Adminstering Nitro w/out a line in place

Sizz

Sizz

Forum Lieutenant
Messages
115
Reaction score
0
Points
0
Hey all,

I want to run something past you all and get your feedback. I'll give you the short version summed up:

A few weeks back I was working with my part-time company which is an ALS county service, and was paged to an assisted living facility for a "chest pain" call.

Upon arrival we find an elderly lady with dementia along side a nurse that takes care of her on a normal basis. The pt appears a bit skittish and almost freighted that we're there , but does not seem to be in distress or showing your classical signs of a serious cardiac issue. Nurse stats earlier in the day the pt had complained of chest pain, and this evening she again mentioned she had discomfort in her chest. The pt is put onto the monitor which if I recall was slightly sinus tach, nurse states the pressure she received was 190/100 and we obtain something similar on scene as well. Pt is on a new medication for anxiety , a dementia medication, but no hypertensive medication I can recall. I administered our chewable ASA then packaged the pt and loaded for transport.

It's my call and I'm with another medic who has 6+ months more experience than I and is a full timer with the company, a 10 yeared Medic arrives to "assist" on the call(the call crew show's up and helps on calls in town upon hearing a page upon their own discretion....not always sure why but they always have done this). As soon as I get into the rig both of the other medics are racing for the nitro and shoving it down my pt's throat. I stated I want a line in place before hand(I feel it's necessary if you're giving any medications and my full-time ALS job it's required / protocol) and both of them come back to me with " She's hypertensive and needs nitro now" the line an wait....I let back at this point as I knew the 10 yr medic and other would not agree with me and would still continue with the med without my discrection. The pt started to throw PVC's and even had a slight run of v-tach (a symptomatic) after nitro was given the medic on with me attempted 2 IVs , failed and I was able to secure one myself. During this time the 2nd crew is paged out at which point the elder medic left(how ironic is that, even being on the opposite side of town ya?!).

Anyhow we transported the pt and afterwords I expressed my concern and that I was unhappy with what had happened. The medic I was on with told me he use to "follow the same rule of thumb" but he's never had any issues and was apparently advised by a big city medic way back when that "Never withhold treatment that reduces pain to the pt - NTG". He then mentions if something would have happened with pt he would just drop an IO into them and work em. Later tries explaining the good old sad :censored::censored::censored::censored: story I hear from people from time to time - "People take nitro all the time at home, do they have an IV in place, do they have issues...."

Our pt never really expressed pain or discomfort to us - she did not really understand much that was happening nor the 1-10 scale etc.

Secondly I'm trying to avoid having to bottom out the pt in the first place causing a draw on the cardiovascular system and having her arrest in the first place...so let's avoid this - to the IO response.

And lastly I told him that "Yes, pt's are prescribed nitro at home but USUALLY this is for a diagnosed case of angina where the their cardiac history has been looked over extensively and usually are not have right ventricle issues or it most likely would not be prescribed...it's more of a controlled than dropping 400mcg of nitro into a random chest pain / hypertension.

Who know this pt could have had hypertension for 12 hours before it was caught...taking the couple minutes to setup and start a line is not going to make or break this pt.

Sadly I've seen this happen with other calls from other medics with this company even with normotensive pt's having chest pain vs the hypertensive pt we had.

I do not agree with this, although I'm not sure how to approach it if I should even attempt to but next time I'm working for this company you can bet I'm going to make it clear up front if you decide to bypass my treatment and give this pt nitro without my consent it's YOUR pt now and you'll be attending and reporting.

Any thoughts on how you would handle the situation or just in general?
 
A few things.... first off... if this was your call and YOUR patient no other Medic (regardless of experience) should be stepping in and making treatment decisions especially when they end up bailing on you for another call.

I think it is prudent to have a line before NTG in some cases but don't think it's an absolute. More importantly, what was the 12-lead showing? I do believe in trying to get a 12-lead pre-treatment. This way, you will be able to pick up the inferior wall MI / RVI prior to giving NTG even if you had a line started.

I see where your peers are coming from. If the B/P is truly 190/100 I wouldn't be fearful about giving NTG without a line... at least not the initial dose. Think about that pressure. If a patient is having an ACS, a pressure that high is very taxing on the heart. Diastolic pressure correlates to afterload and at 100mmHg it is a great force the heart has to overcome to eject blood. I have never seen a single nitro drop a pressure by more than a 100 points which would put the patient into an area for concern.

Also, a lot of patients with inferior wall MI / RVI are hovering around the border-line hypotension range or low end like SBP 110-115's. In this case, yes I would want a line first before nitro. Heart rate is also often on low end or bradycardic with inferior wall / RVI and commonly seen with a heart block, N&V.

Where I work, BLS protocol allows Basics to give NTG on their own (carried on the ambulance) without IV access. So its not an absolute.
 
Last edited by a moderator:
18G said:
A few things.... first off... if this was your call and YOUR patient no other Medic (regardless of experience) should be stepping in and making treatment decisions especially when they end up bailing on you for another call.

I think it is prudent to have a line before NTG in some cases but don't think it's an absolute. More importantly, what was the 12-lead showing? I do believe in trying to get a 12-lead pre-treatment. This way, you will be able to pick up the inferior wall MI / RVI prior to giving NTG even if you had a line started.

I see where your peers are coming from. If the B/P is truly 190/100 I wouldn't be fearful about giving NTG without a line... at least not the initial dose. Think about that pressure. If a patient is having an ACS, a pressure that high is very taxing on the heart. Diastolic pressure correlates to afterload and at 100mmHg it is a great force the heart has to overcome to eject blood. I have never seen a single nitro drop a pressure by more than a 100 points which would put the patient into an area for concern.

Also, a lot of patients with inferior wall MI / RVI are hovering around the border-line hypotension range or low end like SBP 110-115's. In this case, yes I would want a line first before nitro. Heart rate is also often on low end or bradycardic with inferior wall / RVI and commonly seen with a heart block, N&V.

Where I work, BLS protocol allows Basics to give NTG on their own (carried on the ambulance) without IV access. So its not an absolute.
Click to expand...

agreed


where I work as long as the sys pressure is over 110 we can give it without a line.
 
The other medics probably shouldn't have over run you, but I also don't think a line is mandatory for giving nitro. As was mentioned above, you can determine the likelihood of right sided involvement based off of the 12 lead and assessment. In low chance cases I don't have a problem giving nitro before I have a line.
 
is 190/100 really cause for "stuff nitro down her throat" as fast as possible? 190/100 isn't all that high... now if you said 240/140, with other ACS related symptoms, than i'm going to start saying time is def of the essence.

Was he grossly diaphoretic? or showing any other signs of poor perfusion? if not that i'm still not rushing.

IV access is nice because 1) protocol requires it and (more importantly) 2) if something happens, or you need to push IV meds in a hurry, you already have the line in place, and don't need to start fishing for access.

If the patient is hypertensive, odds are the NTG won't drop their BP into a problematic rate. however, if they have another problem unrelated to the htn, and needs medication, I'd rather have the line in place, than have them go into vtach and then be found behind the 8 ball.
 
With pressures like that you probably aren't going to bottom them out with a spray of nitro. I'd personally be comfortable giving it without a line but a line would be high on my list of priorities. Personally I'd only give the first spray before getting a line but that's also because she's probably not the easiest stick so if she's hypertensive it may make the line easier to obtain.

Like someone said, this was your call, why were the other medics walking all over you? Personally this one would go up the chain to an appropriate supervisor. My call, my responsibility, my treatment path.

What did the 12-lead show? In my opinion we should be getting a 12-lead before administering NTG, as it helps us build a trend to show responses to treatments. That is our protocol and my personal preference along with the emergency physicians and cardiology groups here.

I've got a zinger...You had 3 paramedics on scene. Why can't one be capturing a 12-lead while the other works on obtaining a line and the 3rd gets the NTG and other meds ready and possibly the first spray onboard after the 12-lead is finished? Delegation or resources at it's finest. Rather than arguing on scene in front of the patient.

You were put in a pretty :censored::censored::censored::censored:ty situation, if you are attending the call no other medic should step in and start making treatment decisions, regardless of their seniority or experience, unless you are doing something that is going to harm the patient. By the sounds of it you definitely weren't doing anything that could harm her.
 
The pt was reportedly having chest discomfort, which is arguably a good reason to give nitro in this case. If they were giving it only because of the BP that is a no no. Treating asymptomatic HTN in the field is stupid. The current recommendation is that people with HTN have their BP lowered over weeks so their body can adjust. Afterall, their BP didn't go up suddenly, it shouldn't go down suddenly.
 
Just to touch on the B/P issue. In the older population who present with ACS and found to be hypertensive I think of CHF. A lot of CHF patient's present with hypertension as the neurohormonal compensatory response. Just something to think about too as CHF can cause B/P to spike quickly and that is a case were B/P reduction is quickly needed.
 
True, but in that case you aren't lowering their BP just for the sake of getting a better number. You are lowering it to treat a specific issues that are present. Plus those pts are usually have some other symptom aside from HTN.
 
If it's your patient, it's your call, and it's bad taste to have the others just override you.


Having said that, I personally don't require an IV in place before I give NTG. It's something I prefer to have, but lack of it won't keep me from giving it. As has been stated, many patients take it every day without starting their own IV with little chance of negative outcome.

If a BP is 110/70, I'd prefer a line. If it's 190/100, it's either/or. If it's a hard stick, I go ahead with the NTG. I have the IO to fallback on if need be. You're not likely to drop from 190/100 to 60/p from a single SL nitro, but the NTG COULD potentially relieve the pain.



Do you also require an IV for Fentanyl or benzo administration given IN?
 
It's all about the situation. I will (and have) given up to four NTG tabs simultaneously to a fulminant CHF patient prior to having a line, so that once I got the CPAP mask on it stayed on. I've yet to kill one of these patients. A protocol saying you must have a line is your medical director's way of saying "I don't trust you not to be stupid".

I won't give it without a 12 lead in hand though.
 
If that patient's got a BP of 190/100, I wouldn't fear about giving NTG to her without a line. That small amount of NTG probably won't drop her pressure enough to make much of a difference, even if she has an IWMI or RVI. Now if her vital signs were near normal or slightly low from what I'd expect, I'd hold the NTG until after I get a 12-lead, and possibly establish a line. I wouldn't necessarily give the NTG specifically for reducing the BP though. There are other meds that can do that and that last longer. Sometimes the best Tx is to do nothing but provide a nice, quite ride in. Sometimes, you have to empty the shelves of whatever drugs you have... if it's indicated.

In her case, I'd probably be inclined to have one of the other medics get an EKG going (preferably a 12-lead), another flood a line for me and get things ready in the ambulance, while I continue evaluating the patient and devise a treatment plan. If my plan calls for NTG, I'll be the one to order it.

Also, if that patient is my patient, I am the person in charge of her care until I RELINQUISH IT specifically to someone else. If any other medic bulldozes in, and tries to take over care, I'm more than happy to tell them that they can take over complete responsibility for the patient... and that means riding all the way into the hospital while taking care of that patient and doing ALL OF THE PAPERWORK. That also means taking all the credit or blame for what happens with that patient.

That pretty much lets the 30-year volunteer medic that just decided to vanish... vanish from the scene that much quicker, and your partner make a very quick decision about whether or not they want to do all the paperwork for a patient that initially wasn't theirs...
 
Last edited by a moderator:
Out here the protocols for my city/volunteer employment clearly state

NTG can be admin in 0.4mg q3-5 does with a bp of

greater than 120 systolic without IV access
greater than 100 systolic with IV access.

The only patients I ever give NTG to without a 12 lead are patients in severe APE that we need to get moving with. If I can hear them drowning and they are HTN we usually do a 3 lead, give them a double spray, stick an IV in if possible and head to the vehicle.

I really don't see anywhere that I could feel it necessary to administer nitro with a BP around 120 let alone 100 IV or no IV. There is no reason to risk creating further problems whether they are easily resolved or not.

I was always taught that we give nitro to reduce the workload of the heart and as a diagnostic tool to make a presumptive diagnosis of ACS. It is not primarily given as a pain treatment. Thats just an added bonus. If my primary concern is to treat pain, I have plenty of morphine to go around.

Just like everything else, clinical judgment is paramount. IV should always come first in my mind at a minimum as a preventative measure. If my patient could deteriorate, I want to be ready. Unfortunately many times we may not be able to get that IV, but if the patient has a cardiac history and is hypertensive im not going to withhold a treatment that could improve their condition greatly.
 
Last edited by a moderator:
Was she currently complaining of pain/pain symptoms when you gave the nitro? We only give it here if they have current symptoms. No pain/ discomfort = no nitro.

We routinely give up to 2 x spray without an IV
 
Thank you for the replies

Thanks guys for the feedback,

To answer some commonly asked questions and to clear up a few things is yes a 12 lead ECG was done initially inside the retirement home upon applying the cardiac monitor- sinus tach.

The pt had pretty bad dementia and I could not gather she was having all that much pain, even upon asking and making it as simple as I could she really had little to no pain if any it appeared when she pointed out a pain area it was upper GI lower chest which did change to other area's but again she was freighted anyhow by us and did not seem to grimace in much of any pain, I feel the nurse attending might have "caught wind of the word pain in the chest area and hit 911 as a precaution etc.

Not much "fighting went on" other than I made the other 2 very aware I did not agree at the time with the NTG being given before my line was in place. Once we loaded the pt in our 10 min time frame and the NTG was given , the my partner was attempting a line while I tried to further evaulate the pt's pain / symptoms and anything else I could get out of her but again she pretty much gave me the blank, confused look and was not answering my questions properly due to her dementia. Once the NTG was given the 3rd medic (who joined us that was on 2nd call) caught a PVC on the monitor at which point a strip was printed, a second ECG was captured along with the run of V-tach that resolved within 10-15 seconds...at which point she was tripped out...and left. No IV was yet established as my P was having no luck with his few tries, I was able to secure a line and then we headed to the ED.

I've picked up a lot from this forum post which has helped me and also allowed me to lighten up a bit on the situation but I completely agree ...next time if it's my pt it's my care / path otherwise it's your pt and problems and paperwork like mentioned! I would only expect someone to step in and take action if I'm making a mistake or making a call that could cause unintentional harm ....but of course that was not the case.

Thank you again your replies have been helpful
 
Nursing home patients with dementia can be really hard to assess so I hear ya. Absence of ischemic 12-lead changes surely isn't 100% confirmatory of no cardiac issue, but if the 12-lead is normal and the pt. is not evidencing or stating chest pain or some kind of anginal equivalent I would probably withhold NTG. Sometimes providers (not saying you) can get pulled into a complaint stated by dispatch or someone else onscene.

You seem like you have a great attitude and are very humble which makes a great Medic. This forum is a great resource and has helped me a lot.
 
What did the call come in as anyway?
 
Our protocols give precedence to NTG over an IV for treating ACS. Granted, you want to get that IV in case they crump on you, but with a strong pressure, I wouldn't worry too much about it, even if they were having an inferior wall or right ventricular infarct.

In fact, our protocols state to start with a double dose of 0.8 mg if the pressure is over 150 systolic.
 
Even at my mickey-mouse level of certification we are not required to have a line in place before administering Nitro. Given that I have never been in such a situation where I am the highest level provider on-scene I have never really been in a position to make that call. What do others think about getting a saline lock in place first, is it worth the time?
 
In this particular setting, if you're going to put in a lock, you might as well put in a line. You probably can convert over to a lock later, or just let the hospital staff do that.
 
Last edited by a moderator:
You must log in or register to reply here.
Back
Top