Nitro before IV

18G said:
How so?
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ISIS-2 amongst others demonstrated that Aspirin is the only drug that we routinely give in the field that has any positive impact on mortality and morbidity from ACS.

It is very cheap, extremely safe and tastes yummy.

Nothing else has been proven to have such a benefit, or indeed any benefit at all, and many of those wonderful routine ambulance driver things we do may actually cause harm (High concentration O2 anyone?)
 
I know that hyperoxia in ACS/MI is detrimental and can worsen ischemia... this finding goes back to research done in the 1950's. It was so nice to see it included in the new AHA guidelines.

Nitro has not been shown to decrease mortallity per se, but it does have medical benefit as it relieves pain which decreases catacholamine release, improves the O2/demand ratio by reducing workload, and can improve coronary blood flow. Is this not a medical benefit?

Pain meds don't fix a fracture but they are still of medical benefit.
 
In our new protocols we need an iv or io line before nitro application.
We only give nitro after 12 lead ECG and we sure that the patient have no Right Heart Failure !!
Here is a short overview from our ACS / thorax pain protocoll:

1. Oxygen + ECG, BP, SpO2, Glucosetest
2. Asperin iv or io
3. Morphin iv or io
4. Nitro po (if you have no right heart failure!! >>> if you have one you should give NaCl 0,9% 500ml as a bolus)
5. Contact cath labor to give plavix 600mg and Liquemin 5.000i.E. Only for STEMI
6. Lasix iv or io if you have pulmonary edema

Matt
 
It is in our protocols that a patent IV MUST be established prior to the administration of Nitro. Also, systolic must be at least 100 or higher before the admin. of Nitro.
 
If combat medicine has taught me anything it is unless it is a trauma code or your taking fire that's truly the only times to rush. As the prior posts stated abc IV, EKG then if still needed MONA. take your time and remember your training no need to rush to pharmacology just because we can.
 
Amazing we dispense NTG to patients daily by the millions without an IV to those in clinic settings. The reason being is that they are diagnosed with angina, not having an AMI. This being, NTG is a medication and along with that is the responsibility of knowing when and why, it should be administered.

I believe the question should be not having an IV but rather..."Is NTG appropriate to administer?"... Hence being, right ventricular infarct, poor preload factor, baseline blood pressure to handle vasodilation, chronic angina vs. acute AMI?. The old saying; it's not going to hurt to.. is simply a long standing myth and not accurate.

With the advances and ease of the I/O, one can (or should be able to) always administer fluid bolus and allow compensation to occur. Best..? no but to withhold general treatment for the sake of ... "in case".. in not justifiable

R/r 911
 
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Our Technicians have been giving GTN without an IV for oh gosh, ten years?
 
Ridryder911 said:
Amazing we dispense NTG to patients daily by the millions without an IV to those in clinic settings. The reason being is that they are diagnosed with angina, not having an AMI. This being, NTG is a medication and along with that is the responsibility of knowing when and why, it should be administered.

I believe the question should be not having an IV but rather..."Is NTG appropriate to administer?"... Hence being, right ventricular infarct, poor preload factor, baseline blood pressure to handle vasodilation, chronic angina vs. acute AMI?. The old saying; it's not going to hurt to.. is simply a long standing myth and not accurate.

With the advances and ease of the I/O, one can (or should be able to) always administer fluid bolus and allow compensation to occur. Best..? no but to withhold general treatment for the sake of ... "in case".. in not justifiable

R/r 911
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Salient points as always ridders. I brought up the scenario (more than once) of pts with angina long standing or otherwise who use GTN for years without dropping in a screaming heap. But as you pointed out they are using it for angina not an infarct. If they call us its not working like it's supposed to and its then up to us to figure out whether their angina has become unstable (ACS) or an MI is underway - that's what they pay us for after all. It goes without saying an IV is pretty much standard fare for the cardiac pt but before every GTN admin? - unless obviously or looking like they are getting crook no. If guys are thinking they are going to dump in fluids every time the BP gets a tickle hence the urgency on the IV they should have another think. If you can't feel comfortable giving GTN to a pt on the basis of a thorough history and clinical assessment without plunging straight into an IV (and where is your plan of attack if you miss it? Now its IO "just in case" for every cardiac pt?) then maybe you shouldn't be doing it in the first place. Put the monitor on, give the aspirin, give the GTN, get your IV going and see where things stand. If its not angina you won't be going that path anyway. Of course if your service docs stipulate "IV - point 1" and your sphincter tone is directly proportional to your compliance with said stipulations then go for it. Whats the big hooha about all this anyway?

MM
 
MrBrown said:
Our Technicians have been giving GTN without an IV for oh gosh, ten years?
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Just because something has been done for a long time does not imply it is being done well. I feel strongly on this as where I work I may be the only medical for 100's of miles and don't have the luxury of flying by the seat of my pants. I feel we do a discredit to out profession every time we take a short cut. If you just by looking at the Pt can assure there is ZERO chance of a Rt sided AMI then good on you, myself I am not that good hence I acquire a 12 lead. As for the argument of time slow is smooth and smooth is fast I can establish IV and 12 lead in under 3 min by myself or maybe with a willing lay rescuer. I am one who is not a cook book medic but do believe in fundamentals. Just my .02 :)
 
Boston.Tacmedic said:
Just because something has been done for a long time does not imply it is being done well. I feel strongly on this as where I work I may be the only medical for 100's of miles and don't have the luxury of flying by the seat of my pants. I feel we do a discredit to out profession every time we take a short cut. If you just by looking at the Pt can assure there is ZERO chance of a Rt sided AMI then good on you, myself I am not that good hence I acquire a 12 lead. As for the argument of time slow is smooth and smooth is fast I can establish IV and 12 lead in under 3 min by myself or maybe with a willing lay rescuer. I am one who is not a cook book medic but do believe in fundamentals. Just my .02 :)
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Two shifts ago, I had a chest pain patient I could not canulate. She had finished a course of chemo recently, and four sticks later, I still didn't have a stinking IV. She had what based on my assesment was unstable angina. No inferior ST elevation was present, her pressure was not labile and no other signs indicating preload dependence were present.

What your saying is I shouldn't have provided this lady with relief from a painful but easily treatable condition because I couldn't start an IV?

For the record she got NTG prior to even attempting an IV.
 
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Your response to my stand point is not truly complete. You variable you left out is transport time, if you were close then yes I would have withheld. I also would ask myself how comfortable I am with my EKG. At this point if my transport is extended I would consider it however I would call my doc first I may skip the NTG and go with just morphine to calm said PT and help alleviate said discomfort. If my PT becomes so acute that nitro is clearly needed and I was not having an A game day then I would establish an IO 100mg lido for Pn at site and give fluid then NTG. Again just how I roll, all sizes may not fit all ;-)
 
Boston.Tacmedic said:
Your response to my stand point is not truly complete. You variable you left out is transport time, if you were close then yes I would have withheld. I also would ask myself how comfortable I am with my EKG. At this point if my transport is extended I would consider it however I would call my doc first I may skip the NTG and go with just morphine to calm said PT and help alleviate said discomfort. If my PT becomes so acute that nitro is clearly needed and I was not having an A game day then I would establish an IO 100mg lido for Pn at site and give fluid then NTG. Again just how I roll, all sizes may not fit all ;-)
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So, you would rather do an IO (a painful and not necessarily benign procedure) "just in case" to give nitro, than administer a medication that is given without a line literally thousands of times a day world-wide?

Alternately, you would rather give a medication that the AHA now recommends be given with caution in NSTEMI and unstable angina because it may increase mortality, and in addition has a very unpredictable effect on blood pressure due to the side effect of histamine release. You would give it IM, which has 15-20min onset rather than a 5 minute absorption SL like NTG.

Transport time does not play into my decision here. Whether it's 5 minutes or 50 minutes I'm going to try to relive the condition to the best of my ability. If this is how you roll, you need to seriously think about if what your doing is best for your patients and not your comfort level.
 
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usalsfyre said:
So, you would rather do an IO (a painful and not necessarily benign procedure) "just in case" to give nitro, than administer a medication that is given without a line literally thousands of times a day world-wide?

Alternately, you would rather give a medication that the AHA now recommends be given with caution in NSTEMI and unstable angina because it may increase mortality, and in addition has a very unpredictable effect on blood pressure due to the side effect of histamine release. You would give it IM, which has 15-20min onset rather than a 5 minute absorption SL like NTG.

Transport time does not play into my decision here. Whether it's 5 minutes or 50 minutes I'm going to try to relive the condition to the best of my ability. If this is how you roll, you need to seriously think about if what your doing is best for your patients and not your comfort level.
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I would thread cautiously in questioning my comfort level. I have done escharotomys in remote villages and treated ENT as well my comfort level is not in question nor is my personal skill set so before you continue you a personal attack I will stop you there. Topic at hand if your concerned with histamine release we carry drugs to handle that ( your system may differ) as to IO and Pn bones do not feel pn the change in pressure can cause discomfort hence why I said "lido .5-1mg/kg in an alert PT". The question of transport time is pertinent because if the ER is 5 min transport time then all this what if is a mute point then, they will just goto ER were at worst case scenario is they get a central line. Our world is not black and white we work and live in the grey. This is my style your Millage may vary.

~ Fin~
 
ASA is of great benefit, with little risk. ASA also reduces blood clotting, (makes it slippery) and will help the blood flow through the narrowing artery caused by the heart attack. Also remember, do not give ASA if there is an allergy, or taking a blood thinner, or if your doctor told you not to take.

Nitro is a vasodilator, and will reduce preload, consider the risks

Heparin has a mild benefit and you need to consider the risks
 
Err....

Could you clarify exactly what you mean by "blood thinners" as ASA (an anti-platelet) is commonly given with Clopidogrel (plavix) (a seperate anti-platelet) in patients with ACS. Similarly, warfarin (anti-coagulent) isn't a contraindication for even long term management per Up-To-Date (it's more of a caution for bleeding, but definitely not an absolute contraindication, plus what's the bigger risk, possibly increasing a bleed or an MI? This makes the decision significatly different from long term use to treatment of acute disease).

With heparin, I wonder why if system is using it in the field why they would choose heparin proper in light of low molecular weight heparin. LMW heparin carries significantly less risks and, unlike heparin, doens't require constant monitoring of aPTT.
 
An IO isn't really all that painful. I've seen several people get IO's while fully awake and they barely (if at all) flinched. The pain comes from the initial flush and flow of fluid into the medullary space which lido helps with.

If the patient's pressure is high enough and the patient has prescribed NTG I don't see a problem with giving NTG prior to having an IV. If the patient becomes really hypotensive than start an IO.

I think many people become scared at the idea of poking a needle into the bone and hesitate to go that route.
 
18G said:
An IO isn't really all that painful. I've seen several people get IO's while fully awake and they barely (if at all) flinched. The pain comes from the initial flush and flow of fluid into the medullary space which lido helps with.

If the patient's pressure is high enough and the patient has prescribed NTG I don't see a problem with giving NTG prior to having an IV. If the patient becomes really hypotensive than start an IO.

I think many people become scared at the idea of poking a needle into the bone and hesitate to go that route.
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They are amazing, I have 2 styles in my IFAK kit. I also use combitubes more than traditional intubation (oh i know perish the thought) I guess it just depends on your service or environment, but yeah IO is a blessing.:wub:
 
Boston.Tacmedic said:
I would thread cautiously in questioning my comfort level. I have done escharotomys in remote villages and treated ENT as well my comfort level is not in question nor is my personal skill set so before you continue you a personal attack I will stop you there.
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So please understand this is not a personal attack. However, what do ENT and escharotomies have to do with a cardiac patient? These treatments/procedures are not proof of education, experience or understanding of the subject at hand. Put another way, there are many military medics I would trust to cric someone but wouldn't let them transport a patient on multiple pressors between facilities.
Boston.Tacmedic said:
Topic at hand if your concerned with histamine release we carry drugs to handle that ( your system may differ)
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We carry multiple anti-histamines, however most antihistamines are non-competitive antagonist which means they won't reverse exiting hypotension immediately, meaning you have to pre-treat.
Boston.Tacmedic said:
as to IO and Pn bones do not feel pn the change in pressure can cause discomfort hence why I said "lido .5-1mg/kg in an alert PT".
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"Pain at the site" is a universally listed side effect.
Boston.Tacmedic said:
The question of transport time is pertinent because if the ER is 5 min transport time then all this what if is a mute point then, they will just goto ER were at worst case scenario is they get a central line. Our world is not black and white we work and live in the grey. This is my style your Millage may vary.
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The world in far from black and white, which is why I can't imagine someone limiting themselves to only giving NTG if venous access is present regardless of clinical situation. If a patient is alert and oriented, is not tachycardic, does not have a labile pressure and shows no other signs of instability or preload dependence (including RVI) than why are we discarding it? Especially if there is a willingness to give other drugs which affect blood pressure such as morphine.To do so is simply being afraid of "the big bad NTG tablet" and is not grounded in clinical reality.

I support having an I/O ready in case of profound hypotension, but can't see establishing it. If the patient grows unstable, by all means go for the bone. I doubt however, you will find a physician that establishes central lines or I/O just to give NTG. The will evaluate the patient and then go ahead and order it if the patient does not seem unstable.

Are people afraid of NTG or of their assessment ability?
 
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usalsfyre said:
Two shifts ago, I had a chest pain patient I could not canulate. She had finished a course of chemo recently, and four sticks later, I still didn't have a stinking IV. She had what based on my assesment was unstable angina. No inferior ST elevation was present, her pressure was not labile and no other signs indicating preload dependence were present.

What your saying is I shouldn't have provided this lady with relief from a painful but easily treatable condition because I couldn't start an IV?

For the record she got NTG prior to even attempting an IV.
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I was reading through this thread and yes im just a basic but did she not have a PICC or a Port since she was in chemo?
 
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