NTG for chest pain... even when you're thinking respiratory.

[Shishkabob]

So this has been a point of contention between me and my FTO.


He is of the thought process "If they're complaining of chest pain, even if I think it's respiratory in nature, they get a nitro SL just to test it out". I'm of the opposite view... I'm not against trialing NTG if I deem it worthy, but if I think something is "solely" respiratory in nature (IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors) they probably won't get a nitro from me.

He admits that nitro can stop non-cardiac chest pain just as likely as it is to not do anything for cardiac pain, but still questions my not doing nitro for chest pain "just to check". If he backed it up by saying "I do it for the pain", that'd be one thing, but that's not his reasoning.



Views on nitro for chest pain, even when not convinced it's cardiac in nature?

 

[Brandon O]

Relief from nitro is, at best, a weak supporter of cardiac etiology.

A 12-lead is a great one though, so unless you guys don't have that capability I'm not sure why you'd have to resort to anything else.

 

[AlphaButch]

Sometimes it's difficult to nail down whether it's cardiac or non-cardiac in nature, and giving it for pain would be an option. However, doing it to "test" whether it's cardiac or non-cardiac seems poor reasoning for administration (particularly given the studies done on the matter).

 

[DV_EMT]

Views on nitro for chest pain, even when not convinced it's cardiac in nature?

As taught by the Los Angeles EMT Expanded scope, "If it dosent DIICE out, you dont give it"

DIICE

Drug/Dosage
Indication/Integrety
Contraindications
Expiration

If it presents as respiratory and isn't indicated as cardiac in nature (EKG and pain), don't give it. I went to the ER the other day for substernal chest pain that worsened with swallowing. Did it present as cardiac, maybe with the pain location, but the fact that my vitals were stable and that the pain worsened with swallowing made me think it was GI or Respiratory. they got an Xray, Labs, and EKG (all negative). Turned out to be esophagitis with refered chest pain.

... And no, I didn't get any nitro ^_^ - instead I got some prilosec and a "don't eat too much turkey"

 

[Smash]

Views on nitro for chest pain, even when not convinced it's cardiac in nature?

Does he give it to someone with sudden onset, severe, tearing pain radiating through the back and into the groin with pallor, diaphoresis, nausea and hypotension? You know, just to check?

Lazy, not very bright, potentially dangerous and at best a waste of time.

 

[mike1390]

As taught by the Los Angeles EMT Expanded scope, "If it dosent DIICE out, you dont give it"

DIICE

Drug/Dosage
Indication/Integrety
Contraindications
Expiration

This has nothing to do with the question at hand...moving on.

If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.

 

[Handsome Robb]

This has nothing to do with the question at hand...moving on.

If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.

Because using a medication when it is not indicated is bad medicine.

If she is showing a STEMI on the monitor then treat it as such. If there's no STEMI present and the pain, after assessment, is deemed to be pleuritic in nature NTG is not indicated or appropriate.

So she is short of breath and having chest pain and showing a STEMI on the monitor, do you give albuterol to treat her SOB/diff breathing even though the albuterol will boost her myocardial O2 demand through it's beta 1 effects and worsen the ischemia to the heart? :wacko:

 

[mike1390]

could be angina not a STEMI, NTG will relieve that pain.And it is indicated she's c/o CP. Its a matter of opinion like giving MS for a paper cut, pt states 10/10 on the pain scale do I withhold cause its a paper cut? You treat your patients the way you want ill do it my way.

 

[DV_EMT]

This has nothing to do with the question at hand...moving on.

Uh, yes it does

He is of the thought process "If they're complaining of chest pain, even if I think it's respiratory in nature, they get a nitro SL just to test it out". I'm of the opposite view... I'm not against trialing NTG if I deem it worthy, but if I think something is "solely" respiratory in nature (IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors) they probably won't get a nitro from me.

If its not indicated (see the DIICE pneumonic I used) then why would you give it. Linuss states that he wouldn't give it for a person without a HX of cardiac issues. You wouldn't just give a drug just cause you want to test the waters... especially if you can't reverse it.

Example - I had substernal Chest Pain w/ some shortness of breath on inspiration. I had been down with a cold x2 days prior to onset. I have no Cardiac History, but a Hx or Pneumonia...and I'm 22 y/o. My vitals were stable. If a paramedic had tried to give me Nitro prior to getting an EKG and a set of vitals, I would have refused it because I - the patient - knew that there was no way in hell that i was having angina pectoralisis or an MI given my HX.

Why give a drunkard or diabetic with slurred speech & loss of motor coordination a clot buster when they don't have an active stroke.

 

[mike1390]

right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude and tell me how many times you run on new onset cadiac symptoms.... things dont always start when your getting a check up at the doctors. what would I need to reverse? .4 NTG isn't going to bottom this pt out, but in the rare case it does happen, Iv got fluids and dope. If you've never had a cardiac event before how would you know you arnt having one. hence why out in the field everyone who is having a panic attack and has no cardiac HX thinks their having a MI. I see it at least once a shift. And I would hope no medic would give NTG before a 12-lead.

 

[Handsome Robb]

could be angina not a STEMI, NTG will relieve that pain.And it is indicated she's c/o CP. Its a matter of opinion like giving MS for a paper cut, pt states 10/10 on the pain scale do I withhold cause its a paper cut? You treat your patients the way you want ill do it my way.

That's fine. Everyone has opinions and I respect that. I agree, NTG will help CP secondary to angina but that isn't the question presented in this thread. The question was do you trial NTG in a patient with CP that, after assessment, is presumably not of cardiac origin to rule out cardiac etiology.

All I will say is last time I checked, which was recently seeing as I'm in school, NTG is indicated for chest pain with suspected cardiac origin not just chest pain.

 

[Smash]

Thousand Oaks is in California right? Well, I guess that explains things. One more place to add to my Never Get Sick Here List.

Lazy, not very bright, potentially dangerous and at best a waste of time. That could describe so many things...

 

[usafmedic45]

Lazy, not very bright, potentially dangerous and at best a waste of time.

I've seen several people suspended without pay for that approach and one of them actually had a complaint filed with the state by our medical director for doing it again after two prior reprimands for it.

 

[usafmedic45]

This has nothing to do with the question at hand...moving on.

If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.

You scare the crap out of me and make me want to pray for your patients.

 

[usafmedic45]

Thousand Oaks is in California right? Well, I guess that explains things. One more place to add to my Never Get Sick Here List.

Couldn't have said it better myself.

 

[mike1390]

yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?

 

[Handsome Robb]

yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?

I'd love a response seeing as I didn't attack you directly

 

[mike1390]

well rob because you seem to not be a pompous douche like others who sit in the holy EMS Heaven that is EMTLIFE which is like being the coolest kid on the short bus.

to answer your question. If after my lazy and my I add not very bright assessment, we pin pointed exactly what type of pain and where it is, if i was lead to believe that it was due to a cough then no I wouldnt just try NTG out. At no point did I say that I try drugs on pts just for kicks. If this lady was adamant that she was having chest pain... not pain when she coughs but actual chest pain, Then I would go down the chest pain route.

 

[DV_EMT]

right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude and tell me how many times you run on new onset cadiac symptoms.... things dont always start when your getting a check up at the doctors.

Paragod

10char

 

[Smash]

(IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors)

If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.

Which is the opposite of:

to answer your question. If after my lazy and my I add not very bright assessment, we pin pointed exactly what type of pain and where it is, if i was lead to believe that it was due to a cough then no I wouldnt just try NTG out.

So why change your tune?

yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?

Yes it is. That's why I said it is.

well rob because you seem to not be a pompous douche like others who sit in the holy EMS Heaven that is EMTLIFE which is like being the coolest kid on the short bus.

Of course you are above all of that...

This has nothing to do with the question at hand...moving on.

right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude...