5 responsibilities of an EMT

[BrushBunny91]

So the PDE inhibitors is what we must avoid and not always erectile drugs? I'm having a little bit of trouble following your explanation. I am intrigued.

 

[BrushBunny91]

As for the high dose of nitroglycerin. I read that the patients that were reviewed received two mg of nitro every three minutes for a total of ten doses.
But as an emt I am still restricted to three doses max correct?

 

[systemet]

So the PDE inhibitors is what we must avoid and not always erectile drugs? I'm having a little bit of trouble following your explanation. I am intrigued.

This has to do with the physiology of smooth muscle contraction.

NTG, and similar medications like sodium nitroprusside, donate nitric oxide (NO). This diffuses across endothelial cells, into vascular smooth muscle cells, where it activates an enzyme called guanylyl cylcase. Once activated this produces another signalling molecule called cyclic GMP (cGMP). cGMP ultimately activates cGMP-dependent protein kinase (PKG), which affects calcium levels within the smooth muscle cell and the sensitivity of the contractile apparatus to calcium, causing relaxation and vasodilation.

So in EMT school, it's often taught NTG--> smooth muscle relaxation --> vasodilation, we can look at it in increasing levels of complexity, e.g.

NTG--> NO --> cGMP --> PKG --> decreased [Ca2+] and decreased Ca2+ sensitivity --> decreased activation -->relaxation --> vasodilation.

Now, to make things more confusing, we have an enzyme that breaks down cGMP (phosphodisesterase V --- well other enzymes do this as well, but we'll focus on this). This makes sure that the signal is turned off eventually. So giving NTG will increase cGMP, but phosphodiesterase will rapidly consume this cGMP, so that the effect of the NTG wears off over time.

There are also medications that inhibit this process, by "turning off" phosphodiesterase, and resulting in higher levels of cGMP. These include Viagra and Cialis. This also causes vasodilation in some vessel beds.

Viagra --> inhibition of phosphodiesterase --> increased cGMP --> --> --> vasodilation

This means that patients taking these medications are especially sensitive to the effects of NTG. So if we give them NTG, they have a rapid increase in cGMP, without much phosphodiesterase activity to limit the increase or bring it back down. This can result in a large amount of vasodilation, and profound hypotension / death (the profoundest of hypotensions).


* And yes, these phosphodiesterase inhibitors aren't always used for erectile dysfunction.

This image gives an idea, albeit in the context of erectile dysfunction:

 

[Handsome Robb]

1So the PDE inhibitors is what we must avoid and not always erectile drugs? I'm having a little bit of trouble following your explanation. I am intrigued.

ED drugs are a contraindication to NTG if the ED drug was taken with a certain time. Depending on the ED drug it can be 24-36 hours. Viagra is 24hrs, Cialis is 36hrs.

PED-5 Inhibitors block PED-5 which is responsible for breaking down cGMP. cGMP is the "brake pedal" for vasodilation in the penis among other things.

Think Sympathetic(SNS)/Parasympathetic(PNS) nervous systems. The SNS is the "gas pedal" and the PNS is the "brake pedal".

Nitro is the "gas pedal" for vasodilation. cGMP is the "brake pedal". By blocking cGMP there is nothing to control vasodilation so when you administer a drug that promotes vasodilation there is nothing to antagonize (or counteract) it. It allows for the vasodilating agent to have its way with the vasculature and puts the patient at risk for extreme hypotension which is the same reason we don't give patients who recently have take ED drugs nitro.

Does that make sense? Sorry, it's late and I'm burnt from hw so I might be babbling.

JP, or anyone else for that matter, feel free to rub my nose in my own poo if I'm completely wrong and sending BrushBunny down the wrong path.

Per NREMT the max dose for nitro is 1.2 mg or 3 sublingual sprays or tablets, 1 spray or tablet being 0.4 mg. When working for an agency it is going to be protocol dependent. Where I work we can administer NTG as needed provided the systolic BP stays above 100 mmHg. If we have a long transport time we usually use NitroPaste instead of the spray. Now where I work when I say long transport I mean like 20 minutes tops unless we are way out on the edge of the county, then your looking at more like 30-45 but thats super rare.

Another thing to consider about Nitro is that it doesn't stay good for very long when prescribed as a home med. You'll find that when assessing a patient that's prescribed it they may have taken much more than 3 tablets with no relief. The next thing you want to find out is how old their nitro is and where they store it. If its old or stored improperly those 6 tablets may not have even worked.

Alright I need to go to bed I feel like I'm just babbling.

 

[BrushBunny91]

Ahhhhhh(moment of enlightenment) Thank you systemet and NVROB. You cleared up the confusion I had about nitro ^_^

 

[systemet]

Another thing to consider about Nitro is that it doesn't stay good for very long when prescribed as a home med. You'll find that when assessing a patient that's prescribed it they may have taken much more than 3 tablets with no relief. The next thing you want to find out is how old their nitro is and where they store it. If its old or stored improperly those 6 tablets may not have even worked.

Really good post.

We used to use a new nitrospray with every patient, because of the risk of deterioration over time. However a few people got in trouble with the pharmacists union for giving the patient the nitrospray to keep. It seemed counterintuitive to throw away a full bottle after 3 sprays. But apparently this is dispensing, and illegal unless you're a pharmacist

 

[Anjel]

Asthma is also a contraindication for beta blockers.

Im finding out why that is right now. Cuz I have both.

And why would you give nitro to someone with a head injury?

 

[DV_EMT]

Really good post.

We used to use a new nitrospray with every patient, because of the risk of deterioration over time. However a few people got in trouble with the pharmacists union for giving the patient the nitrospray to keep. It seemed counterintuitive to throw away a full bottle after 3 sprays. But apparently this is dispensing, and illegal unless you're a pharmacist

correct.... says the Rx Tech

 

[JPINFV]

Think Sympathetic(SNS)/Parasympathetic(PNS) nervous systems. The SNS is the "gas pedal" and the PNS is the "brake pedal".

This doesn't have anything to do with SNS vs PNS. Even if the patient was maxed out on atropine, PDE 5 would still be active since you need someway to remove the signal, or else the signal would always be present.

Nitro is the "gas pedal" for vasodilation. cGMP is the "brake pedal". By blocking cGMP there is nothing to control vasodilation so when you administer a drug that promotes vasodilation there is nothing to antagonize (or counteract) it. It allows for the vasodilating agent to have its way with the vasculature and puts the patient at risk for extreme hypotension which is the same reason we don't give patients who recently have take ED drugs nitro.

cGMP is also a part of the gas pedal. It's like a pulley system that magnifies the signal (which is one of the major functions of secondary messengers), and is one component in the chain leading to vasodilation. Remove cGMP, no dilation.

I guess another way of looking like it is that PDE is the spring that pulls the gas pedal back and NO is the foot pressing on the gas pedal. If you remove NO, you need something to pull the gas pedal back, or else the car will continue to accelerate. Removing PDE 5 is removing that spring, thus making it so that the car won't slow down on it's own.

 

[JPINFV]

ED drugs are a contraindication to NTG if the ED drug was taken with a certain time.

See below.

So the PDE inhibitors is what we must avoid and not always erectile drugs? I'm having a little bit of trouble following your explanation. I am intrigued.

Yes. The caveat to this is that the vast majority of times you're going to see a PDE 5 inhibitor is in ED drugs, but it's due to the mechanism of action of the class of drug, not what specifically the drug is used for.

 

[mycrofft]

Boy the weather has been nice lately

Oh, this isn't the pointless thread?

 

[sop]

My 5:

1. Come to work on-time.

2. Check the coffee.

3. Clean everything I see.

4. Make sure I have gloves to fit my hands.

5. Ask my co-worker what we need and try to obtain it.

 

[usalsfyre]

Obviously your from a hosemonkey background...

 

[firetender]

Hijack back to the OP

May i know what you guys have?? And thanks

5 responsibilities of an EMT.. (not d star of life ok) thanks

This was not a frivolous question.

It was treated as if every book on EMT level care starts with "The Five Responsibilities of an EMT". They do not. He was treated as if he was trying to take something away from us rather than learn.

Once the OP id'd self as Asian, I wondered if he could be from a different system that actually DOES identify the five major responsibilities of an EMT.

We'll never know, will we? All he asked was "What do you guys have?" and he was pounced on.

He easily could have been answered by some people who took the time to take the question seriously. Maybe we all could have learned from it, like.

1) Respond to emergencies safely and expeditiously
2) Scene management: establish scene safety, protect the patient, utilize available personnel/standers-by appropriately
3) take immediate intervention if needed or determine next level of care
4) communicate with appropriate personnel
5) transport to approprite facility

Have at it because it's a simple question worth looking at.

 

[Handsome Robb]

This doesn't have anything to do with SNS vs PNS. Even if the patient was maxed out on atropine, PDE 5 would still be active since you need someway to remove the signal, or else the signal would always be present.

I was trying to relay an example, not a actual correlations, should have been more clearly worded.

 

[Handsome Robb]

We used to use a new nitrospray with every patient, because of the risk of deterioration over time.

That's an interesting practice. I see why it would be used but doesn't seem like the most economical way to go about it.

If your rural and don't see a ton of ACS patients I can see how it would be favorable but in my system we are very busy and tend to use our nitrospray bottles relatively quickly + a monthly inspection of all the equipment on-board for expired or nearly expired meds and supplies.

 

[firetender]

Get back on track

...or start a new thread please.

Thank you.

 

[Handsome Robb]

...or start a new thread please.

Thank you.

Aye Aye, captain!

1. My safety.
2. My partner's safety.
3. My equipment.
4. Patient Care/Safety/Advocacy.
5. Safety of the public.

 

[JPINFV]

This was not a frivolous question.

It is a frivolous question. It's just not the OPs fault that his instructors are asking frivolous questions.

 

[firetender]

It's only a frivolous question if you choose to treat it frivolously.

In this case, it wasn't about the question, it was about the poster. Were you to take the question seriously, what are the top five things an EMT is expected to do?