ASA in Chest Pain

[Arovetli]

Not sure which forum is most appropriate.

My service/hospital administers 325mg ASA to chest pain patients. I'm interested to know, how many of you administer this dose? AHA recommends the 160mg dose over the 325mg. The literature indicates we are overdosing people on ASA and doing nothing except increasing the risk for an adverse event. Off the top of my head ISIS-2, GUSTO-1, GUSTO-3 and CURE are trials which advocate the 160mg dose.

Also thoughts on administering ASA to chest pain patients who take long term low dose (81mg) ASA? My previous service did not administer additional ASA under the belief that the cyclooxegenase was fully inhibited while at my current service the attendings administer, and want us to administer 243mg of ASA so they can go down on paper saying the patient got 325mg of ASA today. How does you service do it and what are your thoughts?

***

In the spirit of education ASA, or acetylsalicylic acid, reacts its acetyl group with serine in the cyclooxegenase (COX-1/COX-2) receptor. The binding of the acetyl group irreversibly blocks the cyclooxegenase. The affected platelet is inactive until it dies (life span 10 days). In normal function the cyclooxegenase catalyzes prostiglandin production (prostiglandin H2) and thromboxane A2 production. Thromboxane A2 acts as a local messenger mediating glycoprotein 2b/3a sites (fibrinogen binding sites) and activating and attracting platelets. It hangs out for about 30 seconds before disintegrating into inactive thromboxane b2.

 

[Medic Tim]

Where I work we give 160mg even if the pt has already taken ASA.

 

[EpiEMS]

Where I work we give 160mg even if the pt has already taken ASA.

Quick question:
I asked an instructor about this a while ago, and he indicated that if a patient has taken ASA in the morning, then it's not necessary to give them (and is contraindicated, even) ASA when they present with chest pain, because the ASA has already reached whatever level in the blood necessary to act as an anti-clotting agent. Does that strike you as reasonable?
I'm assuming that another 160 mg certainly wouldn't harm the patient, but curious whether it would help.

 

[Handsome Robb]

Quick question:
I asked an instructor about this a while ago, and he indicated that if a patient has taken ASA in the morning, then it's not necessary to give them (and is contraindicated, even) ASA when they present with chest pain, because the ASA has already reached whatever level in the blood necessary to act as an anti-clotting agent. Does that strike you as reasonable?
I'm assuming that another 160 mg certainly wouldn't harm the patient, but curious whether it would help.

Umm you just reiterated the original question. You just used simpler wording.... It's not contraindicated unless they have taken the max dose already.


We give 324 mg. If they have already taken ASA today and we can determine how much they took and it is less than 324 mg we are supposed to give them enough to reach the 324 mg dose.

 

[awesomemedic]

Give this, don't give that. Too much of this, not enough of that. I find that there are enough studies to effectively put an end to pre-hospital care. My favorite is the study about pre-hospital NS in trauma patients is causing an increase in mortality rates. But what the study failed to mention was that patients requiring pre-hospital fluid infusion are typically on their way to death anyway. I'm not bashing the OP and am interested to hear more about this new study about the one proven med we carry to help an ACS patient is suddenly causing adverse effects. I just want to know when the study on studies is published.

 

[Bullets]

I am allowed to give up to 325mg of ASA or if the patient has relief. So if i give the patient 81mg and they have total relief i dont have to give them more.

 

[EMSrush]

We administer 324mg ASA for CP.

 

[Arovetli]

I'm not bashing the OP and am interested to hear more about this new study about the one proven med we carry to help an ACS patient is suddenly causing adverse effects. I just want to know when the study on studies is published.

Not new studies and plenty of research showing increased risks with ASA administration. It's not suddenly causing anything, its been well established that asa increases bleeding risks. There's alot of data out there other than the 4 studies I quoted. Just wondered how practices varied and who followed what regimen.

We should constantly be questioning ourselves and our established practices to ensure optimal care. Note I said constant questioning not constant change. Change should only follow well established science. I do find it interesting how resistant to change physicians and clinicians can become at times, even though we tout evidence based approaches.

 

[EpiEMS]

We give 324 mg. If they have already taken ASA today and we can determine how much they took and it is less than 324 mg we are supposed to give them enough to reach the 324 mg dose.

Sorry, guess I misread the original question. That makes sense.

 

[Anjel]

We give the 324mg. 4 81mg tabs. Unless they took.it prior to us getting there. Then we dont.

 

[Medic Tim]

I am allowed to give up to 325mg of ASA or if the patient has relief. So if i give the patient 81mg and they have total relief i dont have to give them more.

so your protocols use ASA as pain relief for ACS? How long do you wait before giving more?
do you have your pt's chew the ASA or swallow?

 

[mycrofft]

If ASA is such a perilously dosed anticoagulant...

With so many people presumably taking ASA for pain as it was originally intended, why aren't they dropping like flies from exsanguination caused by traumas large and small? I think armchair scientists try to see the most minimal dose to reach a 50% (median) of sample positive response to avoid giving one extra atom, and to achieve scientific elegance.

A lifelong chronic dental patient, I have seen that other NSAIDS like Ibuprophen and naproxyn sodium really increase bleeding too, and are taken in large doses (500 mg for Naprosyn, 800 for Motrin).

PS: An NSAID given for chest pain due to complaint and not assessment may be addressing chest wall pain. No harm unless the pain is referred from a gastric or esophageal ulcer...going back to why the smaller dose of enteric coated drug is given. Even in those cases, it could decrease pain for a little while before it came back.

 

[Devilz311]

I am allowed to give up to 325mg of ASA or if the patient has relief. So if i give the patient 81mg and they have total relief i dont have to give them more.

Unless it's psychologic, I highly doubt the Pt is going to report a relief in CP from ASA in the field... AND it's given all at once. What protocols are you referencing? NJ EMT-B's can't directly give a Pt ASA anyway...

 

[Devilz311]

so your protocols use ASA as pain relief for ACS? How long do you wait before giving more?
do you have your pt's chew the ASA or swallow?

It's not. NJ ALS standing orders are a max dose of 324mg ASA and SL NTG q5 for a SBP >100mmHg.

I just checked the NJ EMT-B regs, ASA isn't even mentioned. They can ASSIST with SL NTG, but can not physically give aspirin.

 

[EpiEMS]

I just checked the NJ EMT-B regs, ASA isn't even mentioned. They can ASSIST with SL NTG, but can not physically give aspirin.

"Oops, I must have dropped these 4 81 mg chewable tablets of aspirin, which can possibly help in the situation you're in, sir. If I were having an MI, I'd take four 81 mg chewable aspirin like these..."

 

[tylerp1]

Our protocol states we give 325 mg ASA whether they've had ASA already or not.

 

[Cup of Joe]

Our protocol states we give 325 mg ASA whether they've had ASA already or not.

Almost the same for us. We give max 325mg (4x 81mg chewable tablets) unless the patient takes chewable ASA, in which case we subtract their dose from the max allowable.

 

[Tigger]

Straight from the MA protocols:

administer aspirin (dose 162-325mg, chewable preferred) if not contraindicated and not already administered.

If they've already taken ASA, I've been told to just give the 162mg dose, if not give all.

 

[the_negro_puppy]

We carry 300mg aspirin tabs, and aim for a dose between 300-450mg.

Many cardiacd pts are on daily 100mg tabs so we usually give another 300mg on top.

What are the protocols in other services for patient on warfarin/plavix?

I tend not to give ASA to pts on warfarin unless they are strongly suspected to be suffering from ACS.

 

[jjesusfreak01]

I don't want to be the bad guy here, but whenever someone just lists their protocol in one of these conversations, it sounds like this,

"here's what my protocol says. I don't know why it says that, or whether i'm doing what's best for my patient, but a doctor wrote the protocol so it must be right"

Interspersed between these posts are the occasional instructional posts about the mechanism of the drug or new studies that have demonstrated new risks to certain dosages of administration. That's what we like to see here.

As EMS struggles to gain recognition as a true profession, it should be everyone's focus to educate themselves to the point of being experts on what we do, why we do it, and how it affects the human body. Even if at times this means that our medical knowledge supersedes or even differs from protocol, so be it. That's a good problem to have.