JPINFV
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Trendelenburg? I guess we could try some magic beads as well.
Nitro before IV
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FFMedic1911
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Thanks for the replys.In medic school I was taught to always start a line.I would like to add this for discusion.When you have a pt. with right sided Mi do you give nitro or hold off.Once again this seems to be a debate among medics I have talked too.I give it but am ready if there is problems.
MSDeltaFlt
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Here's the deal with NTG admin on CP: It's not a ''see this, do that'' type of scenario. It depends on the clinical condition of your pt. ''Clinical condition'', people requires ''thorough assessment''. You need to know what's going on, where it is, how bad it is, where you are in reference to the hospital, what you have to do until you get to the hospital, where you are in your protocols, where and if your pt falls outside of your protocols, and knowing the difference in order to better care for your pt.
That's how your treat your pt. That's what's got to go through your mind when you do this. That's why I said all of that in order to say this: When it comes to NTG admin and sarting a line or not or whatever, either for Angina, AMI (Rt or Lt), it depends on the situation.
That's how your treat your pt. That's what's got to go through your mind when you do this. That's why I said all of that in order to say this: When it comes to NTG admin and sarting a line or not or whatever, either for Angina, AMI (Rt or Lt), it depends on the situation.
volparamedic
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Good point Nitro is used for angina and CHF but also an adjunct treatment in AMI. Nitro increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas. Thus, reduces myocardical oxygen consumption and reduction of damage to the heart. Then again, there is also stable angina and unstable angina...leading to AMI.
Ridryder911
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You will never see a well documented article of saying.."withold NTG on ride sided or inferior wall AMI's".... Why? Because, it can be given... with extreme caution.
I have given it and seen the patient get better and I have seen it and the patient get extremely worse.
Alike what was said, it depends upon your patient. Evaluate their baseline, look at the MAP as well if they are as well hemodynamic compromised with such as bradycardia also. Personally, I like Fentanyl for pain for such AMI's and do not even like Morphine (especially if they have a Hemiblock). Again treat accordingly and cautiously, as well as be prepared for the feces to strike the oscillating rotary device...
R/r 911
I have given it and seen the patient get better and I have seen it and the patient get extremely worse.
Alike what was said, it depends upon your patient. Evaluate their baseline, look at the MAP as well if they are as well hemodynamic compromised with such as bradycardia also. Personally, I like Fentanyl for pain for such AMI's and do not even like Morphine (especially if they have a Hemiblock). Again treat accordingly and cautiously, as well as be prepared for the feces to strike the oscillating rotary device...
R/r 911
rhan101277
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As far as basics go we can help pts. with their nitro, as long as no contraindications exist. Systolic BP has to bee above 100mmHg. When dialating someone's arteries it causes lower BP which is supposed to take the workload off the heart. But how come the heart doesn't just think you are bleeding out and try to re-constrict to bring BP back up. Is it because the nitro stops that effect?
daedalus
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I think that is no longer the school of thought with nitrates. Rid or Vent might chime in here, but it is my understanding that the new line of thinking is that nitro reduces afterload, therefore reducing the work and oxygen demand of the myocardium.
OK my answer to the initial question is that I want a line first but I really really want a 12-lead. If I have an inferior infarct then I need a right sided 12-lead and with RVI then I need to be really careful with that ntg. I will almost certainly be preloading my pt. w/ fluids prior to ntg irrespective of my protocol.
Now in response to this can anyone produce any literature that ntg reduces the m/m of MI pt's? I have a friend who is a cardiology PA who swears, and I believe him, that ntg for MI is simply empirical medicine and no one can show that it is of clinical benefit. Can anyone point to contrary literature? Now I still give them ntg
J
Now in response to this can anyone produce any literature that ntg reduces the m/m of MI pt's? I have a friend who is a cardiology PA who swears, and I believe him, that ntg for MI is simply empirical medicine and no one can show that it is of clinical benefit. Can anyone point to contrary literature? Now I still give them ntg
J
try the AHA website
Anytime that I have questions regarding cardiac care and why we do something I look in the AHA website. The entire 2005 guidlines are online and provide some great insight into why we do things the way we do.
http://circ.ahajournals.org/content/vol112/24_suppl/
Anytime that I have questions regarding cardiac care and why we do something I look in the AHA website. The entire 2005 guidlines are online and provide some great insight into why we do things the way we do.
http://circ.ahajournals.org/content/vol112/24_suppl/
Melbourne MICA
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Gtn s/l
Treating angina is bread and butter ambo work for BLS or ALS. Take a thorough history, do a thorough exam, exclude allergies and contra-indications, do your ECG, check their meds then treat with aspirin, GTN +- Nitro patch. Inform patient of likely side effects - if they get a headache or feel faint tell them to spit out the pill and lay down (they should be sitting in the first place). nset of GTN is fast so if its going to drop a BP to near fainting level it will ahppen quick. More often than not it will be the first time user who goes flat or the operator giving it with a marginal BP/fast HR - signs that should make you suspicious to begin with
Do your IV, give some Morph down the track if 2 or 3 GTN's have no effect on pain. History is the key. Pts know their condition and have their own meds so they are more often than not reliable historians on their own angina.
9/10 AMI is a catastrophic event. If you note the pt looks very crook you can bet your tools will verify it. If this is the case you have a new ball game.
Otherwise if its angina, chill. Put the IV in along the way. It doesn't necessarily have to go in before, during or after. Whatever your preference. Just watch the patient, don't do silly things and understand the process. Besides what happens if you like to start with a line but don't get the line in? Have five goes whilst not treating the angina? Or not give the GTN at all because you fear you might trash the BP but have no line?
There are many papers on GTN in R sided infarcts by the way. Our guys here researched it and had our guideline changed as a result. Not a good idea unloading the right side when its not filling the left in the first place. Besides a pt with a good BP in infarct is a bonus - the idea is to hang on to it. The fastest way to kill an infarcting pt is to lose it.
Treat the sympathetics, fill the right side with fluid boluses and always have atropine and Adrenaline ready and drawn up. Brady and flat - thats typical for inferiors/R infarcts.
Chest pain is about 40% of our routine work here. Similar over in US?
Melbourne MICA
Treating angina is bread and butter ambo work for BLS or ALS. Take a thorough history, do a thorough exam, exclude allergies and contra-indications, do your ECG, check their meds then treat with aspirin, GTN +- Nitro patch. Inform patient of likely side effects - if they get a headache or feel faint tell them to spit out the pill and lay down (they should be sitting in the first place). nset of GTN is fast so if its going to drop a BP to near fainting level it will ahppen quick. More often than not it will be the first time user who goes flat or the operator giving it with a marginal BP/fast HR - signs that should make you suspicious to begin with
Do your IV, give some Morph down the track if 2 or 3 GTN's have no effect on pain. History is the key. Pts know their condition and have their own meds so they are more often than not reliable historians on their own angina.
9/10 AMI is a catastrophic event. If you note the pt looks very crook you can bet your tools will verify it. If this is the case you have a new ball game.
Otherwise if its angina, chill. Put the IV in along the way. It doesn't necessarily have to go in before, during or after. Whatever your preference. Just watch the patient, don't do silly things and understand the process. Besides what happens if you like to start with a line but don't get the line in? Have five goes whilst not treating the angina? Or not give the GTN at all because you fear you might trash the BP but have no line?
There are many papers on GTN in R sided infarcts by the way. Our guys here researched it and had our guideline changed as a result. Not a good idea unloading the right side when its not filling the left in the first place. Besides a pt with a good BP in infarct is a bonus - the idea is to hang on to it. The fastest way to kill an infarcting pt is to lose it.
Treat the sympathetics, fill the right side with fluid boluses and always have atropine and Adrenaline ready and drawn up. Brady and flat - thats typical for inferiors/R infarcts.
Chest pain is about 40% of our routine work here. Similar over in US?
Melbourne MICA
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...I have a friend who is a cardiology PA who swears, and I believe him, that ntg for MI is simply empirical medicine and no one can show that it is of clinical benefit. Can anyone point to contrary literature? Now I still give them ntg
J
MI = ischemic tissue
ischemic tissue = irritable tissue
irritable tissue = arhythmias
...and while ntg may only help perfuse an ischemic area of the heart 'temporarily' (in AMI), it is absolutely necessary to maintain function of the affected cells until they can be surgically corrected. I don't see how one could reasonably make the claim that nitro is of no benefit to AMI (or angina, for that matter), as we've all seen it work...if it didn't then what have I been titrating ntg drips to?
Outbac1
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Well here PCP's give nitro for cardiac c/p without a line. I agree that a line and 12 lead should be done first if possible. However while nitro can cause a catastrophic drop in b/p, how often does it actually happen? I think our medical director is looking at the benifits to the many vs the detriment of the few.
Does anyone know how often nitro causes a major drop to an unsafe b/p? Is it 1 in 5, 1 in 100 or 1 in 1000?
Does anyone know how often nitro causes a major drop to an unsafe b/p? Is it 1 in 5, 1 in 100 or 1 in 1000?
It's caused a significant drop in about 1 in 100 for me.
Not a lot. But when it has happened, it's been a dangerous drop.
I don't disagree that empirically we have all seen Pt's cp pain scale drop w/ Ntg. The gauntlet thrown was a published peer reviewed study in a journal showing ntg decreasing m and m. Anyone?
J
And the more I think about this quote the more I think it correlates well to fluids and PASGs in trauma. Now there was great theory out there that "I don't see how one could reasonably make the claim" that fluids and PASGs is of no benefit to hypotensive Pt.'s with penetrating chest trauma as we've all seen BP's coming back up. In the short term, in the back of the unit. The problem is when the research was done, and I can't quote the paper but Dr. Paul Pepe published the results based on a study in Houston, the theory didn't play out to Pt.'s walking out of the hospital any better off. Now I understand that there are very accomplished physicians that argue with some of the concussions drawn from that study but we have definitively trended away from there two ideas, PASGs and fluid boluses, in trauma based on research. I don't think the research exists to show that Ntg. works, and when I say work I mean that more Pt.'s walk out of the hospital alive and w/ less cardiac deficit then Pt.'s that do not get Ntg.
Well I definately agree with your point on PASGs.
And thanks for clarifying (long-term outcome vs. pain control).
I think the difference here is with PASGs these patients almost always ended up in surgery, where research and studies have a lot more consistency and reliability; where a comprehensive study on nitro use would have to encompass so many different units, it would be very difficult to track.
It is funny how some of the things we're taught to be life-savers one day turn out to be life-takers or time-wasters the next day... PASG, bicarb, LR, wide-open fluids, intracardiac drugs, lidocaine uses, all the changes in CPR...
And thanks for clarifying (long-term outcome vs. pain control).
I think the difference here is with PASGs these patients almost always ended up in surgery, where research and studies have a lot more consistency and reliability; where a comprehensive study on nitro use would have to encompass so many different units, it would be very difficult to track.
It is funny how some of the things we're taught to be life-savers one day turn out to be life-takers or time-wasters the next day... PASG, bicarb, LR, wide-open fluids, intracardiac drugs, lidocaine uses, all the changes in CPR...
Medexpresso
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nitro first...?
what do your local or state protocols say? that's the safest way to go...
what do your local or state protocols say? that's the safest way to go...
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Melbourne MICA
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Nitro
Nitro has been used for about a hundred years for "Angina". What the Cardio types have moved to now is to standardise approach across the board with two aims. To identify those developing an ominous coronary artery disease instability for early CAGS and to intercept the infarct before it either kills the pt or leaves them a cardiac cripple for life.
The methodology is of course aimed at one goal - prevention. This is why the pt is educated as well - take two or three GTN s and call for help when they don't work. It's also why we all have pretty much the same guidelines. Even the questions we ask our pts are probably the same. It's also why pts use pretty much the same types of meds all aimed at risk factor management - you know, anti - cholesterol, platelet antagonist, beta blocker, clopridogrel etc etc before and after infarct or CAGS.
This is of course because there are rarely singular events in the natural progression of IHD. The pt had an infarct twenty years ago and now has angina and will end up with CAGS - the whole thing never stops, we just intercept the nasty bits as best we can and give the pt a lifestyle and an ongoing life because of it.
The latest guidelines for our cardiologist community come from discussions and recommendations from the American and European HA. They have been adopted throughout the wetern medical world.
At least in cardiac medicine we EMS types do have a well quantified and important role even though I have found myself saying when the next call comes in ".......geeze - not another Nanna with Chest pain!!!!"
A last point on the IV before GTN debate - Pts use them all the time at home don't they? Without any IV being involved?
On the other point - Maddox and Pepe 1994 - fluid resuscitation in penetrating truncal trauma was the paper wasn't it?
Lot's of ifs if medicine - And schools of thought and practice. Evidenced based is the way to go now.
MMICA
Nitro has been used for about a hundred years for "Angina". What the Cardio types have moved to now is to standardise approach across the board with two aims. To identify those developing an ominous coronary artery disease instability for early CAGS and to intercept the infarct before it either kills the pt or leaves them a cardiac cripple for life.
The methodology is of course aimed at one goal - prevention. This is why the pt is educated as well - take two or three GTN s and call for help when they don't work. It's also why we all have pretty much the same guidelines. Even the questions we ask our pts are probably the same. It's also why pts use pretty much the same types of meds all aimed at risk factor management - you know, anti - cholesterol, platelet antagonist, beta blocker, clopridogrel etc etc before and after infarct or CAGS.
This is of course because there are rarely singular events in the natural progression of IHD. The pt had an infarct twenty years ago and now has angina and will end up with CAGS - the whole thing never stops, we just intercept the nasty bits as best we can and give the pt a lifestyle and an ongoing life because of it.
The latest guidelines for our cardiologist community come from discussions and recommendations from the American and European HA. They have been adopted throughout the wetern medical world.
At least in cardiac medicine we EMS types do have a well quantified and important role even though I have found myself saying when the next call comes in ".......geeze - not another Nanna with Chest pain!!!!"
A last point on the IV before GTN debate - Pts use them all the time at home don't they? Without any IV being involved?
On the other point - Maddox and Pepe 1994 - fluid resuscitation in penetrating truncal trauma was the paper wasn't it?
Lot's of ifs if medicine - And schools of thought and practice. Evidenced based is the way to go now.
MMICA
I think that there should be an IV and vitals before any NTG is given. Especially if the pt isnt prescribed it and doen't know their reaction to it. I would hate to give it to someone who is sensitive to it. Also,I've heard on rare occasions when someones having a Rt Sided MI NTG can bottom them out.