# Nitro spray on skin before IV



## Moshi (Jun 18, 2012)

I was talking to a colleague of mine who said he knows someone who uses Nitrolingual spray on skin before applying IV needle on patients with small/hidden/bad veins.

Theoretically it seems plausible but has anyone ever tried that? What do you think? Does it work?


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## Tigger (Jun 18, 2012)

I was told by my IV instructor that this trick doesn't work very well and just wastes another medication.


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## Moshi (Jun 18, 2012)

OK, so it doesn't work very well. But it does work a bit? Isn't that still better than nothing when you can't find a vein?


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## the_negro_puppy (Jun 18, 2012)

I've never tried it, but you would want to be very careful using a medication for a purpose other than what it was designed for. From what I read on here EMS workers in the US get fired over trivial things, these seems like one of those


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## NYMedic828 (Jun 18, 2012)

Don't know if it works, don't know if it would work and I'm not going to try and find out.

If I can't find a vein, there's plenty of other tricks I would try first that can't get me jammed up.


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## Veneficus (Jun 18, 2012)

Moshi said:


> OK, so it doesn't work very well. But it does work a bit? Isn't that still better than nothing when you can't find a vein?



It is not better than nothing. 

Somebody who knows anatomy, including common variations, well enough to apply such knowledge as to where the vein is likely to be not only more effective whether they can see the vein or not, but also have no use for such nonsense.

Because of embyological development of the upper limb in humans, the cephalic and basilic veins have very little deviation in most people. 

I have found it really helps a lot to understand where they can be found, even if they cannot be seen.


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## systemet (Jun 18, 2012)

Moshi said:


> I was talking to a colleague of mine who said he knows someone who uses Nitrolingual spray on skin before applying IV needle on patients with small/hidden/bad veins.
> 
> Theoretically it seems plausible but has anyone ever tried that? What do you think? Does it work?



This is a nitropatch.  This particular nitropatch gives 0.4 mg / *hr* transdermally.







And you have a patient, with poor venous access, and you're planning on spraying 0.4mg of nitroglycerin on their hand / forearm?

I hope the patient doesn't have poor vascular access because they're hypotensive.


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## fast65 (Jun 18, 2012)

I've never heard of this trick before, and I'm certainly not willing to try it. Like Vene said, it's better to have a thorough understanding of the anatomy, than it is to rely on some folk trick, especially a folk trick that involves giving a medication to someone that doesn't need it.


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## Medic Tim (Jun 18, 2012)

Ppl seriously do this? I am constantly amazed at the half assed tricks people come up with that really don't work. If they put that time into some constructive like education, ems would be in a much better place than it currently is in the us.


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## Moshi (Jun 18, 2012)

Okay seems like noone here likes it. I was also a bit shocked when I first heard it. Didn't know what to think of it. Now I believe it's not right even as a last resort.


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## Veneficus (Jun 18, 2012)

fast65 said:


> I've never heard of this trick before, and I'm certainly not willing to try it. Like Vene said, it's better to have a thorough understanding of the anatomy, than it is to rely on some folk trick, especially a folk trick that involves giving a medication to someone that doesn't need it.



Giving medication to somebody who doesn't need it is not a folk trick, it is a medication error.

Thought I would point that out.


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## TransportJockey (Jun 18, 2012)

I'd never heard it until now... told my coworkers about it and none of us thought it was a good idea at all.


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## RustyShackleford (Jun 18, 2012)

Your co-workers obviously have enough common sense to figure out the farce that this so called "trick" is.


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## bigbaldguy (Jun 18, 2012)

I've heard of it but mostly along the lines of "back in the day we used to" kind of thing. Sounds like in theory it would work as far as the vein goes but as others have mentioned side effects could make the whole thing a very bad idea. If you really can't get access and access is critical now we have alternatives like EZIO so I think this is one of those things that is going to probably say a "back in the day" kind of thing.


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## MedicBender (Jun 18, 2012)

bigbaldguy said:


> I've heard of it but mostly along the lines of "back in the day we used to" kind of thing



That's my thought as well. 

I asked around at work and the only medic who had heard of it was a guy that's been a medic for 25 years.


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## LondonMedic (Jun 20, 2012)

systemet said:


> I hope the patient doesn't have poor vascular access because they're hypotensive.


It is not going to be absorbed into the vein and passed around the peripheral circulation until it reaches the central circulation where it _then_ causes massive horrific vasodilatation.


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## Akulahawk (Jun 20, 2012)

bigbaldguy said:


> I've heard of it but mostly along the lines of "back in the day we used to" kind of thing. Sounds like in theory it would work as far as the vein goes but as others have mentioned side effects could make the whole thing a very bad idea. If you really can't get access and access is critical now we have alternatives like EZIO so I think this is one of those things that is going to probably say a "back in the day" kind of thing.


I have heard of this as well. I personally have never tried it nor have anyone that I know of tried it in my presence. If I have trouble getting a vein to pop up using a traditional TK, I use a BP cuff manually inflated to just about the DBP. If the veins don't get seriously engorged with blood and you still can't feel them, something is wrong. Seriously wrong. I much prefer the regular little rubber (latex or non-latex) tourniquets over the BP cuff, partly because they're easier/faster to remove and they're cheap & disposable.

Oh, and +1 to Vene: using NTG (or GTN) spray in that manner is contrary to labeling and how we're supposed to administer it. Therefore, doing so is a med error.


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## NYMedic828 (Jun 20, 2012)

If the situation is so bad that you need to get an IV on the patient and would even consider something as silly as this, just go to the damn hospital.

I never understood people who will putz around on-scene for an extra 10 minutes making someone a pin cushion when they could be halfway to an ER.

A few minutes fine, 1 or two attempts sure. But some people go WAY overboard.


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## jroyster06 (Jun 22, 2012)

I think the nitro spray is a bit much. I have seen a couple of old school medics use a very very SMALL amount of nitro paste on the area they are looking at, about the size of a ball point pen. Not enough to cause any pressure drop but just enough to get the vein to pop up. I know what yall are going to say and i will be chastised but i will say from what I have seen.. It works.

I was just talking about this to another medic around here a couple weeks ago. He said he agrees it works and Hospitals have used local nitro paste in area's such as a brown recluse bite to dilate the veins because apparently that is where the necrosis comes from is vaso constriction but i havent researched enough of the patho of a brown recluse bite to know for sure.


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## gordonfreeman (Aug 4, 2012)

Why not just go the IO route?


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## Shishkabob (Aug 4, 2012)

NYMedic828 said:


> I never understood people who will putz around on-scene for an extra 10 minutes making someone a pin cushion when they could be halfway to an ER.



Because in some situations we do the exact same things the hospital will do for the issue at hand, so there's no point in rushing?


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## NomadicMedic (Aug 4, 2012)

For what it's worth, my fiancé is a critical care vet, and they use the dab of paste trick to get a vein on dogs and cats that they are having a hard time sticking. She swears by it. 

Of course, she also can dump in  a liter of fluid subq, so she does have options.


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## Jon (Aug 4, 2012)

gordonfreeman said:


> Why not just go the IO route?



Because not everyone even has one.

And sometimes it's less cruel if you can put a needle in WITHOUT a power tool.


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## Tigger (Aug 4, 2012)

Jon said:


> Because not everyone even has one.
> 
> And sometimes it's less cruel if you can put a needle in WITHOUT a power tool.



Even though it's supposed to hurt the same if not less than an IV insertion? Supposedly only med pushes are what causes pain.


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## bigbaldguy (Aug 4, 2012)

Tigger said:


> Even though it's supposed to hurt the same if not less than an IV insertion? Supposedly only med pushes are what causes pain.



Perhaps physical pain is less but the mental trauma of seeing someone screwing a needle into your leg with a black and decker is going to leave a mark. We need to remember that physical pain is usually more transient and less important than psychological pain.


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## NomadicMedic (Aug 4, 2012)

If they need an IO, usually they are past caring about my driving a needle into their tibia. 

There is ALWAYS access if you really need it. Let's not forget about EJs.


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## Tigger (Aug 4, 2012)

bigbaldguy said:


> Perhaps physical pain is less but the mental trauma of seeing someone screwing a needle into your leg with a black and decker is going to leave a mark. We need to remember that physical pain is usually more transient and less important than psychological pain.



I think if you take the time to explain the procedure you can mitigate much of the emotional trauma. Alternatively you could tell them to shut their eyes, and as nlixi notes, if they need an IO they're likely already in trouble.


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## Handsome Robb (Aug 4, 2012)

gordonfreeman said:


> Why not just go the IO route?



You better have a damn good reason as to why you're drilling an IO on a live patient. "I couldn't get IV access" doesn't count unless they are in extremis.


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## Handsome Robb (Aug 4, 2012)

Tigger said:


> Even though it's supposed to hurt the same if not less than an IV insertion? Supposedly only med pushes are what causes pain.



That's why you flush it with lidocaine first  20-40 mg should be plenty.


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## Tigger (Aug 4, 2012)

NVRob said:


> That's why you flush it with lidocaine first  20-40 mg should be plenty.



From what I have seen the lidocaine may have made some difference but the patient(s) were still less than pleased. The local EMS was also not carrying lidocaine at the time, though that has been remedied with the increased use of IOs.


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## Shishkabob (Aug 4, 2012)

bigbaldguy said:


> Perhaps physical pain is less but the mental trauma of seeing someone screwing a needle into your leg with a black and decker is going to leave a mark. We need to remember that physical pain is usually more transient and less important than psychological pain.



Hence the retrograde amnesia with benzos.  They won't remember a thing!  h34r:




Jon said:


> And sometimes it's less cruel if you can put a needle in WITHOUT a power tool.


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## abckidsmom (Aug 4, 2012)

Linuss said:


> Hence the retrograde amnesia with benzos.  They won't remember a thing!  h34r:



I'm still scarred for like from that stupid jamshidi needle. 

The only live patient I ever drilled was a simple hypoglycemic. It was the right choice at the time.


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## jwk (Aug 5, 2012)

Linuss said:


> Hence the retrograde amnesia with benzos.  They won't remember a thing!  h34r:



That's largely a myth - hope you don't count on that routinely.


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## bigbaldguy (Aug 5, 2012)

Linuss said:


> Hence the retrograde amnesia with benzos.  They won't remember a thing!  h34r:



I don't know. Just because you don't remember something doesn't mean it doesn't still effect you on other levels.


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## PVC (Aug 5, 2012)

Here is a link where in trials Cardiologist use topical Nitro to facilitate Radial Arterial Cannulation. 

So topical Nitro works on arteries, Has anyone seen any studies on veins.

http://techtransfer.universityofcalifornia.edu/NCD/20036.html

The difficulty I would see is medics/cardiologist using a drug and without it being approved for that effect.

It concerns me that the lower levels of care are willing to attempt experiments with medications that are not approved that use for t. I would worry of legal complications regardless of production of desired effects.



jroyster06 said:


> I think the nitro spray is a bit much. I have seen a couple of old school medics use a very very SMALL amount of nitro paste on the area they are looking at, about the size of a ball point pen. Not enough to cause any pressure drop but just enough to get the vein to pop up. I know what yall are going to say and i will be chastised but i will say from what I have seen.. It works.



Did you notice if they documented their topical Nitro administration in their PCR?


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## Asclepius911 (Aug 5, 2012)

Lol I don't mean to sound rude but,  you guys are beginning to sound like Mexican witch doctors,  rub some alcohol mixed with vapor rub and "yerba Buena" (mint leaf) on your forehead and it will make you smarter ... don't believe people that haven't done clinical research on the effect of untraditional application of drugs, you don't want to be the first to find out the adverse side effects as a result of curiosity


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## PVC (Aug 5, 2012)

Asclepius911 said:


> Lol I don't mean to sound rude but,  you guys are beginning to sound like Mexican witch doctors,  rub some alcohol mixed with vapor rub and "yerba Buena" (mint leaf) on your forehead and it will make you smarter ... don't believe people that haven't done clinical research on the effect of untraditional application of drugs, you don't want to be the first to find out the adverse side effects as a result of curiosity



Getting rubbed all over with an egg has got to be the best.


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## Asclepius911 (Aug 5, 2012)

I heard if they rub you down with a tabacco leaves and decapitate a  chicken causing the blood to squirt on you, it cleanses your spirit to take out the stress demon.. lol .. sometimes I wonder how the witch doctor's crazy ideas were taken serious


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## NYMedic828 (Aug 5, 2012)

abckidsmom said:


> I'm still scarred for like from that stupid jamshidi needle.
> 
> The only live patient I ever drilled was a simple hypoglycemic. It was the right choice at the time.



Story behind that one?


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## medicconnor (Aug 5, 2012)

systemet said:


> And you have a patient, with poor venous access, and you're planning on spraying 0.4mg of nitroglycerin on their hand / forearm?
> 
> I hope the patient doesn't have poor vascular access because they're hypotensive.



yep, nitro works transdermal, not a good idea just get better at your IV skills.


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## Doczilla (Aug 5, 2012)

PVC kind of elluded to this: 

Nitro is a large-vessel dilator. Not a small vessel dilator. 

This is why nitroglycerin does not work for HAPE. (High altitude pulmonary edema).


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