# Contraindications and Critical Thinking: NTG/CPAP



## ekgshelly (Apr 27, 2016)

Hello Forum, 

I recently got into a friendly debate with a colleague about the treatment of an acute pulmonary edema (APE) patient who has a BP of 220/140 ish.  

My local protocols would dictate this patient should get high dose (1.6mg) SL NTG and CPAP; We cannot initiate a NTG drip (but if we sounded competent upon contacting medical control probably could and complete necessary deviation paperwork afterwards...)

Here is the issue: the patient had a decreased LOC.

I feel like the spray would be better than nothing (and not present a possible airway comprise from shoving tablets SL in an AMS patient), and it is something to get started before you have a chance to contact MC for "outside of protocol" orders. He disagrees completely, saying NTG would be contraindicated - I can't find anything to support this...

CPAP issue: our protocol lists "Altered Mental Status" as a contraindication. Therefore, he (and others) would not initiate CPAP on a patient with perhaps a GCS fo 13-14? I have worked in other systems, and have a looser interpretation that as long as the patient can tolerate the mask, does not have an airway threat, and will be able to follow coaching somewhat should have CPAP started.

I fully understand the pharmacology and pathophysiolgy reasons behind both treatments, and reviewed these other threads to ensure I wasn't repeating an already answered question:

high-dose-nitro.26745 (both from emtlife/als discussions - I don't have clearance to post hyperlinks...)
nitro-drip-for-chf.39449

Bottom line - I want some input from others: *SL NTG and CPAP in the AMS APE patient - yes/no/maybe?*


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## Carlos Danger (Apr 27, 2016)

Tell your colleague to use his brain and stop being such a protocol monkey.


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## NomadicMedic (Apr 27, 2016)

I guess the big question is, how decreased is the PT? 

Totally obtunded? Well, probably not. Can you make the argument that the patient was arousable and would tolerate a mask with coaching?

I think that sedation in an agitated CHF patient that cant tolerate a mask is certainly indicated (and if the delayed intubation thing ever really happens, we'll be sedating and CPAPing a lot more people...) It's my belief that if your somewhat altered patient will receive any benefit from the CPAP, you should give it a go. 

And yes, spray that NTG in there.


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## ekgshelly (Apr 27, 2016)

I am not sure exactly how obtunded his patient was, but the conversation led me to believe the pt was likely just confused/inappropriate responses and was cooperative.

I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute.


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## SandpitMedic (Apr 27, 2016)

If they can tolerate the mask then why not use it? Obviously there is a point in which your clinical judgement comes into practice- where you ask yourself "are we past this or can we turn the pt around?" 

NTG spray for the win.


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## Carlos Danger (Apr 27, 2016)

CPAP on a GCS <8 is not a good idea. By definition those patients cannot control their airway. It may work out fine in some cases, but it certainly won't always, and when it doesn't it can be disastrous.

But GCS 13-14? Uhh, yeah......


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## TrueNorthMedic (Apr 27, 2016)

If the patient is a little drowsy or lethargic you should still be able to apply CPAP, providing they are still able to understand your coaching and directions. Just coach them through it and explain what you're doing to them. Our protocols allow application of CPAP with a GCS of 13 or above.  
   Of course, clinical judgement comes into play here, too. There are some, (but very few)  patients who just won't tolerate it, even with good coaching. If you can get the patient to try it even for a couple of minutes, they will usually start feeling the benefits of it and want to keep it on. 
   As for nitro, as long as you can physically get the patient to open their mouth and lift their tongue, go for it. I've never heard of nitro being contraindicated solely because of AMS.


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## SeeNoMore (Apr 28, 2016)

I have had debates with more than one provider who felt passionately that any level of fatigue or confusion in a patient with respiratory distress should be seen as a reason to avoid CPAP. Often the logic would be "they are too tired they need a tube".  Obviously this is absurd. Many hypoxic patients are confused and/or lethargic and  CPAP may be an important part of the pre RSI medical management and pre oxygenation strategy.


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## ERDoc (Apr 28, 2016)

If they aren't altered enough to forget to swallow their secretions or pull the mask if they vomit, CPAP would be fine.  I agree with SeeNoMore about the too tired comment.  The whole idea of CPAP/BiPAP is to avoid intubating someone and having to deal with the complications that come from intubation.


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## TXmed (Apr 28, 2016)

I agree with everyone above me. But o would be cautious with the patient in this scenario due to the BP being so high. If you put them on CPAP it can/will reduce cerebral venous flow putting them at increase risk of cerebral vascular problems. Was this person altered due to O2 saturation? or due to a hypertensive crisis that you can make worse if you rush this treatment? I would 0.4mg of nitro then use a BVM absent PEEP valve for a short time then depending on how I feel about repeat BP switch to CPAP.


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## usalsfyre (Apr 28, 2016)

TXmed said:


> I agree with everyone above me. But o would be cautious with the patient in this scenario due to the BP being so high. If you put them on CPAP it can/will reduce cerebral venous flow putting them at increase risk of cerebral vascular problems. Was this person altered due to O2 saturation? or due to a hypertensive crisis that you can make worse if you rush this treatment? I would 0.4mg of nitro then use a BVM absent PEEP valve for a short time then depending on how I feel about repeat BP switch to CPAP.


Treating acute decompensated heart failure aggressively isn't going to lead to cerebrovascular problems. The B/P isn't a compensatory mechanism for perfusing the brain, it's due to the RAA system going wild from decreased CO. The appropriate treatment for this patient is lots of NTG, Bi/CPAP and afterload reducers like enalirpilat, followed possibly by Lasix depending on lab work. A BVM minus a PEEP valve and 0.4mgs of nitro won't do anything for your patient.


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## Mitchell Snyder (May 11, 2016)

Patient would clearly benefit from NTG dose SL and clearly would benefit from CPAP as ALOC is surely due to hypoxemia, if patient can control his/her own airway enough to follow commands a gcs of 13-14 would not be a contraindication for CPAP, can a dementia patient with a GCS of 13 not control their own airway ?


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## Carlos Danger (May 11, 2016)

Mitchell Snyder said:


> Patient would clearly benefit from NTG dose SL and clearly would benefit from CPAP as ALOC is surely due to hypoxemia, if patient can control his/her own airway enough to follow commands a gcs of 13-14 would not be a contraindication for CPAP, *can a dementia patient with a GCS of 13 not control their own airway ?*



Actually, those types of patients are at a much higher risk for aspiration, so not the best example. But your main point is 100% correct.


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## usalsfyre (May 11, 2016)

Remi said:


> Actually, those types of patients are at a much higher risk for aspiration, so not the best example. But your main point is 100% correct.


#swallowstudy


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## TomB (May 12, 2016)

Nitroglycerin with a pressure like that and heart failure? You bet. CPAP? It depends. If you're worried the patient might stop breathing you're better off placing the patient in high-Fowlers, standing in back, and using the BVM (a very difficult skill but old school paramedics will know what I'm talking about). Once it starts to take effect and the patient perks up a little bit you can transition them to CPAP.


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## Akulahawk (May 13, 2016)

TomB said:


> Nitroglycerin with a pressure like that and heart failure? You bet. CPAP? It depends. If you're worried the patient might stop breathing you're better off placing the *patient in high-Fowlers, standing in back, and using the BVM* (a very difficult skill but old school paramedics will know what I'm talking about). Once it starts to take effect and the patient perks up a little bit you can transition them to CPAP.


Yeah, glad I haven't had to do that... The older school paramedics that are still working... I'm glad it's still in their toolbox!


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## captaindepth (May 13, 2016)

I have noticed a number of patients that present with severe difficulty breathing/increased work of breathing but with a solid GCS of 15, and after a few minutes on CPAP have significant improvement and THEN become tired and more lethargic. I believe they are working so hard to breath/stay alive, that once the work of breathing decreases they relax into an exhausted state. As long as they are continuously improving and remain alert to verbal stimulus I leave them on it. I have also been using Nitropaste and having great results. It's nice to not have to move the mask to give a SL dose or spray.


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## NUEMT (May 19, 2016)

Remi said:


> CPAP on a GCS <8 is not a good idea. By definition those patients cannot control their airway. It may work out fine in some cases, but it certainly won't always, and when it doesn't it can be disastrous.
> 
> But GCS 13-14? Uhh, yeah......




GCS again?....oh jeez.  Just stop.  

http://www.annemergmed.com/article/S0196-0644(11)00655-X/abstract

Was never designed to be used in EMS.  Is not accurate, and in its most accurate state, is stated as ekgshelly did "I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute."


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## Carlos Danger (May 19, 2016)

NUEMT said:


> GCS again?....oh jeez.  Just stop.
> 
> http://www.annemergmed.com/article/S0196-0644(11)00655-X/abstract
> 
> Was never designed to be used in EMS.  Is not accurate, and in its most accurate state, is stated as ekgshelly did "I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute."



Are you for real?

Sorry, but whether you like it or not, the GCS is still by far the most widely used method of assessing and conveying gross neurologic status. I tell you what: when you are giving report at the ED and someone asks you what the initial GCS was, just tell them "the inter-rater validity of the GCS is poor, and anyway it was designed for use in the ICU, not in the field. So I don't worry about the GCS". Make sure you get back to me on how that works out for you.

And I'm not sure I see your point about that other post. Some chick put CPAP on a patient with a GCS of 10, and his GCS improved. What exactly are you getting at?


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## NUEMT (May 19, 2016)

Remi said:


> Are you for real?
> 
> Sorry, but whether you like it or not, the GCS is still by far the most widely used method of assessing and conveying gross neurologic status. I tell you what: when you are giving report at the ED and someone asks you what the initial GCS was, just tell them "the inter-rater validity of the GCS is poor, and anyway it was designed for use in the ICU, not in the field. So I don't worry about the GCS". Make sure you get back to me on how that works out for you.
> 
> And I'm not sure I see your point about that other post. Some chick put CPAP on a patient with a GCS of 10, and his GCS improved. What exactly are you getting at?




I am referring to how she presented her score.  If you use GCS, this is how you do it.  And my ED stopped asking for GCS a while ago.  Being that so many EMS providers calculate it poorly it really wasn't of any use.


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## Carlos Danger (May 19, 2016)

NUEMT said:


> I am referring to how she presented her score.  If you use GCS, this is how you do it.  And my ED stopped asking for GCS a while ago.  Being that so many EMS providers calculate it poorly it really wasn't of any use.



So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.

I still don't see what any of this has to do with the discussion at hand.

I've never really bought the "GCS of 8, intubate" mantra, but the reason that came to be is that anyone with a GCS at that level is neurologically depressed enough that their CN function is considered unreliable, REGARDLESS of which combination of scores exist to add up to 8. On a very gross level it makes sense, so even though it is imperfect and should not dictate clinical decisions, it is a decent rule of thumb to keep in mind. Mix in uncontrolled positive pressure and a non-NPO patient, and you are asking for trouble.


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## NUEMT (May 19, 2016)

Remi said:


> So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.
> 
> I still don't see what any of this has to do with the discussion at hand.
> 
> I've never really bought the "GCS of 8, intubate" mantra, but the reason that came to be is that anyone with a GCS at that level is neurologically depressed enough that their CN function is considered unreliable, REGARDLESS of which combination of scores exist to add up to 8. On a very gross level it makes sense, so even though it is imperfect and should not dictate clinical decisions, it is a decent rule of thumb to keep in mind. Mix in uncontrolled positive pressure and a non-NPO patient, and you are asking for trouble.




Really?  Irony doesn't really register with you does it.  REMI, sometimes you give me hope.  Then you totally drive off the cliff.  



Remi said:


> So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.



Nope.  Our docs just follow the latest evidence.  Hardly feel like that was a lecture.  Where do you practice again?


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## NomadicMedic (May 19, 2016)

NUEMT said:


> GCS again?....oh jeez.  Just stop.
> 
> http://www.annemergmed.com/article/S0196-0644(11)00655-X/abstract
> 
> Was never designed to be used in EMS.  Is not accurate, and in its most accurate state, is stated as ekgshelly did "I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute."




Curious how long you've been doing this...


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## Carlos Danger (May 19, 2016)

NUEMT said:


> Really?  Irony doesn't really register with you does it.  REMI, sometimes you give me hope.  Then you totally drive off the cliff.
> 
> 
> 
> Nope.  Our docs just follow the latest evidence.  Hardly feel like that was a lecture.  Where do you practice again?



Look, you do not know what you are talking about. Just stop.


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## NUEMT (May 19, 2016)

DEmedic said:


> Curious how long you've been doing this...


The forum thing?.....eh not long.


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## Carlos Danger (May 19, 2016)

NUEMT said:


> The forum thing?.....eh not long.



No, he wasn't talking about "the forum thing".....


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## gotbeerz001 (May 19, 2016)

NUEMT said:


> I am referring to how she presented her score.  If you use GCS, this is how you do it.  And my ED stopped asking for GCS a while ago.  Being that so many EMS providers calculate it poorly it really wasn't of any use.


Sounds like a problem with your system... 


Sent from my iPhone using Tapatalk


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## gotbeerz001 (May 19, 2016)

A good rule of thumb for me is that if @Remi and @DEmedic are basically calling me an idiot, I am probably wrong. Where are @ERDoc and @STXmedic? I think we need their input, too. 


Sent from my iPhone using Tapatalk


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## ERDoc (May 19, 2016)

The GCS was created to assess neuro function in a traumatic brain injury.  It was not designed for any other purpose although it has been widely accepted and used for other purposes.  In fact, the new ICD 10 codes (for those who follow the stupidity of medicine) require documentation of a GCS on any pt who is diagnosed as AMS, even if there is no trauma.  I don't believe it has ever been validated for any other purpose, although someone could google it to be sure.  I don't believe in the GCS of 8 mantra.  If they can't protect their airway, they get the tube regardless of their GCS.  It was designed as a test to look for a change in status over time.


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## NUEMT (May 20, 2016)

ERDoc said:


> The GCS was created to assess neuro function in a traumatic brain injury.  It was not designed for any other purpose although it has been widely accepted and used for other purposes.  In fact, the new ICD 10 codes (for those who follow the stupidity of medicine) require documentation of a GCS on any pt who is diagnosed as AMS, even if there is no trauma.  I don't believe it has ever been validated for any other purpose, although someone could google it to be sure.  I don't believe in the GCS of 8 mantra.  If they can't protect their airway, they get the tube regardless of their GCS.  It was designed as a test to look for a change in status over time.




Thanks doc.


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## usalsfyre (May 20, 2016)

GCS is a piss poor surrogate for actual level of neuro function following an acute event, it wasn't ever intended to be added together and used the way we do. That said....

It's just about all we've got physical exam wise. I know for a fact that if I have a patient who I can assume was formerly conscious and now has a GCS <8 there's been a fairly devastating neurologic event that needs my attention and very likely the airway managed as a result. I probably end up doing tubes on deteriorating mental status far more often than just "less than 8, intubate", however, it's not a terrible rule of thumb.

If your docs have stopped using GCS completely, they're almost certainly not an ACS Level I or II trauma facility.


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## ERDoc (May 20, 2016)

usalsfyre said:


> If your docs have stopped using GCS completely, they're almost certainly not an ACS Level I or II trauma facility.



Good point.  On the wall in our trauma bay we have a huge poster with the GCS criteria with pictures.  It is an easy test (in theory) that gives some information, especially if used for serial exams but was never designed for its current use.  This is especially true when it is used in pts who have other causes of altered mental status such as EtOH, drugs, etc.


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## NUEMT (May 20, 2016)

ERDoc said:


> Good point.  On the wall in our trauma bay we have a huge poster with the GCS criteria with pictures.  It is an easy test (in theory) that gives some information, especially if used for serial exams but was never designed for its current use.  This is especially true when it is used in pts who have other causes of altered mental status such as EtOH, drugs, etc.



Docs still use. Consideration of the EMS gcs score not so much. 7 level ones.


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## Jim37F (May 20, 2016)

We've been required to document the GCS on every patient, period. It's in the same part of my ePCR as airway patency, lung sounds, skin signs, pupils etc, and is coded as a critical field (must be filled out otherwise it won't let me upload the form). 

While there's a second GCS chart right below it to document any changes to GCS that occurred  (last time I used that was for a diabetic with low blood sugar who was like a 9 on arrival and then a 15 after some D50).

But now they've put out a memo saying that second GCS is now mandatory on loddy-dotty-everybody as part of the transfer of care vitals (that also HAS to be within 5 min of our documented available time because....reasons?) Doesn't matter if the Chief Complaint/Reason for Transport was a major trauma with altered mental status or flu like symptoms or a scheduled transfer (and if there was a change in GCS, they want all 3 documented). So safe to say GCS is still alive and well here. And is apparently as important to constantly monitor as blood pressure and pulse rates.


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## ERDoc (May 20, 2016)

On a personal note, I have an issue with any scale that gives a dead person a score of 3 and not 0.


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## cruiseforever (May 20, 2016)

ERDoc said:


> On a personal note, I have an issue with any scale that gives a dead person a score of 3 and not 0.



Totally agree.  Had a status seizure pt. yesterday and the GCS that I got said he should be dead.


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## Carlos Danger (May 20, 2016)

cruiseforever said:


> Totally agree.  Had a status seizure pt. yesterday and the GCS that I got said he should be dead.


Which GCS score indicates death?


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## usalsfyre (May 20, 2016)

NUEMT said:


> Docs still use. Consideration of the EMS gcs score not so much. 7 level ones.


So basically your guys suck too bad to apply it correctly. 

I'm not saying I like GCS, but call a spade a spade.


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## usalsfyre (May 20, 2016)

Jim37F said:


> We've been required to document the GCS on every patient, period. It's in the same part of my ePCR as airway patency, lung sounds, skin signs, pupils etc, and is coded as a critical field (must be filled out otherwise it won't let me upload the form).
> 
> While there's a second GCS chart right below it to document any changes to GCS that occurred  (last time I used that was for a diabetic with low blood sugar who was like a 9 on arrival and then a 15 after some D50).
> 
> But now they've put out a memo saying that second GCS is now mandatory on loddy-dotty-everybody as part of the transfer of care vitals (that also HAS to be within 5 min of our documented available time because....reasons?) Doesn't matter if the Chief Complaint/Reason for Transport was a major trauma with altered mental status or flu like symptoms or a scheduled transfer (and if there was a change in GCS, they want all 3 documented). So safe to say GCS is still alive and well here. And is apparently as important to constantly monitor as blood pressure and pulse rates.


Because documenting a 14 or lower throughout transport helps justify ambulance billing.


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## NUEMT (May 20, 2016)

usalsfyre said:


> So basically your guys suck too bad to apply it correctly.
> 
> I'm not saying I like GCS, but call a spade a spade.




Ya i wont be calling everyone in in ems in Chicago "my guys".


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## SpecialK (May 21, 2016)

Teasdale and Jennett only ever intended the GCS to measure responsiveness in patients with severe TBI.  The fact it has become the default assessment of the conscious state is probably somewhat of an erroneous extrapolation.  The components (scores) individually are helpful but "at a glance" the total scale on its own (sum of scores) I don't think is overly helpful in isolation of the greater clinical context.


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## cruiseforever (May 21, 2016)

Remi said:


> Which GCS score indicates death?


 
3 = coma or death from the way I understand it.  My pt. was a 4 when having the seizure.  So no he was not dead.  As others have said it is a poor scale for some pts. that we encounter.


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## NomadicMedic (May 21, 2016)

Yes, it's a poor scale for some of the patients that we encounter. For others, it's a fair way to measure changes in responsiveness and document those changes. 

 For example, using GCS for the documention of the change in responsiveness in a hypoglycemic, both prior and post dextrose administration, is entirely appropriate. _For the sake of documentation_. 

 Do we need something better for serial assessment of gross changes in responsiveness prehospital? Maybe. But we've been using the GCS for a minute, and while a bit clunky, it seems to get the job done in most cases.  That is, It gets the point across to the emergency department as to the status of the patient over the course of your encounter.


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## NPO (May 22, 2016)

My protocols also list AMS as a contraindication for CPAP. For nitro though... never heard of it. Even with an altered patient, a SL tab wouldn't concern me. They are tiny, and dissolve quickly. Keep their head up and there shouldn't be a problem.

In my case, I'd give SL NTG as we can only take nitro drips on transfers and CPAP is strictly contraindication in AMS under my protocols.


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## gotbeerz001 (May 22, 2016)

NPO said:


> My protocols also list AMS as a contraindication for CPAP. For nitro though... never heard of it. Even with an altered patient, a SL tab wouldn't concern me. They are tiny, and dissolve quickly. Keep their head up and there shouldn't be a problem.
> 
> In my case, I'd give SL NTG as we can only take nitro drips on transfers and CPAP is strictly contraindication in AMS under my protocols.



The level of AMS will be a judgement call; for me, it's the point where the pt becomes profoundly altered. If the pt is actively working, is aware of our presence but not necessarily interacting  appropriately with us then they will still get CPAP. If they continue to deteriorate then I'll discontinue and switch to the BVM. 


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## Bobbob1354 (May 22, 2016)

Im sure someone probably touched on this, but a BVM, PEEP valve and NC under the mask could provide a pseudo-CPAP you are looking for.


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