ASA in Chest Pain

[jjesusfreak01]

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.

Well, here's a good question. Warfarin works by blocking production of clotting factors, but depending on the patients specific needs and the target INR, we can't know to what degree these clotting factors are in effect. Aspirin inactivates the protein that causes platelets to stick together, preventing further clots or worsening ischemia in the case of ACS.

On one hand you could argue that since your patient is already taking anticoagulants, then they probably don't need aspirin.

On the other hand, you can argue that because your patient is already taking anticoagulants, a little bit of aspirin probably isn't going to hurt them more than the coumadin they are already on, and that if somehow they are still clotting up their coronary arteries even with all that coumadin running through their system, then they need all the help they can get.

 

[Hellsbells]

Heres an interesting fact about my service (forgive me for quoting protocols). Dispatch now directs pts to take 325mg of ASA online, prior to our arrival. A practice I find reprehenisible, as our dispatch struggles with determining a proper C/C on the average call, let alone directing pts to take meds over the phone.

There is no hard and fast rule where I work about the dose of ASA, so long as its between 160-325mg range. I typically administer 160mg, even if the pt has taken their normal Rx dose, as I don't know for sure if they have actually taken their ASA that day, I'd hate to see an MI pt not receive any ASA due to a drug error on the pts part.

 

[tylerp1]

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"

With all due respect, I, along with others, was simply answering OP's question; I shared what my protocols are, though I haven't come to a conclusion whether I should or shouldn't give ASA in certain circumstances after having discussed this matter to doctors with whom I work.

It also seems as if OP also explained some biochemistry of ASA. I figured why beat a dead horse?

In case you forgot:

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.

 

[mycrofft]

The standardized procedure I referenced was for RN's in our correctional setting. If vitals were stable and pt was otherwise unremarkable as far as signs (no diaphoresis, skin color good, resp unlabored at rest, chest clear, no distal leg edema) and symptoms (no c/o n/v, no weakness), we could actually give a swallow of liquid antacid while monitoring. We caught quite a few esophagitis, upper gastritis and spastic esophagi this way, but we also had a hair trigger about calling the doc if things just didn't look right. Also while doing the rest, we would palpate the rib cage including sternal depression while lying down or supporting the mid-thoracic spine with the other hand and ask if that reproduced the pain.
It's a professional decision thing, within the SP's.

 

[jjesusfreak01]

With all due respect, I, along with others, was simply answering OP's question; I shared what my protocols are, though I haven't come to a conclusion whether I should or shouldn't give ASA in certain circumstances after having discussed this matter to doctors with whom I work.

It also seems as if OP also explained some biochemistry of ASA. I figured why beat a dead horse?

In case you forgot:

You make a good point, the OP did ask for protocols. That said, I don't believe its generally helpful to list protocols without the evidence behind them. It is extremely common for many people to pipe up on threads here simply listing their protocols when the objective of the OP was to have a genuine medical discussion about the evidence and efficacy of drugs and treatments.

 

[Melclin]

We give 300 in one tablet. Regardless of previous administration.

Aspirin being the most important drug we give and reasonably harmless, even on top of a previous dose. Add that to people being rubbish historians especially when they old/scared. I almost always just give them one of ours.

I'd be interested to see the outcome of this thread.

 

[Arovetli]

Thanks everyone for the replies. Its interesting how different things can be from one place to the next.

 

[johnrsemt]

Kind of scary how many areas out there that the EMT-B's can't give ASA to cardiac symptom patients or assist with patients NTG: here they have to call and get permission from Medical control; and half of our response area is out of radio and cell range for upto 1-2hrs.
So they are taking away what little Basics can do to help people.

 

[johnrsemt]

Back where I used to work Basics could give 162mg baby ASA chewable, and assist with up to 3 doses of patients NTG (BP dependent), and O2, all without needing to call in for orders.

and that was with an average of 10 minute transport time with medics crawling out of the woodwork.

 

[Bullets]

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?

ASA can be administered in any incident of non-traumatic chest pain. It is to be delivered in a cumulative dose not to exceed 325mg but does not give a specific time period. All aspirin must be chewed

And this is literally a brand new change from the NJ DOH/OEMS, some agencies aren't even aware of it

 

[Cawolf86]

Our service carries 325mg tablets. I will give a patient 325mg ASA and have them chew - regardless of daily dosing of ASA or other anticoagulants. Our county dispatch uses EMD protocols which often directs chest pain patients to take their own 324/325mg prior to our arrival. In that case we will not administer more. All this taking allergies/ulcers into consideration.

Edit: When I was in a past county we gave 81mg regardless of them taking it prior to our arrival.

 

[18G]

I've always given 324mg in the three states I've practiced. If a patient has already taken 81mg of ASA I would still give them 324mg most times as it's not going to hurt them and then I know for sure they got ASA onboard.

And unless a patient has a true allergy to ASA (ie hives, swelling, dyspnea, etc)... give the ASA! Many times you have to ask the patient about why they claim to be allergic to it. Many will say it makes their stomach upset, etc. If that's the case they need to be getting ASA. It's a risk/benefit thing. What would you rather have, a minimal chance of some bleeding or irritation that can be managed or a 23% decreased chance of dying? I will choose a 23% reduction in mortality.

ASA is vital and is the only drug we give that has been shown to decrease mortality in MI. I went to the JEMS Conference and Dr. Cory Slovis spoke about this very thing.

One of the dispatch centers around here also instructs patients to take ASA when they call 911.

 

[18G]

On one hand you could argue that since your patient is already taking anticoagulants, then they probably don't need aspirin.

On the other hand, you can argue that because your patient is already taking anticoagulants, a little bit of aspirin probably isn't going to hurt them more than the coumadin they are already on, and that if somehow they are still clotting up their coronary arteries even with all that coumadin running through their system, then they need all the help they can get.

Coumadin isn't a contraindication for ASA. It is important to know that ASA and Coumadin compete for the same binding site on the cell. When ASA is given, it causes more Coumadin to become unbound and exert it's effect.

There is more than one pathway to inhibit clotting and preventing platelet aggregation. This is why patient's on heparin may also be started on Aggrestat or Integrilin. And again, in some patient's who are poor historians they may not be the best to know if they took their Coumadin or not.