfiles.com/2011/11/03/just-so-were-clear-on-the-concept/



The author seems to be conflating two issues, the treatment of congestive heart failure with acute pulmonary edema, and the managment of acute coronary syndromes.

I agree wholeheartedly that patients presenting with cardiogenic pulmonary edema with a reasonable pressure should receive a large amount of nitroglycerin, coupled with CPAP (or some sort of BPAP if available), and maybe an ACE inhibitor.    

I don't know that I see the need for bolus IV NTG in the vast majority of CHFers.  I'm not convinced that there's the evidence to support its safety and efficacy, especially prehospitally.

I disagree with the author's opinion on the safety of NTG in ACS without a 12-lead.  I disagree strongly with his position that patients that are preload dependent will present looking unstable.  Anyone who has used 12-lead for any length of time has seen just how many patients look incredibly sick but don't show STEMI (and are even cleared for NSTEMI later), and how many patient seem very minor, or even noncardiac, and the 12-lead reveals a massive STEMI.  A percentage of these patients are preload dependent RVIs for whom indiscriminate NTG use is potentially disastrous.

These are two entirely different patients.  The preload dependent RVI patient should have clear lung fields, unless something else is going on.


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## 18G (Jan 10, 2012)

DrParasite said:


> the NTG dilates the blood vessels, and the CPAP pushes the fluid out of the lungs and back into the vessels, which can handle the additional fluid because they have been dilated by the NTG.



Somewhat. But not really.  

In CHF, the neurohormonal responses (sympathetic, RAAS) kick into high gear to compensate for the reduced cardiac output. The side effects of this response are very high B/P (unless cardiogenic shock), increased HR, and increased afterload. 

The APE comes from the failing LV which cannot handle the blood being returned to it and as a result it backs up into the left atrium and than the pulmonary vasculature. This creates a much higher pressure within the pulmonary system. This increased pressure is what forces fluid across the alveolar-capillary (AC) membrane and into the interstitial and alveolar spaces resulting in acute pulmonary edema (APE). 

This fluid in the lungs has several negative effects with mainly being increased diffusion distance... gases have to travel further through the fluid to reach their destination... and atelectasis... the fluid causes the alveoli to collapse from surfactant washout. As a result, work of breathing goes way up as it takes more force to inflate a collapsed alveoli... this is where the beauty of CPAP comes in. 

With CPAP, there is a continuous pressure applied to the airways on expiration which keeps the alveoli from collapsing. Since the alveoli are always partially inflated, it lessens the amount of work to expand them and have them take part in gas exchange.Think of a balloon. What is the hardest part of blowing up a balloon? It's always the initial blow right when the balloon is completely empty. Once you have a little air in the balloon you don't need to blow near as hard to inflate it. It's the same concept in the lung and this is what dramatically reduces the work of breathing. CPAP aids in recruitment of alveloi.  

So the benefits of CPAP are: reduced atelectasis, reduced work of breathing, and increased surface area available for gas exchange. With the positive pressure induced within the chest, there is also reduced preload and a reduction in afterload which is a great thing. Reduced preload results in further reduction of B/P and reduced afterload makes it easier for the heart to eject blood.   

Hopefully you can see there is no actual "forcing of fluid" out of the airways. The fluid leaves the airways mainly as a result of restoring the pressure gradient in the lungs by lowing the blood pressure. 

The main goal of NTG in CHF is pressure reduction for reasons stated above. It's vital to get the B/P down to allow the fluid to retreat back across the AC membrane to where it belongs. Other main goals are to reduce the workload of the heart. To dilate is to reduce preload which makes the heart work less hard and reduces myocardial oxygen consumption. NTG also has effect on afterload especially with higher doses which makes the heart work less hard as it doesn't have near the resistance to pump against. A reduction in afterload is where ACE inhibitors come into play as that is what they do - some current evidence strongly recommend ACE inhibitors early. 

A lot of patients in CHF are euvolemic (normal volume) or sometimes even dehydrated. Lasix isn't where the prize is. Along with diuresis effect, Lasix also relaxes blood vessels as well. But evidence doesn't hold Lasix real high anymore. And morphine has been shown to be bad in CHF. I like fentanyl personally. To treat with opiates helps to reduce the sympathetic response.  

I just spewed this out but hopefully it helps to understand what is really going on and what the initial treatment goals are.


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## Hunter (Jan 10, 2012)

18g said:


> somewhat. But not really.
> 
> In chf, the neurohormonal responses (sympathetic, raas) kick into high gear to compensate for the reduced cardiac output. The side effects of this response are very high b/p (unless cardiogenic shock), increased hr, and increased afterload.
> 
> ...



+102


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## epipusher (Jan 10, 2012)

Our protocols are(bp dependent of course)3 sprays of ntg at a time every 3-5 minutes. CPAP is used as well. It has been in our protocols for years, but we are often asked by ER staff why the ntg if no complaint of cp.


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## Scott33 (Jan 12, 2012)

NYMedic828 said:


> NYC has unlimited standing order nitro Q3-5 for Chest Pain or APE. If a patient is hypertensive we usually hit them with a double dose before going to the ambulance.
> 
> Lasix was actually moved to a medical control option. The docs don't usually like to give it to us either unless the patient is already prescribed it.
> 
> Morphine was also removed as a medical control option for Chest pain but continues to be used for APE. We can still call for discretionary morphine of course.



I didn't realize FDNY did not have CPAP. I know glucometry is a recent addition too in some agencies, although with the revised hypoglycemia / AMS protocol (BGL of <120 = give glucose) what does it matter? <_<

I agree with lasix being withdrawn from the MAC standing orders, particularly for those who have CPAP and no limit on nitro, if hemodynamics allow. It was always more trouble than it was worth.


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## jjesusfreak01 (Jan 18, 2012)

I've been told that no one is going to get upset if you fluid bolus pulmonary hypertension patients in order to keep their BP high enough for continued nitro...


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## systemet (Jan 19, 2012)

jjesusfreak01 said:


> I've been told that no one is going to get upset if you fluid bolus pulmonary hypertension patients in order to keep their BP high enough for continued nitro...



When you say "pulmonary hypertension" here, do you mean as a result of LV failure, e.g. the acute CHF patient?  I would agree that a lot of these patients are actually volume-depleted and could do with some fluids.

Or are you referring to the rare disease called "Pulmonary arterial hypertension", where the treatment considerations are quite different?


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## jjesusfreak01 (Jan 19, 2012)

systemet said:


> When you say "pulmonary hypertension" here, do you mean as a result of LV failure, e.g. the acute CHF patient?  I would agree that a lot of these patients are actually volume-depleted and could do with some fluids.
> 
> Or are you referring to the rare disease called "Pulmonary arterial hypertension", where the treatment considerations are quite different?



First one of those.


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