The improper incorrect thread: what do you do that's not in the protocols but WORKS?

[Smash]

I've posted two articles so far. NTG is beneficial in ACS, but in a proximally occluded RCA it needs to be titrated IV with fluids to keep the patient hemodynamically stable. Also, remember that I said this is how some patients are treated in hospital. I agree that a sublingual bolus of nitrates in the field for RVI patients is too risky and I do not do it.

17 year old review quoting studies up to 45 years old, small samples, hetrogenity of subjects; I could go on. No need to though as I've already posted a couple of more up to date, larger and more robust multi-center trials that are considered seminal and form much of the cornerstone of modern ACLS. Of course they are also subject to further investigation and analysis

It sure beats twee remarks with smileys plastered on it, I'll give you that, and I'll happily discuss it on it's merits as a result.

I know 'hospitals' that don't cool post arrest patients or that load acute cardiogenic pulmonary edema patients up on furosemide. It doesn't mean that is going to be my practice though, and neither is playing seesaw with cardiac output in a compromised patient.

 

[Melclin]

Nitrates in all forms should be avoided in patients with initial systolic
blood pressures less than 90 mm Hg or greater than or equal
to 30 mm Hg below baseline, in patients with marked
bradycardia or tachycardia, and in patients with known or
suspected RV infarction. In view of their marginal treatment
benefits, nitrates should not be used if hypotension limits the
administration of beta-blockers, which have more powerful
salutary effects.

Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, et al. ACC/AHA Guidelines for the Management of Patients with STEMI. Circulation 2004;110;588636.

Five years ago from the ACC/AHA. If the ACC/AHA are telling doctors its a crappy idea to give nitrates to RVI pts then I'd probably go with their opinion given my year and a half of paramedicine. They list that conclusion as being Class Three, Level C; meaning that it is recommended against on the grounds that it isharmful, but that recommendation is based on limited evidence: case studies and expert opinion. Not to mention the fact that my guidelines are almost identical and it makes sense in terms of cardiac physiology.

 

[emtbill]

Here's more:

The literature on isolated right ventricular infarction is reviewed and local experience is reported. Chronic lung disease is an important risk factor. Chest pain and breathlessness are common. Syncope and sudden collapse can also occur. Rhythm disorders include sinus bradycardia, atrial fibrillation and ventricular tachycardia or fibrillation. Atrioventricular block is rare. Hypotension and a right-sided fourth heart sound are common. Cautious use of slow-release nitroglycerin is not hazardous in the absence of hypotension. High doses of steroids and anticoagulants can be helpful. The prognosis is usually good, although sudden collapse can occur due to ventricular fibrillation, rupture of the right ventricular free wall or massive pulmonary embolism.

Our experience with 18 cases of isolated right ventricular infarction is reported and the literature is reviewed. Chronic lung disease with right ventricular hypertrophy is an important risk factor. Chest pain is the usual symptom at presentation but some cases can have breathlessness, palpitations or syncope. Some cases can have sinus bradycardia, atrial fibrillation or ventricular tachycardia. Atrioventricular block is rare. Cases with pulmonary artery hypertension, extensive right ventricular infarction due to proximal occlusion of the right coronary artery, right atrial infarction or atrial fibrillation can have hypotension and/or systemic venous congestion. A surface electrocardiogram mainly showing changes in leads conventionally considered to represent left ventricle and right-sided chest leads may not show an infarct pattern in some cases. Echocardiography is, therefore, more reliable in diagnosing this condition. The cautious use of small doses of nitrates and diuretics is not hazardous in the absence of hypotension. High doses of steroids and anti-coagulants can be helpful. The prognosis is usually good, although sudden collapse can occur due to ventricular fibrillation, rupture of the right ventricular free wall or a massive pulmonary embolism.

There is certainly conflicting literature on the subject and the articles I quoted were from the early 90's. I realize the standard of care has probably changed since then but as some in this thread have said NTG can be used cautiously in RVI. The key word is cautiously, and in fact the AHA's 2005 article in the ACLS supplement on management of ACS (http://circ.ahajournals.org/cgi/reprint/112/24_suppl/IV-89) recommends avoiding nitrates all together in RVI, however hypotension caused by these drugs can be easily corrected with a fluid bolus.

Again let me be clear that I am not advocating field treatment of RVI with a sublingual bolus of NTG. That is not cautious. How do you give a cautions dose of NTG sublingually? Do you sneak up on the drug before you give it? I don't know. To me, cautious means a drip, and that is generally out of an EMS provider's scope of practice. However, hospitals can be a little more creative with their treatments (e.g. fluids with a nitro drip). That really doesn't seem too off the wall to me: give nitrates to increase oxygen delivery while simultaneously giving fluids in sync with the NTG to keep cardiac output up.

I didn't know my earlier post would have caused such an uproar. I will certainly ask the cardiologists about this treatment the next time I am near our CCU.

 

[reaper]

The second article is in line with what most Cardiologist are in agreement on. Yes, small dose of NTG is considered SL. If the pt is not hypotensive, use caution.

If the pt is hypotensive, you will preform a balancing act with NTG and fluids. When we are talking about fluids, we are not talking in terms of 300-1000cc's. We are talking in terms of 3-5 liters. A RVI in hypotension may require up wards of 10-20 liters of fluid, before advancement to a Cath lab.

This very subject has been discussed before on the site. Lots of literature was posted at those times. Search back and read them. RVI Mi's are tricky to deal with, but must be done, for the treatment of the pt.

 

[Smash]

The key word is cautiously, and in fact the AHA's 2005 article in the ACLS supplement on management of ACS (http://circ.ahajournals.org/cgi/reprint/112/24_suppl/IV-89) recommends avoiding nitrates all together in RVI, however hypotension caused by these drugs can be easily corrected with a fluid bolus.

That really doesn't seem too off the wall to me: give nitrates to increase oxygen delivery while simultaneously giving fluids in sync with the NTG to keep cardiac output up.

I didn't know my earlier post would have caused such an uproar. I will certainly ask the cardiologists about this treatment the next time I am near our CCU.

The uproar is not from your posts. The evidence you put forward earlier has been superseded, and I disagree with the rationale behind treating with both nitrates and fluids as you are achieving two polar opposite effects with them.

However I am more than happy to argue those points on their merits, and indeed healthy debate is exactly what we need.

The uproar for me is caused by comments such as:

Do you have studies that show an increase?



We can do this all day

I don't play games with patient's lives. I have a clear rationale for all interventions I carry out based on the best available evidence that I can find in concert with local protocol. If protocol calls for a treatment that I know to be harmful (eg nitrates in RVI, large doses of furosemide in CHF) then protocol gets forgotten.

I also strive to be professional (a term that gets bandied about a lot here). The above attitude epitomises an unprofessional attitude to patient care, education, research and EBM which should form the foundations of professional paramedic care.

Where I work paramedics are accepted as an integral part of the health system. We are held in high regard by the public and by health care professionals. We are involved in and instigate research in our field and we are are often on the cutting edge of care. We get paid well and we have good benefits.

In short, we have gone a long way to achieving what we all want to achieve: recognition as professionals.

My reaction may seem extreme, but I am sick to death of hearing people carping on about 'professionalism' ad nauseam and yet this is the type of comment we see time and time again on EMS forums.

 

[mycrofft]

I'm enjoying the tone of this mostly, thanks!Now how about ortho, spinal, psych, etc?

Here's some to toss in:

-Agency dictates every pt c/o headache be given a full workup including a family history for headaches. Guess what gets left off?

-Splinting severly lacerated extremities without strict signs of fx?

-"Clearing" chest pain pts on scene by VS, exam and monitor rather than automatically going into Johnny and Roy mode and getting them ready for The Big One and scrambling for home at Warp Four.

-Performing some necessary and sanctionsed functions without the proper supplies or equip due to it being missing, broken or used up?

 

[el Murpharino]

Glucagon for beta blocker overdose

 

[Melclin]

Glucagon for beta blocker overdose

How'd you discover that one. Is it legitimate in any way?

 

[EMS49393]

How'd you discover that one. Is it legitimate in any way?

You didn't know? It's been a treatment for over 50 years.

http://www.ncbi.nlm.nih.gov/pubmed/6144498

There is an abstract of only one of the studies and in the abstract it does contain the physiological basis for why this treatment works.

Hope that helps, and keep learning.

 

[el Murpharino]

How'd you discover that one. Is it legitimate in any way?

I just pump different drugs into suspected overdoses until I find something that works. Luckily Glucagon doesn't start with a 'Z'.

/sarcasm

Yes it is an accepted treatment for beta blocker overdoses. One issue with it is that it takes about 2-5 mg of glucagon, and glucagon is VERY expensive. That being said, I'm sure I'd have no problem getting an order for it via med control, but in some areas where I work, radio/cellular contact with med control is sketchy at best.

 

[Smash]

I just pump different drugs into suspected overdoses until I find something that works. Luckily Glucagon doesn't start with a 'Z'.

/sarcasm

:lol:

Yep, done this too. Very effective. For a short time till my stocks run out!