ASA & Nitro

TKO said:
What you witnessed, was one of those rare occurrences in EMTLife Hx -- Rid made an error.

Of course, he later corrected himself. He never meant to say Left-sided AMI, he intended to say Right.

That's assuming I read your post correctly. As per Hx, I make my share of mistakes all the time.
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oh, ok. I think he actually edited that post while I was writing that question, it was up for about 5 hours cuz I was running calls while writing it. Thanks for pointing it out.

So is my thinking on the right sided MI along the right lines?
 
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You are correct on the right side AMI (sorry any confusion, I too was in between calls) as well your theory of poor pre-load causing problems.

R/r 911
 
NTG is a very safe medication and in my opinion it is overboard to have a 12-lead before NTG. Only a small percentage... a very small percentage... of patients would be adversely effected and MI exacerbated with NTG. I've been doing this for 12 years as a career and active volunteer and NEVER once experienced a death or worsening of an MI from NTG. Could it happen... sure. Can a COPD patient stop breathing from to much O2 even though hypoxic? sure.

What are the chances? What is the benefit vs risks? Should we withhold early nitro therapy from 99% of the population bcause of 1% that may have a worsening of their MI?
 
We do not 'administer' NTG, we are however able to 'assist a pt with a prescribed medication'. The difference is we don't make the call, being BLS, this is outside of our scope of practice. But, if someone has a prescription for nitro, which means they can take whether we want them to or not, we can help. I have on few occasions, contacted MPD with a pt, 10:10 chest px, and a blood pressure that looks more like the dow than a vital sign. I have been told by the MPD to administer NTG to the pt even though they did not have a scrip for it. The difference is, it wasn't my call, it was the doc's.
 
We can administer it, 1 spray, sublingually (0.4mg), up to three times with re-evaluations of vitals every 2-5 minutes post administration).
 
ok so heres what i have....he could of had a embolism which would have reduced cardiac output and so by giving him the nitro lowering his BP even more causeing a lack of input into the right atrium and then inevidebly causeing extreme hypoperfusion...putting him towards shock and giving him the cyanotic look and the 80/60....
 
ResTech said:
NTG is a very safe medication and in my opinion it is overboard to have a 12-lead before NTG. Only a small percentage... a very small percentage... of patients would be adversely effected and MI exacerbated with NTG. I've been doing this for 12 years as a career and active volunteer and NEVER once experienced a death or worsening of an MI from NTG. Could it happen... sure. Can a COPD patient stop breathing from to much O2 even though hypoxic? sure.

What are the chances? What is the benefit vs risks? Should we withhold early nitro therapy from 99% of the population bcause of 1% that may have a worsening of their MI?
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Are you sure there were no risks if you did not do a 12 lead? Why one only look at a small view of an ECG. As those that really understand cardiology say ..."those that view in three, do NOT see".... And can you say there is a small percentage of inferior AMI's? Is this based upon your clinical experience or AMI's in the U.S.? What are you basing your data upon? As well, exactly how do you know you did not increase the size of the AMI? If you did not have a pre twelve lead, then you have nothing in comparison. Not all (especially in post-inferior wall AMI) are symptomatic as they increase in size. As well, NTG is usually not beneficial treatment in a true obstructive AMI in comparison to Angina.

So you much rather gamble and take the chance of even causing more harm than to await to perform a 30 second twelve lead, that will help aid in diagnostic of the type of an AMI. Again, I am quite aware it may not affect ALL patients with an AMI, but just to cause increase work load in one patient is too many... all for an additional 30-45 seconds. I have seen many patients that "bottom out" when given just one dose of NTG.

Do you not establish an IV prior to NTG administration as well? If not you are foolish. Then I ask you; what is the primary treatment of an inferior AMI ?

Do you agree to give NTG prior to 12 lead in a BBB patient? (again only determined by a 12 lead) as well; knowing that those with a BBB (wider than 170ms) only have about a 25% ejection fraction. So what do you think happens to these patients when NTG is given?

This is the same philosophy of not also believing in checking for bifascicular block/LBB before administering Morphine? Realizing that even M.S. may or will further the slow conduction through the ventricles and having a high risks of inducing a complete heart block, possibly ventricular aystole.

Attempting to compare oxygen toxicity to an inferior AMI has nothing even similar to comparison. The etiology and duration of time, percentage of occurrences has no similar comparison and is a very poor analogy.

R/r 911
 
I believe the purpose and emphasis of why EMT's are giving NTG to patients should be addressed. EMT's are treating the "chest pain" as primarily being anginal. If pain persists, or increases it probably is ischemic or an AMI. ASA should have also been introduced by now, one of the very few medication known in EMS to really be beneficial in treating an AMI.

One of course has to follow local policies and restrictions no matter what.

My point was to understand different philosophies of care and attempt to see "outside the box" and not just the cookie cutter treatment. There are different ways to skin a cat.... heck, it may not even have to be skinned.. ;)
 
Rid...have you ever considered med school?! or at this point becomming a professor?

you truly are a great asset to this forum

and thanks to everyone!
 
piranah said:
ok so heres what i have....he could of had a embolism which would have reduced cardiac output and so by giving him the nitro lowering his BP even more causeing a lack of input into the right atrium and then inevidebly causeing extreme hypoperfusion...putting him towards shock and giving him the cyanotic look and the 80/60....
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LOL! That's really over-thinking it. A lot of times in EMS, you should employ one of the most important mnemonics of all: KISS (I am certain you know this one).

So you can guess that a "blockage" would cause hypertension. Yet, we have hypotension. So what happened between the initial chestpain and my later b/p reading to change hyper to hypo? And why? KISS!

It's good you are thinking. Really good. But some basic problem solving skills will serve you much better as an EMT than advance A&P will. And most of those skills will come with experience. We all had to start somewhere and see it once for ourselves.

I bet you get it on the next try!
 
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actually im in a medic class and we're going through our A/P and pathophysiology....so im kinda in that mindset right now...lol sorry bout the overkill.lol....ya i know what KISS means "keep it simple stupid"...
 
TKO said:
It's good you are thinking. Really good. But some basic problem solving skills will serve you much better as an EMT than advance A&P will. And most of those skills will come with experience. We all had to start somewhere and see it once for ourselves.
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Of course the difference is that A/P can be taught whereas problem solving skills can't (but they can be developed, especially in certain courses).

I think a better saying than KISS is "If you hear hoof beats, think horses not zebras."
 
KISS method is great for some cases but medicine is not always that simple. True many times the most easiest approach is using the most simplistic approach. I agree experience helps develop problem solving skills, but there is research demonstrating that we can help develop and address critical thinking skills (which are the same as problem solving skills). These are definitely needed for working in the field. EMS is not a black and white situation, rather gray and some cannot function or find it difficult.

Before a mechanic can repair a car, they have to know the parts and how they work the same is true on the human body. Otherwise you will treating per shotgun or blanket approach.. a hit and miss type of treatment.

I do like the Zebra analogy... my other point for those beginning is
...."First thing to do when treating a cardiac arrest is to check you own pulse...
 
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I know exactly what your saying and i used to be a car tech so thats how i look at medicine i see the individual systems and parts in my mind and visualize what the problem is with the sign and symptoms that are given.
 
Well, it is common sense that you should have lots of different mental tools at your disposal when employed in EMS. An understanding of A&P, critical thinking skills and experience-based logic are all required for a successful career.

However, we should always approach a problem from the simplest point of view to begin with and then deal with the complicated as it presents. Going in the reverse is just an easy way to get lost in the problem... I am sure we've all done that somewhere in the beginning or middle of our careers once or twice. :)
 
ASA isnt for pain! !!! Nitro is for pain.its important to give every patient asa unless theyre allergic to it or GI bleed.
 
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