Nitro before IV
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Ridryder911
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Geez, just how silly are we or is it ignorance is peeking its ugly head again? Really... we are debating squirting NTG and have someone chew some ASA? Really, does one really think the effect of ASA acts immediately and exactly how long does it take to administer either one?..
If you’re not administering ASA on any type of ACS and solely discreetly using a nitrate, you’re playing with fire. I would like to know exactly what differential diagnostic material you’re determining if it is an unstable/stable angina vs. an AMI?
C'mon folks, surely if we are going to debate semantics and treatment modalities, let's pick our fights better. As well, I truly hope that other are not expecting the byproduct of analgesic effects of the ASA decreasing pain in an AMI or even angina taking effect soon.
R/r 911
If you’re not administering ASA on any type of ACS and solely discreetly using a nitrate, you’re playing with fire. I would like to know exactly what differential diagnostic material you’re determining if it is an unstable/stable angina vs. an AMI?
C'mon folks, surely if we are going to debate semantics and treatment modalities, let's pick our fights better. As well, I truly hope that other are not expecting the byproduct of analgesic effects of the ASA decreasing pain in an AMI or even angina taking effect soon.
R/r 911
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JPINFV
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Well, as long as the dogma in EMS is "SECONDS COUNT!!!!111ONEONETWO12" then obviously the order of nitro vs ASA matters. What EMS needs to realize is that seconds, and even minutes, rarely matter, and those times that they do we're normally well behind the eight ball already.
Ridryder911
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Exactly, we have lost all common sense! Seriously, expediting care and yes not delaying of care as in packaging in a timely manner, and preventing untimely delays. As mentioned, splitting hairs is only comical ... heck give them both at the same time!..
R/r 911
Melbourne MICA
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ASA GTN - issues
Some extraordinary things being said here.
Aspirin - an anti platelet aggregation agent - the opposite of what has been described by some. For a start, the wrong tense of aggregate was used - (semantics I know but speak English please). If you were describing it the way you are it would be platelet aggregator and that's wrong for starters. Aggregation means accumulation thus - "The aggregate effect of all these changes was to ......blah blah blah". Lets hope aspirin isn't causing platelets to aggregate in coronary arteries eh?
Reference for pharmacology of aspirin.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317722/pdf/jathtrain00031-0062.pdf
Its ant-platelet actions are precisely why we use it for ACS and AMI - to aid in reducing red thrombus formation at the fissured plaque site. The antipyretic, anti-inflammatory and analgesic properties of aspirin are too mild to be of value in the acute setting of ACS/AMI - spot on about that Ridders if you're reading. (Though the anti-inflammatory properties are of value - prevents formation of prostaglandins). The inflammatory component of the disease process has received significant attention from researchers as well as links between infection and acute coronary disease. Who knows - in the future the treatment for ACS by EMS may be early admin of antibiotics/antivirals and anti inflammatories.
Onset times and half lives of GTN and aspirin - aspirins' antiplatelet properties last for days (8-10) hence its value both in preventing thrombus formation in the acute phase of ACS/AMI and also down the track - makes a heck of a lot of sense doesn't it and why this drug is so valuable in the acute coronary pt.
Aspirin starts functioning pretty quickly but obviously with no discernible effect for the pt, except of course they may well not infarct. It lasts for the natural life of platelets.
GTN - tried and tested drug with an onset time of about 30secs - two minutes (buccal - quicker for IV) - reaches therapeutic range in about 10mins with a duration total of about 15-30mins. Whats this guff about 5mins of action - what bloody use would this drug be if lasted just 5mins?
What order to give these drugs? Who gives a rats bit? You see the pt during the acute phase of their clinical problem so the time frame for treatment is early anyway - hospital treatment is a good 30mins - an hour away so give both as early as possible (appropriate to the pts clinical problem and presentation and the CI/SE's/precautions of the drugs) and you've done the right thing. One is to treat the symptoms the other the causative factors at work - I'll let you guess which one does what.
I can't believe there has been 15 pages spent mostly on arguing which one goes first and whether you put an IV in before or after GTN. How many of these pts do we do every shift?
Next subject please.
MM
Some extraordinary things being said here.
Aspirin - an anti platelet aggregation agent - the opposite of what has been described by some. For a start, the wrong tense of aggregate was used - (semantics I know but speak English please). If you were describing it the way you are it would be platelet aggregator and that's wrong for starters. Aggregation means accumulation thus - "The aggregate effect of all these changes was to ......blah blah blah". Lets hope aspirin isn't causing platelets to aggregate in coronary arteries eh?
Reference for pharmacology of aspirin.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317722/pdf/jathtrain00031-0062.pdf
Its ant-platelet actions are precisely why we use it for ACS and AMI - to aid in reducing red thrombus formation at the fissured plaque site. The antipyretic, anti-inflammatory and analgesic properties of aspirin are too mild to be of value in the acute setting of ACS/AMI - spot on about that Ridders if you're reading. (Though the anti-inflammatory properties are of value - prevents formation of prostaglandins). The inflammatory component of the disease process has received significant attention from researchers as well as links between infection and acute coronary disease. Who knows - in the future the treatment for ACS by EMS may be early admin of antibiotics/antivirals and anti inflammatories.
Onset times and half lives of GTN and aspirin - aspirins' antiplatelet properties last for days (8-10) hence its value both in preventing thrombus formation in the acute phase of ACS/AMI and also down the track - makes a heck of a lot of sense doesn't it and why this drug is so valuable in the acute coronary pt.
Aspirin starts functioning pretty quickly but obviously with no discernible effect for the pt, except of course they may well not infarct. It lasts for the natural life of platelets.
GTN - tried and tested drug with an onset time of about 30secs - two minutes (buccal - quicker for IV) - reaches therapeutic range in about 10mins with a duration total of about 15-30mins. Whats this guff about 5mins of action - what bloody use would this drug be if lasted just 5mins?
What order to give these drugs? Who gives a rats bit? You see the pt during the acute phase of their clinical problem so the time frame for treatment is early anyway - hospital treatment is a good 30mins - an hour away so give both as early as possible (appropriate to the pts clinical problem and presentation and the CI/SE's/precautions of the drugs) and you've done the right thing. One is to treat the symptoms the other the causative factors at work - I'll let you guess which one does what.
I can't believe there has been 15 pages spent mostly on arguing which one goes first and whether you put an IV in before or after GTN. How many of these pts do we do every shift?
Next subject please.
MM
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18G
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Great points... sometimes we have to keep the newbies entertained 
Melbourne MICA
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Storm in a teacup
Appreciated. What concerns me some guys have no idea whatsoever about the drugs they are giving, why they give them and when to re-evaluate what you are doing based on sound logic and thorough assessment using all the tools and experince at your disposal. Coronary artery disease is the major killer in western countries and the preventitive and mitigation phases of its management starts with us. Do it right and we save thosuands of people from early death, from disability and take a healthy chunk out of health care budget costs while we are at it.
It's clearly time for all (some?) of us to hit the books, chat with the experts and catch up with the latest in cardiac management practices and research developments.
MM
Great points... sometimes we have to keep the newbies entertained
Appreciated. What concerns me some guys have no idea whatsoever about the drugs they are giving, why they give them and when to re-evaluate what you are doing based on sound logic and thorough assessment using all the tools and experince at your disposal. Coronary artery disease is the major killer in western countries and the preventitive and mitigation phases of its management starts with us. Do it right and we save thosuands of people from early death, from disability and take a healthy chunk out of health care budget costs while we are at it.
It's clearly time for all (some?) of us to hit the books, chat with the experts and catch up with the latest in cardiac management practices and research developments.
MM
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iftmedic
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Could you imagine all this chaos on scene of a chest pain?? When in dought, Vitals, O2, Monitor, IV, Transport . VOMIT. Lol!!!
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JPINFV
Gadfly
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^
Yea.. let's give the patient more free radicals and cause more reprofusion injury. Yea!
Yea.. let's give the patient more free radicals and cause more reprofusion injury. Yea!
iftmedic
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Increase free radicals and more reprofusion injury? ACS patients? By administration of NTG?
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JPINFV
Gadfly
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Emphasis added. No need for supplemental oxygen unless the patient is showing signs, symptoms, or monitor results of hypoxia, not just ischemia.
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iftmedic
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Your Paramedic VOMIT was a memory aid that would help you remember what to do in the event you were spinning your wheels on scene and uncertain on what to do, It would basically include the steps of what they sometimes call general ALS, in school it was used in a sarcastic way for medics that were clueless on scene.
It seemed appropriate to mentioned since we had some much disagreement in previous posts. Little humour that's all, but I think most paramedics heard that term in paramedic school.
It seemed appropriate to mentioned since we had some much disagreement in previous posts. Little humour that's all, but I think most paramedics heard that term in paramedic school.
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Stop talking sense.
We have now replaced anatomy and physiology, with how not to get sued in the EMS training modules.
"dexterious clinical application of cognitive behavior" I like it, Im stealing it.
True, and I agree, but sometimes we do step into a scene where one asks oneself, "What the heck do they expect me to do now?" Usually this involves a mobile home with narrow hallways and a 1000 pound patient, but...
You know, I should write a paper on this. For as lawsuit phobic as EMS types are (and I suspect all medical types, though doctors have some reason for their phobia other than paranoia arising out of reading too many online BBoard posts), the changes of an EMT or paramedic being sued are really quite small.
However, if you're going to be sued, you're going to be sued. If someone wants to file suit, they will, and so there's no reason to obsess about it. Pay your (laughably small) malpractice premiums to HCPSO or whoever, and try not to do anything obviously stupid or intentionally harmful.
Stop talking sense.
Never!
Brown thought you had one of those already? "Ethics and Legal" or something, no?
"dexterious clinical application of cognitive behavior" I like it, Im stealing it.
Royalty fees are payable to Brown Inc
Hey somebody has to pay for my "DOCTOR" jumpsuit .....
JPINFV
Gadfly
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Heck, we did medical jurisprudence earlier this year and the med-mal defense lawyers continually pointed out that, and this is against physicians, the vast majority of lawsuits never make it to a deposition or discovery, and the vast majority that make it that far are dropped before trial. Lawyers don't want to take on bad cases that they're likely to lose, thus costing them money.
Seems kind of a waste to sue a paramedic, let's face it, they haven't much to take, and they are not really collectable.
Better to sue a FD or a company I think. Better insurance payout and maybe even a worthwhile settlement.
Paramedics aren't definitive care, so they aren't expected to "fix it.". Some of the people on this forum may want paramedics to be more than they are at present, but right now, for the most part, EMS is about treating symptoms in the short term to stabilize the patient and delivering the patient to the ER, as quickly and safely as possible. Within those limited parameters, the actual risk of making things worse isn't that huge. And the law also recognizes that what you're expected to do in 10 minutes on a street corner isn't the same as what's expected in a general hospital with lots of resources.
Of course, Veneficus, you'll eventually be expected to "fix it."