Nitro before IV

[rhan101277]

Our BLS Officers can give GTN without an IV and have done so for years

Do patients cannulate themselves before they take a squirt of thier nitro?

No they don't, but I guess physicians think this is better than nothing. But 50% of MI's are right ventricular involved according to some studies.

 

[Shishkabob]

Just because you don't see ST changes denoting an inferior infarct doesn't mean it's not there.


Having said that, just it being an inferior infarct would never stop me, and shouldn't stop you, from giving nitro. Just have an IV and be prepared to give a bolus. IMO, the benefit of giving nitro outweighs the small possibility of the substantial drop in BP. Just more infarct happening.


(Bring on the replies about the "no proven decrease in morbidity/mortality")

 

[rhan101277]

Just because you don't see ST changes denoting an inferior infarct doesn't mean it's not there.


Having said that, just it being an inferior infarct would never stop me, and shouldn't stop you, from giving nitro. Just have an IV and be prepared to give a bolus. IMO, the benefit of giving nitro outweighs the small possibility of the substantial drop in BP. Just more infarct happening.


(Bring on the replies about the "no proven decrease in morbidity/mortality")

Yeah I would give it of course, because you never can know for sure. I'm just saying that that its like you said, if it is RV then you are creating a bigger infarct w/ giving nitro, even though we all have to give it because of protocols unless contraindications exist.

 

[FLEMTP]

Im going to jump in here and give ya'll my .02 cents. The ONLY medication I give in a suspected cardiac event or chest pain WITHOUT an IV is Aspirin. I get a set of vitals, a 12 lead EKG, and if its a chest pain I always put in 2 IV lines. I give a dose of sublingual NTG mainly as a diagnostic indicator. I say this because if the NTG shows a change in the chest pain, or a decrease in the elevation or an improvement in the 12 lead EKG, then I start an IV Nitro drip. I have the second line as a RULE because I will NOT piggy back NTG into a Normal saline line.

Why? Simple. It would be too easy for someone to decide the patient needed an IV medication (fentanyl is a good example) so you draw it up, and plug it into your IV port, and push it. Good.. now you've given your fentanyl.. AND ALL of the IV nitroglycerin thats present in the line between the patient and your Nitro piggy back.

So, always 2 lines, and always BEFORE i give nitroglycerin. If the 2 minutes it takes to put in 2 lines causes the patient to code, then I'd bet the nitro before the line vs after wouldn't have made the difference.

Id also like to point out like anything else we check, a 12 lead is a diagnostic indicator only. it is NOT the final word. Ive had patients in the past with completely not related complaints (cellulitis) and out of sheer boredom i performed a 12 lead. The EKG is screaming ***ACUTE MI SUSPECTED***
but there was, in fact, no STEMI present. The patient stated that EKG machines ALWAYS do that with her EKG.

Most paramedics would have called the STEMI or cardiac alert, and taken the patient to the ER with an "MI" because the machine says so.

The EKG is just a tool to assist in your diagnosis of the patient.

Look at your patient!!

Last friday I had a patient that called us for chest pain. She was obese, a 30 pack year history of smoking, was being treated for hypertension, hyperlipidemia, Non insulin dependant diabetes, and had a cardiac cath with stent placement one month prior. She was pale, cool, diaphoretic, nauseated with 10/10 pressure and squeezing pain in her chest. She was also mildly short of breath.

We placed her on a NRB mask, obtained a set of vital signs (slightly hypertensive and sinus tach at 110/min) and a 12 lead EKG. 12 lead showed no ST segment depression, no wide complex anything, no ectopy of any kind.

Based on her presentation, and my exam, i opted to treat her for an acute coronary syndrome/unstable angina.

I did serial 12 lead EKG's to look for anything in the way of ischemia, or infarct. Nothing

NTG sublingual helped her pain MARGINALLY but after the Nitroglycerin at 10mcg/min her pain did improve slightly. Her blood pressure hovered around 110/systolic. She also got fentanyl for additional pain management.

She was admitted, and I am waiting on final follow up.

The point to all of this? Treat your patient, NOT the monitor...and DONT administer ANY cardiac medication without at least a SINGLE IV line... including NTG. I would consider PO ASA to be the ONLY exception.


Hope this helps!

 

[Veneficus]

Yeah I would give it of course, because you never can know for sure. I'm just saying that that its like you said, if it is RV then you are creating a bigger infarct w/ giving nitro, even though we all have to give it because of protocols unless contraindications exist.

In right sided MIs I have always observed the systolic pressure to quite low, don't ever recall seing it over 80. That would be a contradiction to giving nitro.

FLEMTP:

I understand your reasoning, and it certainly is a reasonable practice decision, but I am a little more fast on the trigger with the nitro. The only thing I want to see before I give it is some indication for it in a patient that clinically could possibly be havings some type of ACS and a bp ~100, though once a line is placed ~90 sys.

My reasoning is that if it is angina, (of any sort) something that can help is administered. In the event it is an MI, it can be useful info even prior to a 12 lead. Finally, in unstable angina, insult has a couple of mechanisms that can cause a plaque rupture which can result in thrombotic event.

As i understand, it is bad practice to piggyback nitro in any case.

But I would mention the action of the NTG (GTN) in spray or tablet has a rather short half life, acts locally instead of centrally, and most providers in the field have paste as maintenence instead of a drip.

Again, my way is not the "right" or "more right way" just a different way. See... "practicing."

 

[FLEMTP]

In right sided MIs I have always observed the systolic pressure to quite low, don't ever recall seing it over 80. That would be a contradiction to giving nitro.

FLEMTP:

I understand your reasoning, and it certainly is a reasonable practice decision, but I am a little more fast on the trigger with the nitro. The only thing I want to see before I give it is some indication for it in a patient that clinically could possibly be havings some type of ACS and a bp ~100, though once a line is placed ~90 sys.

My reasoning is that if it is angina, (of any sort) something that can help is administered. In the event it is an MI, it can be useful info even prior to a 12 lead. Finally, in unstable angina, insult has a couple of mechanisms that can cause a plaque rupture which can result in thrombotic event.

As i understand, it is bad practice to piggyback nitro in any case.

But I would mention the action of the NTG (GTN) in spray or tablet has a rather short half life, acts locally instead of centrally, and most providers in the field have paste as maintenence instead of a drip.

Again, my way is not the "right" or "more right way" just a different way. See... "practicing."

I generally prefer to make sure that the nitro wont be detrimental to a patient because their chest pain and symptoms are due to a dissecting aortic aneurysm or a perforated ulcer, or other conditions from the list that would cause similar symptoms. it doesn't take me but a few minutes to do a fairly thorough history, physical and exam and make a clinical decision regarding a course of treatment. I can however appreciate your being "fast on the trigger" as you put it. Every one is different. Im just a bit more cautious considering how potent IV nitroglycerin is. I find that one can be aggressive with treatment, but still be cautious in that treatment.

 

[Jon]

For those concerned about right-sided MI's... Who does a V4R? Who does a 15-lead?

I do the "Bob Page" 15 Lead - V4r, V8, V9 (As opposed to the Tim Phalen 15 Lead of V7, V8, V9).

Doesn't take that much more time, and there is no reason not to do it.

 

[FLEMTP]

For those concerned about right-sided MI's... Who does a V4R? Who does a 15-lead?

I do the "Bob Page" 15 Lead - V4r, V8, V9 (As opposed to the Tim Phalen 15 Lead of V7, V8, V9).

Doesn't take that much more time, and there is no reason not to do it.

Personally, on any inferior wall MI I assume there IS right ventricular involvement, and treat accordingly.

Hows this for a reason not to do it? you're more concerned with playing with the monitor to do a right sided 12 lead.. but who really is going to pay attention? How will that actually change your patient's outcome? will their MI magically resolve as soon as you do one?

NO

You should be spending the minute or so talking to your patient, reassuring them, and explaining their condition to them, as well as what can be expected once they roll through the ER doors. That will do more for them as a patient than a right sided 12 lead will.

Cardiologists always assume an inferior wall MI has right sided involvement, and they treat accordingly. the patient still gets nitrates for chest pain, along with a healthy dose of fluid to help keep the preload up and help prevent hypotension with nitroglycerin administration.

 

[Coco]

I'd never give Nitro without having an IV. I've seen many doctors doing it, and almost every time the patient collapsed. So, with an IV I'm prepared for this situation.
But however, why you give Nitro? For ruling out angina pectoris? Or for lower the blood pressure?

 

[MasterIntubator]

Guten Abend Deutschland, ich denke, die meisten von uns geben nitro zur schmerzbehandlung, via pharmakologische Physiologie Gründen sollten wir alle wissen. Ich würde Blutdruck Kontrolle in Gegenwart von Herzinsuffizienz/lungenödem, sonst ist normalerweise nicht meine Priorität.
Sorry... could not resist, Coco.... I miss Germany!

Our area has protocols set, if the pt is already prescribed NTG, then the BLS providers and ALS can give NTG prior to an IV ( assessment based decision ).
Now to blindly give it without an IV.... as a general rule, I have taught folks not to. 1 - IV starting does not and should not take that long. 2 - you have a little time. 3 - One day.... you will have that pt get hypotensive, and then you will wish you had an IV... as now it will be a bit more difficult with extra stress to deal with.
I have had my share of folks ( mostly have been female ), where after a single NTG ( with an IV in place ), they have dropped 30-40 systolic points, became pale, diaphoretic and ALOC. Lying them flat and raising thier legs a bit along with fluid caused them to rebound to about 100 systolic. I can not remember what thier cardiac story was... or if they were just nitrate sensitive... never the less... it will happen. So don't do half the job to save time.
If I do suspect right sided, and the leads suggest it, we typically give fluids first, then NTG.

 

[Tal]

line and ekg prior to ntg.

and relevant history...Contra indication etc.
Line before ntg allways, some pts dont hadle it so good as others.

 

[socalmedic]

let me pose this question to you, a decision I had to make last night.

you have a 87 yo female with unexplained syncope. 12 lead shows st elevation V1 and V2. you are unable to get an IV, and dont expect to get one. BP 160/80, P80. do you give nitro?

 

[Shishkabob]

Elevation on V1 and V2... any reciprocal changes in other leads? What sort of S/S does she have going on? What kind of history?

 

[socalmedic]

no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.

 

[FLEMTP]

no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.

This is whats wrong with EMS today. COOK BOOK MEDICINE = FAIL!!!!!!


I am just so damn sick of the ignorance and lack of free thinking in EMS anymore. Makes me just want to hang it up and never look back!:excl:

 

[TransportJockey]

When I was a basic I could give a patient his own NTG w/out a line. Now that I'm an I (or BIV in CO) I make sure I've got a line at the very minimum. Too bad I can't interpret a 12lead by state protocols

 

[socalmedic]

JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.

 

[MrBrown]

JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.

that would make the IAFF and Medicfighters (you know, the Firefighters who fight being a Paramedic every day) unhappy

 

[Outbac1]

you have a 87 yo female with unexplained syncope. 12 lead shows st elevation V1 and V2. you are unable to get an IV, and dont expect to get one. BP 160/80, P80. do you give nitro?
no reciprical changes, hx of dementia, no cardiac Hx. no S/s other than the syncope during bowl movement. county says whenever Mr. LP12 says ***ACUTE MI SUSPECTED*** we treat per chest pain protocol, regardless of C/c or S/s and transport to STEMI center.
JT i know your pain. I am not allowed to inteperate a 12 lead, as a paramedic. BP was high enough and I didnt see any inferior or posterior involvement so I went ahead with the nitro. I just wish I where able to think for my patients.

Probably a vagal episode. I probably wouldn't have given nitro as I don't think it was warranted. (But I wasn't there) Any idea as to her troponins?

 

[socalmedic]

outback- I have no idea what her blood work was, I did not make a return trip to that hospital.

Brown- I ride big red at my main job. unfortunately it is a BLS department and I enjoy ALS.