usafmedic45
Forum Deputy Chief
- 3,796
- 5
- 0
No, wrong is too much of an understatement. They are dangerously :censored::censored::censored::censored:ing stupid.
Antiarrhythmic confusion.........
- Thread starter Sharktooth
- Start date
No, wrong is too much of an understatement. They are dangerously :censored::censored::censored::censored:ing stupid.
epipusher
Forum Asst. Chief
- 544
- 85
- 28
other than an allergy or a bp less than 90, our medical directors repeatedly stress to never withhold ntg. this is brought up time and time again at our audit and review sessions.
epipusher
Forum Asst. Chief
- 544
- 85
- 28
so our team of medical directors with local cardiologist and heart hospitals/centers approval, must all be wrong?
According to the ACC....yes. Or more likely, they're considering paramedics too uneductaed to make a nuanced decision about NTG.
epipusher
Forum Asst. Chief
- 544
- 85
- 28
i love it when folks such as yourself have these type of discussions with our area medical directors. always entertaining.
Ahh yes, because I'm a jack@ss who thinks he's smarter than the physician
I've had these discussions with my medical directors before. I've never once gotten "because my mad physician skills are better than the large body's reccomendations". I've usually gotten one of two answers. 1). The consensus standard hasn't been updated recently and there's newer science out there, or 2). I don't trust the lower-teir providers in our service's judgement.
How about since you now know what your service is doing with regards to NTG runs contrary to what the ACC's consensus standard is YOU ask him why your doing it that. You might be supprised and disapointed by the answer.
the_negro_puppy
Forum Asst. Chief
- 897
- 0
- 0
If NTG/GTN has little effect on myocardial ischaemia why risk giving it to possibly pre-load dependent patients? This is where clinical judgement comes into play. It's a shame that some services have hard and fast protocols with know room for judgement.
For us, GTN is contraindicated by a systolic BP < 100 mmhg and a heart rate below 50 and above 150. An inferior M.I is a precaution due to possibility of RVI. I personally would not give GTN to a pt with S-T elevation in V4R and would be very wary giving it to any infarcting patient with a BP close to 100mmhg. If i withheld GTN from an infarcting pt with a systolic bp of 105 I would not get audited or 'in trouble'. Our service allows room for clinical judgement and evidence based medicine.
As other have said, there's not much point giving GTN then pushing fluids to try and save your patient's preload. Withold the GTN, make sure they have had their aspirin, O2 and morphine and spend the time packaging them and tx to definitive care.
For us, GTN is contraindicated by a systolic BP < 100 mmhg and a heart rate below 50 and above 150. An inferior M.I is a precaution due to possibility of RVI. I personally would not give GTN to a pt with S-T elevation in V4R and would be very wary giving it to any infarcting patient with a BP close to 100mmhg. If i withheld GTN from an infarcting pt with a systolic bp of 105 I would not get audited or 'in trouble'. Our service allows room for clinical judgement and evidence based medicine.
As other have said, there's not much point giving GTN then pushing fluids to try and save your patient's preload. Withold the GTN, make sure they have had their aspirin, O2 and morphine and spend the time packaging them and tx to definitive care.
Last edited by a moderator:
Our position has recently (2009) changed: GTN has little role in STEMI however most clinical people will have given some GTN before acquiring a 12 lead ECG (Paramedic or Intensive Care). Technicians (volunteers) do not have 12 lead ECG. GTN has no role in repeat doses unless clearly associated with improvement.
Smash
Forum Asst. Chief
- 997
- 3
- 18
I love it when people use capital letters. Capitals are important. They are the difference between helping your Uncle Jack off a horse, or helping your uncle jack off a horse...
Regardless of that, if you disagree with the ACC, or you disagree with the rationale some of us have given for withholding nitrates in RVI, can you share your reasoning with us? I don't mean by saying "my medical director told me so" but by actually providing some evidence or some physiological rationale why nitrates are appropriate in the given circumstance.
Maybe we can learn something, which is, after all, the reason we post here.
epipusher
Forum Asst. Chief
- 544
- 85
- 28
I worked for a previous service where we never gave NTG for RVI. Then I moved and started working for my current service, of which I consider a progressive service, and my partners would look at me funny when I stated I was going to withhold NTG with this particular finding. This would be followed by looks of confusion, followed by them wishing me luck when I explained to the er docs why I withheld nitrates. Keep in mind that when we have cardiac patients, we go above and beyond the usual standard of 3 sprays of NTG. Our lead medical director, when explaining the amount of NTG we should be giving to our suspected cardiac related chest pain patients, uses the phrase "copious amounts". I put my faith and trust in all of my medical directors and the other 6 area medical directors that are all pro NTG. As I stated before, someone will always question that decision during one of our Audit and Review sessions. The MD's response is to just be prepared. Have an i.v. and watch for changes in their b/p. As a side note, we also give "copious amounts" of NTG for patients with severe CHF. Please go through and correct my grammar after you are done explaining how I'm wrong again. Thanks for the discussion.
Last edited by a moderator:
usafmedic45
Forum Deputy Chief
- 3,796
- 5
- 0
Actually, I'd take usalfyre's word over your own any day of the week. He's a bit abrasive at times but generally knows his stuff. Even as bright as I am, he'd still not be someone I would pick an argument with unless I was REALLY sure of what I was talking about.
You're in Indy correct? I know most of the medical directors here and have to say that they aren't exactly the best I have ever seen. Not bad, but not great or progressive by any stretch. USALFYRE's right...it's the fact that they don't trust EMS providers and the expectation is to run everyone into the hospital ASAP rather than intervening in the field. Works great right up until the traffic sucks....
I consider my service fairly progressive as well.
Just because your partners look
at you funny is NOT a good reason to base a treatment off of. I make partners look at me funny on a regular basis, doesn't mean it's not good medicine, it means the treatment doesn't fit their paradigm.
We follow up our SL NTG with an infusion up to 200mcg/min. So I know a bit about "copious amounts". But it's only appropriate in certain settings. It's also interesting your medical direction team puts so much faith in a treatment that's never been shown to reduce morbidity or mortality in AMI.
I put my faith in science, physiologic understanding of the med I'm giving and consensus standard of what constitutes good care. I've had a lot of protocols that sucked that were written by paramedics, physicians practicing old medicine or physicians who did not trust their medics.
Or...just avoid iatrogenic cardiogenic shock by withholding a the med in certain settings.
My severe CHF patients tend to get one SL dose of 1.2mgs, a CPAP mask and an infusion at 75-100mcg/min. So it's not a med I'm uncomfortable with, I give without a line all the time, ect.
Several sound physiologic and consensus arguments have been presented here as to why NTG is a bad idea in the setting of RVI. You've failed to present anything more convincing than "my medical director said". Sell it to us, convince us we're wrong.
Ok.
So, as I see it, you're saying you give NTG in RVI. And when asked why, your response is basically:
(1) My medical directors recommend this.
(2) They're very smart people.
(3) They tell you to have an IV first, and "be prepared" for the pressure to drop.
(4) You feel that giving more than 3 nitro is going "above and beyond"
(5) You also do this in CHF (implied, so it's good in ACS /MI)
Is that fair?
I'm sure (1-3) and (5) are correct. I'm sure your medical directors are very smart. Most physicians are. Including the numerous physicians and PhDs (and MD/PhDs) who sit on ILCOR. Your local physician group would be going against the consensus opinion of the major governing body that establishes guidelines that ultimately translate into AHA / CHSF / ERC / etc. guidelines. This has already been pointed out, quite politely.
Are they wrong? Perhaps. I think so. But I'm sure they don't care about my opinion. No one's suggesting that you should decide not to follow your protocols. It is however being suggested that your protocols aren't in line with currently-accepted international guidelines.
With regard to (3) it's fine to be prepared for hypotension. Are you prepared for a sudden VF arrest? Because that's how rapidly your hypotension may develop. What do you think hypotension will do to coronary blood flow? If the blood supply to the myocardium is further compromised, do you think the infarct will extend more rapidly? Aren't we hoping to improve the oxygen supply/demand balance?
As to (4), and (5), I can't say that I think giving > 3 NTG in a chest pain patient is "going above and beyond". I also think that CHF, i..e. LV failure, is a different clinical entity to RVI.
The question has been asked "Why do you do this?". Why do you think it's a good idea to give NTG to an RVI? What effect are you aiming for? How do you think it benefits your patients? What are you hoping to achieve?
Last edited by a moderator:
epipusher
Forum Asst. Chief
- 544
- 85
- 28
Gentlemen, I'm not trying to sell you on anything. I'm not even saying you are wrong. I agree with everything you are saying, and for my first 4 years as a medic, this was how I operated. For the last 5 years I have worked for a different service that follows a completely different path. I am not the type to confront these ER physicians as well as the cardiologists I have heard confirm this way of treatment at various local EMS seminars. "Because my medical director said so", is the only reason I need. Sorry fellas, I'm not trolling.
epipusher
Forum Asst. Chief
- 544
- 85
- 28
Two more after this and I can enter chat!
Come on mate, thats pretty poor. What that says to the rest of us is "I am unable to think for myself".
3 doses of sublingual GTN is nothing to be impressed about, repeated GTN is inappropriate unless clearly associated with improvement, so if the patient improves with each dose of GTN why stop at 3? It sounds like you have been working in places where your delegated authority does not include more than three doses of GTN.
Remind Brown again why we even give some bloke with STEMI GTN? :unsure:
GTN is an anti-anginal agent, does it really have a role in STEMI?
Confrontation is not needed. But educated conversation with the medical community is. ED physicians and medical directors are not dictators. Most physicains I encounter are more than happy to explain XYZ item or issue. But I will be damned if I will blindly follow anyone just because they say so. In my world, physicians do not walk on water. Most are cool dudes with real lives away from medicine. Talk to them about anything but medicine and start building professional relationships.
If a lot of my posts center on people and behaviors it is because my degree is in Sociology.
Last edited by a moderator:
Fair enough.
I like to discuss to physiology and pharmacology because they interest me, and I have a fair bit of education in these areas. While this is probably an unpopular opinion, I think that doing so has made me a better paramedic. But we're all in the same boat here. I can't deliver a therapy that's not available on my ambulance. And while I may have been able to move outside of the medical control guidelines from time-to-time, I can't just decide they're wrong and outright violate them without good cause. I don't think anyone is suggesting that you should either.
Granted the topic of this thread has drifted far away from amiodarone maintenance infusions, but at some point we started discussing the pharmacology of nitroglycerin. Feel free to contribute to that discussion, if you'd like.
If we steer this thread back to the original topic -- I'd always wondered why we use maintenance infusions with an antiarrhythmic like amiodarone that has such a long t1/2. It seems like if we get high enough plasma concentrations to convert / suppress an arrhythmia, that if we're waiting 50 days for he concentration to half, there's not going to be a pressing need to administer more in the next couple of hours (days?).
Then I looked at some research, and saw that amiodarone rapidly redistributes to the adipose tissue from the bloodstream. So I think that after a bolus injection, we see a rapid movement of amiodarone from the bloodstream to the adipose tissue compartment. So in the initial period following IV administration, the plasma concentration actually falls much much more rapidly. The apparent half-life during this period is much shorter. One the amiodarone has redistributed, and the vascular and adipose compartments are in equilibrium, the longer 50 day half-life is seen. So I think the maintenance infusion may be designed to ensure that plasma [amiodarone] stays higher than it would otherwise.
I've got to say though -- given amiodarone's multiple complex, and perhaps not fully understood actions, I think it's surprising that we use a drug with such a long half-life. Once it's in, we're stuck with relatively high levels for a couple of months. Seems like that might present some potential for drug interactions and proarrhythmic effects.