Adminstering Nitro w/out a line in place

[systemet]

As stated earlier, patients self administer their own ntg all the time without first checking a set of vitals, performing an initial 12 lead, or placing an i.v.

Yes. But why is your patient taking NTG? Probably because a physician has diagnosed them with exertional angina. A chronic problem, due to coronary insufficiency that prevents oxygen delivery from meeting oxygen demand when the demand increases.

Now you're evaluating a patient you suspect may be have an acute STEMI. They may now have had an acute blockade of one of the vessels supplying their myocardium. They may have acute ventricular dysfunction. Their entire physiology has changed from the time their physician saw them, and evaluated them for their angina!

What may once have been a benign intervention may now have become very dangerous, depending on which regions of the heart are infarcting, their current cardiac reserve, and how preload dependent they currently are.

Besides which, the argument that we should do something because a lay person does it all the time is hardly logically sound in of itself.

 

[systemet]

Yep they certainly do.
I have never had a pt crash after nitro/GTN

Just bear in mind that just because it hasn't happened to you personally, yet, doesn't mean it might not happen in the future. Or that it hasn't happened to someone else.

I've had a fair number of STEMIs just up and code on me. Sudden arrhythmic death is a major killer in the first 24 hours.

Some of those patients have coded a couple of minutes after NTG administration, in several cases after someone else has given NTG without bothering to evaluate for a RVMI. Causality or correlation? Not sure, but I don't see the rush to get NTG in as soon as possible. Often these patients have waited a couple of hours to access the medical system after the onset of pain. Yet there's no real evidence to suggest that NTG improves long term outcome, so how time-dependent is an event that we can't measure?

however- If the 6 lead ECG revealed changes pointing to an inferior infarct and their heart rate/ BP was on the lower end of normally I would get 12 lead + V4R and IV access first before giving nitro.

This isn't what I do, or would recommend, but it seems like you're making a decision on a balance of risks. Most of your inferior / RVIs are going to be bradycardic and hypotensive or borderline hypotensive. Deciding that these patients are a high-risk group, and choosing to evaluate them further before NTG would seem prudent and reasonable.

But you're relying on a 6-lead, presumably in monitoring frequency to resolve ST changes, which isn't that reliable.

There's also an argument to be made that there's a number of case reports whereby ST elevation was seen in an initial ECG and then resolved in a subsequent ECG following O2 and nitrates. While this is obviously a good thing, these patients should probably be followed up much more aggressively than someone with simple angina. Capturing the ECG first makes sure we don't miss these patients.

 

[mycrofft]

I admit I'm not reading the forest of comments before posting this:
1. Was the EKG specifically indicative of a condition nitro was called for under your protocols or common teaching? (not "rule of thumb", but classroom teaching).
2. Was musculoskeletal pain assessed for? Intermittent chest pain without other cardio-like signs and symptoms, especially in the elderly, by my experience, can be due to bad backs, consto-chondritis, or even referred pain.
3. Does your protocol call for emergent tx/Rx of BP's like hers? Was her BP usually like that (per vital signs from the facility)?
4. Second thing to assess elderly patients for, especially in a nursing facility, is polypharmacy or drug-food interactions (e.g., caffeine). Could this pt be experiencing a drug-drug interaction? This is also more likely in the elderly, not only because of being treated for so much, but also because they/we don't necessarily clear medications from the body as fast or the same as others expect; this goes double for meds that need a pass through the liver to produce active metabolites.

The usual and cautious admin of oral nitroglycerine is allowed to be "assisted" by Am Red Cross basic first-aid-ers, certainly without an IV lines. But it must be prudent, appropriate and cautious as with any drug; cowboy "rules of thumb" should never dictate medicating anyone, especially the fragile elderly.

 

[epipusher]

that is very similar how it is done around here as well.

 

[RocketMedic]

Plus there's always the question of "what's their normal pressure, and is this angina normal or ???"

 

[systemet]

2. Was musculoskeletal pain assessed for? Intermittent chest pain without other cardio-like signs and symptoms, especially in the elderly, by my experience, can be due to bad backs, consto-chondritis, or even referred pain.

This is a valid point, but it's also worth remembering that somewhere around 5-10% of patients experiencing an acute MI may have point tenderness that's reproducible upon palpation. So point tenderness on physical examination alone can't be considered a rule-out.

Swap CJ, Nagurney JT. Value and limitations of chest pain history
in the evaluation of patients with suspected acute coronary
syndromes. J Am Med Assoc 2005; 294:2623–9.

The usual and cautious admin of oral nitroglycerine is allowed to be "assisted" by Am Red Cross basic first-aid-ers, certainly without an IV lines.
But it must be prudent, appropriate and cautious as with any drug; cowboy "rules of thumb" should never dictate medicating anyone, especially the fragile elderly.

But of course, this is comparing apples and oranges. A paramedic has a greater scope of practice, more diagnostic tools at their disposal, and a duty to act. If the various first aid organisations advise NTG assist for a lay person acting as a Good Samaritan, that shouldn't be inferred to be the standard of practice for a "professional", such as a paramedic.

I agree with many people who've said that the risk of a particular patient being preload-sensitive is very low. And that's correct. But why expose the patient to this risk when there's a tool that will allow us to identify some high risk patients (12/15-lead ECG), and an intervention (IV therapy) that will allow us to rapidly treat potential complications of a medication (NTG) that is known to be dangerous to some patients?

I just don't see a benefit that's outweighing that risk. What are we hoping to achieve by giving NTG five minutes earlier? Hey, maybe I'm a dangerous idiot, but it just seems wise to get that IV and 12-lead before giving the NTG. These (along with ASA), are interventions that are far more important. They cut down the time to reperfusion therapy, they allow us to identify patients that may benefit from thrombolytics, and enable us to administer them. Why prioritise NTG over a 12-lead or IV, especially when having these is going to (1) allow us to avoid giving NTG to high-risk patients and (2) make giving NTG to the remaining population safer?

 

[Hunter]

Wouldn't you also wanna consider other things than bp, such as allergic reaction, wether the patient is taking any medication that might doubler the effect of nitro. I'd really want a line befor giving ANY medication, in this case I would've at least attempted it first, the patient doesn't understand the pain scale so there's no way to determine wether or not the nitro is helping anyways.

 

[mycrofft]

Good points.
Chest wall/thoracic spine/referrred pain do not necessarily present as point tenderness unless it was from a hockey game or such. However, nothing to say you can't have CWP AND coronary artery disease at the same time.

The phrase by the OP that bothers me is 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"

That led me to believe the med was given in an extreme and hasty dose with a paucity of evidence for its prudent use.

The ARC and AHA nitro deal for lay persons is a red herring anyway, there is no realistic situation where, unless the pt's hands are somehow impaired, a layperson would not be essentially giving the medicine at the pt's request alone...a "bozo no-no" for professionals as well.

 

[ZootownMedic]

I still haven't heard too many people mention a inferior wall MI with right sided involvement. If I have a patient that is complaining of chest pain and presents as a MI I am darn sure gonna check a 12 lead before I go throwing the NTG at them. I HAVE seen NTG dump a persons pressure that was having an inferior wall MI with right sided involvement and I am not trying to be that guy that explains that one to my medical director. Just sayin........

 

[epipusher]

Here we go with the whole "inferior/right side mi" argument. Again, pt's are administering their own ntg to themselves without an iv in place. Prescribed for angina or previous mi aside.

 

[systemet]

Here we go with the whole "inferior/right side mi" argument. Again, pt's are administering their own ntg to themselves without an iv in place. Prescribed for angina or previous mi aside.

And, again, the fact that a physician is prescribing a patient NTG to relieve their angina is irrelevant to the question of whether it's a good idea for a paramedic to administer nitroglycerin to someone having a STEMI!

"Nitrates in all forms are contraindicated in patients with initial systoloic blood pressure <90 mm Hg or ≥30 mm Hg below baseline and in patients with right ventricular infarction.40,–,42 Caution is advised in patients with known inferior wall STEMI, and a right-sided ECG should be performed to evaluate RV infarction. Administer nitrates with extreme caution, if at all, to patients with inferior STEMI and suspected right ventricular (RV) involvement because these patients require adequate RV preload."

ACLS 2010.

"The treatment benefits of nitroglycerin are limited, however, and no conclusive evidence has been shown to support the routine use of IV, oral, or topical nitrate therapy in patients with AMI.183 With this in mind, these agents should be carefully considered, especially in the patient with low blood pressure and when their use would preclude the use of other agents known to be beneficial, such as angiotensin-converting enzyme (ACE) inhibitors."

ACLS 2010

 

[epipusher]

Everyone is an outside the box medic on an ems forum.

 

[Melclin]

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?

This is my theory and my practice. I don't see that this is outside the box. Thankfully we have discretion about things like the exact order of every single one of our actions

1) GTN isn't proven to improve outcomes.
2) You could significantly bugger up their outcome by giving it to the wrong person. I've seen a relative bucket of pt's go arse up directly after GTN administration (generally not pts who should have got GTN in the first place in my opinion, but thats another story).

As such, I don't have a problem waiting for a line or simply not giving it at all if I don't believe the pt is suffering from a problem with preload/afterload. Unless I think they're going to go arse up, I'll generally trial 300mcg, if there is not improvement, I generally won't go for another one. Other times, I’ll give it straight up if I think its safe and its something that will help.

When I asked a very astute intensive care medic recently why he waited 15 mins, 10mgs of morphine and 2 x 12 leads before the first tentative (and only) 300mcg dose of GTN to a STEMI pt, he replied in his typically colourful manner, “Well you don’t f**k with perfusion. He seemed well perfused and I didn’t wanna f**king kill the c**t”.

Also, I don't understand why people are so keen to give GTN to RVIs with an added, so give them fluid as well. Why take their preload away only to give it back, with perhaps a nasty dip in perfusion along the way? That’s not rhetoric, I’m actually interested in their rationale.