So you don't have a line, you give nitro, and their pressure plunges. OMG! BELLS AND WHISTLES!!! WHAT THE F*** DO WE DO NOW!!! AAAHHH!!!
Hope they don't code. Try and get the IV access that I should have had in the first place. Wonder why I chose to give a medication that hasn't been demonstrated to improve long term outcomes but has been demonstrated to provoke rapid hypotension in some patients without getting IV access first? Hope the medical director doesn't audit my PCR. Wonder a little about what I'm going to eat for lunch.
Lay them back, kick their toes up, throw in a line (don't forget that a quick EJ is sometimes an easy mark) or if you can't nab one then go for the IO.
With the caveat that the hospital will love you if you miss that EJ and fibrinolytics were an option. Or that it might not be so great if you were planning to give them.
HOWEVER>>> 99% of the time giving your first dose of nitro won't cause such a dramatic result.
So we're giving a medication that theoretically should reduce infarct extension by reducing preload and hence wall tension / oxygen demand; and may have some secondary effects like reducing pain / anxiety / sympathetic outflow, etc.
But we can't wait the seconds or minute(s) to get an IV first, and we're willing to accept the definite risks of infarct extension if we bottom coronary oxygen delivery by sewering arterial pressure? And the very real risk of a sudden arrhythmia and/or cardiac arrest? Let alone the compensatory tachycardia we may see if we reduce the pressure too far, which is probably going to increase the oxygen demand we were seeking to reduce in the first place? (Assuming they're physiologically capable of increasing their rate, in which case something worse is going to happen?)
Exactly what benefit is there to giving NTG a minute earlier? Or five minutes earlier? Especially if the patient has been having chest pain for an hour and a half before calling 911?
Yeah, yeah... I'm sure there's one or two of you out there that have "seen this happen" or heard about your cousin's friend's old classmate's medic buddy that had a patient "crash" on them from a single dose of nitro. But it's really very uncommon.
It is, absolutely. Because most of the patients we give nitroglycerin to aren't having an MI. Most, at best, are having some milder form of ACS, a fair majority have a noncardiac etiology. Only a very small percentage of our patients are (i) infarcting, (ii) infarcting their right ventricle, (iii) having an RVI that's preload-sensitive.
I'm just not sure how this justifies rushing to give the NTG? Why not take a few seconds, breath, get a 12-lead, give some ASA, take a look for changes suspicious for RVI, put an IV in, and not fall all over ourselves to give a potentially lethal drug without some thought of doing it safely?
If they've got a non-cardiac etiology, then the NTG will either relieve the pain or it won't. If they're not having an MI, then we're probably not going to provoke one by waiting a minute or two to give NTG. If they're having an MI, it's not like there's a truckload of evidence that NTG has a huge effect, compared to, say, ASA. The delay associated with obtaining IV access is likely to be negligible, and now when you give the NTG, if they do sewer, you can actually do something about it in a timely manner.
It seems like working a code where you've already got an IV in place, and can add some preload, or even bolus epinephrine, might be preferable to working a code where you have no immediate access for fluids, no immediate access for medication administration, and you're crossing your fingers that either you get access quick enough to do something about the preload, or that the t1/2 of the NTG is short enough, and their infarcting heart healthy enough that you get ROSC?
Monitor their pressure, if there's a significant drop after the first dose then you should be a little cautious.
Providing that the first sign of your precipitous hypotension isn't the patient R on T'ing, and going into VF/VT.
Generally speaking though, it's the second or third dose you have to watch out for in those right ventricular infarcts.
Disagree strongly. While you're ultimately constrained by the medical advisory committee of whatever organisation you work for, there's an increasing number of services that defer NTG until you have a 12-lead and IV access. There's also an increasing number that have an absolute, "no NTG in RVI" standard of practice, and a fair number that will require IV access for any SL NTG.
