Contraindications and Critical Thinking: NTG/CPAP

ekgshelly

ekgshelly

Forum Ride Along
Messages
4
Reaction score
1
Points
3
Hello Forum,

I recently got into a friendly debate with a colleague about the treatment of an acute pulmonary edema (APE) patient who has a BP of 220/140 ish.

My local protocols would dictate this patient should get high dose (1.6mg) SL NTG and CPAP; We cannot initiate a NTG drip (but if we sounded competent upon contacting medical control probably could and complete necessary deviation paperwork afterwards...)

Here is the issue: the patient had a decreased LOC.

I feel like the spray would be better than nothing (and not present a possible airway comprise from shoving tablets SL in an AMS patient), and it is something to get started before you have a chance to contact MC for "outside of protocol" orders. He disagrees completely, saying NTG would be contraindicated - I can't find anything to support this...

CPAP issue: our protocol lists "Altered Mental Status" as a contraindication. Therefore, he (and others) would not initiate CPAP on a patient with perhaps a GCS fo 13-14? I have worked in other systems, and have a looser interpretation that as long as the patient can tolerate the mask, does not have an airway threat, and will be able to follow coaching somewhat should have CPAP started.

I fully understand the pharmacology and pathophysiolgy reasons behind both treatments, and reviewed these other threads to ensure I wasn't repeating an already answered question:

high-dose-nitro.26745 (both from emtlife/als discussions - I don't have clearance to post hyperlinks...)
nitro-drip-for-chf.39449

Bottom line - I want some input from others: SL NTG and CPAP in the AMS APE patient - yes/no/maybe?
 
I guess the big question is, how decreased is the PT?

Totally obtunded? Well, probably not. Can you make the argument that the patient was arousable and would tolerate a mask with coaching?

I think that sedation in an agitated CHF patient that cant tolerate a mask is certainly indicated (and if the delayed intubation thing ever really happens, we'll be sedating and CPAPing a lot more people...) It's my belief that if your somewhat altered patient will receive any benefit from the CPAP, you should give it a go.

And yes, spray that NTG in there. :)
 
I am not sure exactly how obtunded his patient was, but the conversation led me to believe the pt was likely just confused/inappropriate responses and was cooperative.

I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute.
 
If they can tolerate the mask then why not use it? Obviously there is a point in which your clinical judgement comes into practice- where you ask yourself "are we past this or can we turn the pt around?"

NTG spray for the win.
 
CPAP on a GCS <8 is not a good idea. By definition those patients cannot control their airway. It may work out fine in some cases, but it certainly won't always, and when it doesn't it can be disastrous.

But GCS 13-14? Uhh, yeah......
 
If the patient is a little drowsy or lethargic you should still be able to apply CPAP, providing they are still able to understand your coaching and directions. Just coach them through it and explain what you're doing to them. Our protocols allow application of CPAP with a GCS of 13 or above.
Of course, clinical judgement comes into play here, too. There are some, (but very few) patients who just won't tolerate it, even with good coaching. If you can get the patient to try it even for a couple of minutes, they will usually start feeling the benefits of it and want to keep it on.
As for nitro, as long as you can physically get the patient to open their mouth and lift their tongue, go for it. I've never heard of nitro being contraindicated solely because of AMS.
 
I have had debates with more than one provider who felt passionately that any level of fatigue or confusion in a patient with respiratory distress should be seen as a reason to avoid CPAP. Often the logic would be "they are too tired they need a tube". Obviously this is absurd. Many hypoxic patients are confused and/or lethargic and CPAP may be an important part of the pre RSI medical management and pre oxygenation strategy.
 
If they aren't altered enough to forget to swallow their secretions or pull the mask if they vomit, CPAP would be fine. I agree with SeeNoMore about the too tired comment. The whole idea of CPAP/BiPAP is to avoid intubating someone and having to deal with the complications that come from intubation.
 
I agree with everyone above me. But o would be cautious with the patient in this scenario due to the BP being so high. If you put them on CPAP it can/will reduce cerebral venous flow putting them at increase risk of cerebral vascular problems. Was this person altered due to O2 saturation? or due to a hypertensive crisis that you can make worse if you rush this treatment? I would 0.4mg of nitro then use a BVM absent PEEP valve for a short time then depending on how I feel about repeat BP switch to CPAP.
 
TXmed said:
I agree with everyone above me. But o would be cautious with the patient in this scenario due to the BP being so high. If you put them on CPAP it can/will reduce cerebral venous flow putting them at increase risk of cerebral vascular problems. Was this person altered due to O2 saturation? or due to a hypertensive crisis that you can make worse if you rush this treatment? I would 0.4mg of nitro then use a BVM absent PEEP valve for a short time then depending on how I feel about repeat BP switch to CPAP.
Click to expand...
Treating acute decompensated heart failure aggressively isn't going to lead to cerebrovascular problems. The B/P isn't a compensatory mechanism for perfusing the brain, it's due to the RAA system going wild from decreased CO. The appropriate treatment for this patient is lots of NTG, Bi/CPAP and afterload reducers like enalirpilat, followed possibly by Lasix depending on lab work. A BVM minus a PEEP valve and 0.4mgs of nitro won't do anything for your patient.
 
Patient would clearly benefit from NTG dose SL and clearly would benefit from CPAP as ALOC is surely due to hypoxemia, if patient can control his/her own airway enough to follow commands a gcs of 13-14 would not be a contraindication for CPAP, can a dementia patient with a GCS of 13 not control their own airway ?
 
Mitchell Snyder said:
Patient would clearly benefit from NTG dose SL and clearly would benefit from CPAP as ALOC is surely due to hypoxemia, if patient can control his/her own airway enough to follow commands a gcs of 13-14 would not be a contraindication for CPAP, can a dementia patient with a GCS of 13 not control their own airway ?
Click to expand...

Actually, those types of patients are at a much higher risk for aspiration, so not the best example. But your main point is 100% correct.
 
Remi said:
Actually, those types of patients are at a much higher risk for aspiration, so not the best example. But your main point is 100% correct.
Click to expand...
#swallowstudy
 
Nitroglycerin with a pressure like that and heart failure? You bet. CPAP? It depends. If you're worried the patient might stop breathing you're better off placing the patient in high-Fowlers, standing in back, and using the BVM (a very difficult skill but old school paramedics will know what I'm talking about). Once it starts to take effect and the patient perks up a little bit you can transition them to CPAP.
 
TomB said:
Nitroglycerin with a pressure like that and heart failure? You bet. CPAP? It depends. If you're worried the patient might stop breathing you're better off placing the patient in high-Fowlers, standing in back, and using the BVM (a very difficult skill but old school paramedics will know what I'm talking about). Once it starts to take effect and the patient perks up a little bit you can transition them to CPAP.
Click to expand...
Yeah, glad I haven't had to do that... The older school paramedics that are still working... I'm glad it's still in their toolbox!
 
I have noticed a number of patients that present with severe difficulty breathing/increased work of breathing but with a solid GCS of 15, and after a few minutes on CPAP have significant improvement and THEN become tired and more lethargic. I believe they are working so hard to breath/stay alive, that once the work of breathing decreases they relax into an exhausted state. As long as they are continuously improving and remain alert to verbal stimulus I leave them on it. I have also been using Nitropaste and having great results. It's nice to not have to move the mask to give a SL dose or spray.
 
Remi said:
CPAP on a GCS <8 is not a good idea. By definition those patients cannot control their airway. It may work out fine in some cases, but it certainly won't always, and when it doesn't it can be disastrous.

But GCS 13-14? Uhh, yeah......
Click to expand...


GCS again?....oh jeez. Just stop.

http://www.annemergmed.com/article/S0196-0644(11)00655-X/abstract

Was never designed to be used in EMS. Is not accurate, and in its most accurate state, is stated as ekgshelly did "I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute."
 
NUEMT said:
GCS again?....oh jeez. Just stop.

http://www.annemergmed.com/article/S0196-0644(11)00655-X/abstract

Was never designed to be used in EMS. Is not accurate, and in its most accurate state, is stated as ekgshelly did "I know I have put CPAP on a patient with a GCS of 3E, 2V, 5M before and seen an improvement to GCS of 15 in under 1 minute."
Click to expand...

Are you for real?

Sorry, but whether you like it or not, the GCS is still by far the most widely used method of assessing and conveying gross neurologic status. I tell you what: when you are giving report at the ED and someone asks you what the initial GCS was, just tell them "the inter-rater validity of the GCS is poor, and anyway it was designed for use in the ICU, not in the field. So I don't worry about the GCS". Make sure you get back to me on how that works out for you.

And I'm not sure I see your point about that other post. Some chick put CPAP on a patient with a GCS of 10, and his GCS improved. What exactly are you getting at?
 
Remi said:
Are you for real?

Sorry, but whether you like it or not, the GCS is still by far the most widely used method of assessing and conveying gross neurologic status. I tell you what: when you are giving report at the ED and someone asks you what the initial GCS was, just tell them "the inter-rater validity of the GCS is poor, and anyway it was designed for use in the ICU, not in the field. So I don't worry about the GCS". Make sure you get back to me on how that works out for you.

And I'm not sure I see your point about that other post. Some chick put CPAP on a patient with a GCS of 10, and his GCS improved. What exactly are you getting at?
Click to expand...


I am referring to how she presented her score. If you use GCS, this is how you do it. And my ED stopped asking for GCS a while ago. Being that so many EMS providers calculate it poorly it really wasn't of any use.
 
You must log in or register to reply here.
Back
Top