Removing Lopressor?

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Petey0397

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I work for two EMS agencies in Iowa. The more "progressive" and larger of the two recently removed Lopressor from the truck altogether. On the one hand, I have read the studies and understand that Lopressor should be used with caution given that it can increase the occurence of cardiogenic shock in the acute MI patient. Studies recommend it be given in the hospital when the patient is more hemodynamically stable and ventricular function can be better assessed, which is why we are no longer carrying it.

Moreover, the service that has it never seems to use it. I recently had a patient with an anterior MI, c/o of abd. pain. I was able to manage his pain and hypertension with ASA, NTG, and Fentanyl per our protocols. Our CP protocol also includes Lopressor, but in my mind it is why down on the priority list. As you all well know, there is a lot going on with critical patients and by the time I had faxed the 12-lead, consulted with Medical Control and called a cardiac alert, established my IV, started ASA and nitro (SL by spray) and started given Fentanyl, we were at the hospital.

What do you think? Should we be prioritizing administration of Lopressor in STEMI patients? Or are there, for lack of a better term, more important things to do with these folks?
 
Petey0397 said:
I work for two EMS agencies in Iowa. The more "progressive" and larger of the two recently removed Lopressor from the truck altogether. On the one hand, I have read the studies and understand that Lopressor should be used with caution given that it can increase the occurence of cardiogenic shock in the acute MI patient. Studies recommend it be given in the hospital when the patient is more hemodynamically stable and ventricular function can be better assessed, which is why we are no longer carrying it.

Moreover, the service that has it never seems to use it. I recently had a patient with an anterior MI, c/o of abd. pain. I was able to manage his pain and hypertension with ASA, NTG, and Fentanyl per our protocols. Our CP protocol also includes Lopressor, but in my mind it is why down on the priority list. As you all well know, there is a lot going on with critical patients and by the time I had faxed the 12-lead, consulted with Medical Control and called a cardiac alert, established my IV, started ASA and nitro (SL by spray) and started given Fentanyl, we were at the hospital.

What do you think? Should we be prioritizing administration of Lopressor in STEMI patients? Or are there, for lack of a better term, more important things to do with these folks?
Click to expand...

I would like to see esmolol.
 
We took it off our trucks last year. Cardiologists did not like it's use in the field.

Best thing you can carry is Hep. Early bolus is beneficial to the pt, especially if going to cath lab.
 
The study that really got people going with beta-blockers in ACS was the ISIS-1 study, which although large, was unblinded. It also only showed a 0.7% reduction in mortality, which may easily be explained by the lack of blinding rather than any beneficial effect of early beta-blockers.

There are at least 3 major reviews of the studies of beta-blockers, including a Cochrane review and a couple from other journal (CJEM and Ann Emerg Med off the top of my head) None of these has shown any benefit in the early administration of beta-blockers in ACS and a small, but significant increase in the incidence of cardiogenic shock.

Unless there are more studies regarding either different types of beta-blocker or different routes of administration (it has been suggested that oral may be better than IV, but this has not been studied) there is no reason to be giving beta-blockers in the field.
 
We have ASA, SL Nitro, Nitro drip, Heparin, then finally if the HR >90 and SBP is >150 and other causes have been ruled out, we have Lopressor. My agency is very much in to the "We're no longer just hauling patients to the ER. We are bringing our hospitals ER to our patients" and their protocols / guidelines are indicative of such.



Considering 45min+ transports are the norm for many of our places to a PCI center, they give us a bit more to work with and to consider.
 
No Beta blockers in California either. Would be nice to have a system Linuss with the mentality of bring the ER to the streets.

While it would be nice to have such toys on the box, does it help when your transport times are short to have things such as esmolol or the likes? I would like to see more anticoagulants before beta blockers.
 
Lopressor on our trucks down here, since just like Linuss we have forty five minutes, at least, if we ground transported to a cath lab.
 
jtpaintball70 said:
Lopressor on our trucks down here, since just like Linuss we have forty five minutes, at least, if we ground transported to a cath lab.
Click to expand...

But....but....but..... WHY?

The only (small) benefit in the administration of beta-bloackers comes after the infarct has been resolved.

Perez MI, Musini VM, Wright JM. Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event. Cochrane Database Syst Rev. 2009;(4):CD006743.

Al-Reesi A, MD; Al-Zadjali N, MD; Perry J, Fergusson D, et al. Do β-blockers reduce short-term mortality following acute myocardial infarction? A systematic review and meta-analysis. CJEM. 2008;10(3):215-23

Sinert R, NewmanDH, Paladino L, Brandler E. Immediate Beta-blockade in Patients with Myocardial Infarctions: Is There Evidence of Benefit? An Evidence-Based Review. Annals of Emergency Medicine. 2010; online,doi:10.1016/j.annemergmed.2010.03.036
 
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No beta blockers here. Last agency I worked for had Lopressor for STEMIs and Labatelol for hypertensive crises.

We will be getting enalaprilat in January for CHF...if SBP >140 after 3x NTG + paste.
 
I don't have the knowledge to add anything productive to this conversation myself, but oddly enough I was listening to this panel discussion on the way to school the other day, and think it provides some good perspective on the research that had been done (up to 2008).

As an added benefit Dr. Hoffman reminds me of George Carlin...

http://www.alllaconference.com/index.php?option=com_content&view=article&id=2350:AllLAConference_20080904-panel-ACS-PE

beta blocker discussion starts at 38 minutes (although the first 38 minutes are good too).
 
We have lopressor on our trucks and I also gave it a lot when I worked as an ER RN.

It has its plusses and minuses. We did have a handful of patient's in the ER who progressed to heart failure and it was contributed to the administration of Lopressor; however do we really know this for sure, how do we know the patient wasn't going to progress into heart failure anyway. How do we know those patients weren't already in failure and if they only had maybe bibasilar crackles that it wasn't missed with all the excitement in getting them medicated and off to the cath lab?! It got to the point that the cardiologists had to order it, instead of the ER docs.

On the other hand we also have it on the trucks and as long as the patient's HR and BP can tolerate it and I do not hear any crackles, I do not hesitate to give it. I have seen patients with frequent ventricular ectopy that has been abolished with the administration of lopressor, so I am still a fan.

Could be a dosing issue, maybe we need to change that.

I do not think there are enough studies to throw in the towel on Lopressor just yet... just my oppinon. We also carry Heparin on our trucks for STEMIS, that is low on my list of things to give.
 
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Metaprolol if BP/pain continues to be a factor after nitro and morphine for acute coronary syndrome.

Labetalol/Metaprolol for Hypertensive Emergencies, both require med control orders.
 
So... We just had metoprolol put on the truck. But not for ACS. We only use it in the case of symptomatic A-Fib with RVR.
 
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