NTG and Morphine I’m Inferior AMIs


Dodges Pucks
Community Leader
Huh, any specific reason? We're talking about ditching the paste since its rarely used and we have it in tab, spray, drip and push dose
Our medical director seems to think that they are as effective. I have no idea what he bases that on. He is also one of the flight program MDs and they have trying very hard to eliminate as many infusions impossible as possible due to space issues. So if flight gets it, we get it, but in this case we lost since I think they have IVP NTG and we do not.

Also, I've always tended to give nitro to hypertensive STEMIs because that just seemed like a good idea and that's what I was taught...but I can't find a whole ton to back that up?


Forum Asst. Chief
We had a lecture from one of the interventional cardiologists at my hospital the other day and he was of the mind that nitro was appropriate in a right sided MI as long as it was given judiciously and you were aware of the potential for hypotension. I don't actually think its a terribly well studied phenomenon, but that's the case with most things we do in medicine.

He must have been reading this thread because he also went on a tangent about hating nitro paste. Specifically he disliked it for acute CHF patients who were peripherally vasoconstricted, since he felt that you would have initially very poor systemic absorption, followed by a sudden larger dose when the patient was stabilized and more normotensive and vasodilated, which could push them into hypotension. I'm not sure how much literature there is to back this up, though anecdotally I've never seen paste be very effective in severe CHFers.


Forum Crew Member
Hey everyone, I know that it took me a long time to get back to all of you and I apologize. All of you had amazing responses and I appreciate your input. A lot of you brought up that administration of NTG should be taken out of the protocols for analgesia in an AMI whether with RVI or not. Most EMS units carry analgesics that can significantly reduce pain without the potential to knock out the patients pre-load.... If this is the case, why are paramedic courses still teaching the “MONA” protocol? I mean, when I worked in facility, we did the same thing. EVIDENCE-BASED MEDICINE.


Forum Lieutenant
[I believe] we’ve framed the issue of Nitro’s efficacy incorrectly. So far I’ve only read people measuring its efficacy based on mortality. We should instead consider quality of outcome as measured by heat muscle preservation. [I believe] Nitro’s therapeutic medhcnism of action is increasing venous capacitence which reduces pre-load, therefore a reducing Frank-Starling mechanisms (greater myocardial stretch = greater contractile force), thus reducing myocardial oxygen demand. This is interpreterd by the clinitian as a reduction in patient pain (as well as anxiolysis).

[I believe] those who think Nitro’s purpose is analgesia are only looking at its symptomatic effects whereas [I believe] Nitro’s physiological benefit is mitigating myocardial necrosis by reducing cardiac workload. In other words, if we approach this as a ‘but did you die’ binary situation we are overlooking the real clinical benefit. Unfortunately I can’t point to any study that supports my belief.


Forum Deputy Chief
Yes you can give nitroglycerine to inferior MI's. You can give it IV or SL. However, if you give it SL you must make sure that there is not RCA involvement. It cannot be a right side MI. Also, depending on a paramedic's scope of practice in your area, you will also need to get medical control authorization to give it. In what world would a medic give SL NTG to an Inf AMI? Simple. Standard ST elevation in II, III, and aVF plus NO RECIPROCAL ST depression in I, aVL, V5, or V6. Not to mention HR and BP must be high enough to allow NTG.

The trick is not just knowing where but also where it is not.