Nitro before IV

[rhan101277]

Well, requiring a semester of anatomy, semester of physiology, semester of biochem and a year of chemsitry would be a great start (the first two should be required, but I can always wish about the second two). My concern over adding things like pulse oximetry to the EMT-B SOP is that I have my doubts that most EMT-Bs have a solid understanding of cardiopulmonary A/P that should be required before they use it. I foresee a lot of providers looking at it as a "stick probe on finger. read results, write down results" with no real understanding on what the device is telling them, but thinking that their patient is all honkey dorey because the number is above 92.

yeah I am in A and P now I like it. You can still have good Sp02 but poor perfusion, I saw over the weekend with some woman who tried to commit suicide by taking a overdose. Her oxygen level was great, but blood pressure was not it was 60/40, MAP was 40'ish, minimum is supposed to be 60 for good perfusion.

I have a strange feeling that some people don't want us basics to know more. They are scared maybe we could save more people, I don't know. What is more important than getting a education to learn to use proper equipment/training to save a life.

 

[Ridryder911]

Now really consider what you just wrote...

If one obtains a formal education and more education in EMS and medicine, then... one would not be a basic would they?


R/r 911

 

[JPINFV]

Now really consider what you just wrote...

If one obtains a formal education and more education in EMS and medicine, then... one would not be a basic would they?


R/r 911

Until there becomes an EMT-JPINFV level, unfortunately an EMT-B with an educational foundation is still an EMT-B. Just as there will still be paramedics that act like technicians once the EMT is dropped from EMT-Paramedic.

 

[Melbourne MICA]

Hence, the problem. You make very important point however; majority of the EMS in U.S. are not nor have the capabilities of performing 12 lead. Even ALS units that provide ACLS care still may not perform twelve lead assessment.

You mentioned the assessment of the patient in lieu of the numbers of the blood pressure, which I totally agree but unfortunately you are discussing an assessment technique to a level that is taught four hours of assessment techniques including trauma and medical. Also the terms or understanding of "preload, after load and even stroke volume" are rarely or never mentioned or even discussed in the basic curriculum, yet we still allow and expect them to administer and decide "which patients" it is safe to administer NTG to. Again, a course that the total cardiac segment is less than four clock hours in length.

In regards to treating the patient that will cause acute hypotension, other than laying the patient in a supine and administering oxygen there is NOTHING they can do. Remember, our national level Basics are not able to cardiac monitor nor establish IV for fluid challenge. As well, myself and many other cardiac educators emphasis is recognizing the damage that might occur if this happens. Having the patient to compensate the sudden drop is the emphasis of worry. Again, causing an increase in heart rate, increasing workload, increasing the oxygen demand upon an already damaged myocardium is never good, as one knows would do nothing more than increase the infarct size.

I am definitely not against NTG. In fact, it is not used enough in the prehospital phase as most Paramedics do not administer it properly as in the dosage or most effective route. Personally, IV NTG should be administered upon those that inferior wall AMI has been ruled out but again most providers do not have IV pumps to ensure the administration to be safe. Even making sure all ALS providers can perform twelve lead ECG's. Again another part of the failing portion of providing adequate care. You may believe costs is the prohibitive factor but in comparison of hazmat, WMD and other trinkets and toys that will never be used it should be a priority, something that would be used. Unfortunately, providing definitive patient care usually makes it on the lower priority list.

R/r 911

I guess Marinemans message reminded of me of myself years ago to some extent when it seemed "enlightenment" on some clincial issues was simply a matter of getting to grips with a couple of numbers or ideas like BP drop versus starting BP. It's a recipe for confusion without an understanding of the larger picture. If Marineman is reading I hope I didn't sound pompous or condescending like I'm some expert - which I am not.

I just wanted to get across the idea that its not matter of one number or another but rather a complex mix of information we must interpret for the best outcome for our patients.

There are always options and things we can do no matter what our level of expertise that are safe, practical and benefit the patient. If all your service does is give you a drug and say "give it under circumstance "X", you can still think things through and take account of each pts situation so when you are about to give it, you give it as a thinking person not a drone. By definition, the more basic your level of training, the more conservative you should be in how you approach your pt management.

On GTN, the great thing about the tablet admin route is if side effects present themselves you can get the pt to spit out the pill. You can' t do that IV. (though IV would be good for well trained ALS types for sure). You can also give a half or even a quarter if you have doubts, are in the ballpark of treatment guidelines and will get your but kicked by your boss if you didn't give it.

The miedical standards committees of all our services must look long and hard at the treatment freedoms they give to EMS staff and I can assure you they do. At the same time they must follow the current medical practices, borne out by research, that provide the most value to the most number of people for the least risk to all stakeholders, in whatever form that may come.

I think you ALS guys need to make clear to EMT-B's who read and post here that they must act with care and take on board only as much information as they can understand within their own limits or can research or discuss with their clinical superiors.

MM

 

[bonedog]

At one time NTG was contraindicated for MI's.

Now it is recognized for pain relief, not treating MI's, unlike ASA, which reduces M&M more than any other treatment...

Line first unless they have used their own NTG prior to arrival.

Great for angina and CHF.

 

[erik412]

Nitro

I prefer to have my line and on a monitor before NTG. Unfortunately, I only have 3 Lead capabilities but it can at least give me some insight as to what is going on.

Erik

 

[tydek07]

12 lead, nitro, line

That is the way I was taught, and have never had a problem doing it that way.

 

[NRCCEMTP26]

Nothing like bottoming out the patient and increasing the infarct size because of a zealous provider.

A twelve lead and IV should be performed before any NTG is administered. Administering NTG before knowing it is not a right sided AMI is only asking for troubles the same as if administering NTG without a line.

R/r 911

Amen to Ridryer911. I also strongly believe that a 12lead and a line should be started. Knowledge of a right side vs left side is uber critical! For any BLS unit dispatched to a cp should wait until ALS arrives before giving nitro.

 

[Outbac1]

Here is an ECG of one I did the other night.
55y/o m, supine on floor. pale, cool, clammy, weak. Had been sitting in a chair talking with his friend when he had a sudden onset of c/p and sob.
He said it came in waves and the pain was severe. His friend helped him lay down on the floor.
HR 80 - 90
B/P 108/80
RR 20 - 24
B/S clear bilaterly
Allergies to rubbing alcohol, bees and shellfish
No previous cardiac hx
only chronic back pain
Hernia operation a month ago for which he takes tylenol 3s with codeine
Pt given O2 via n/c @ 4L/min, ASA160mg PO, 4 lead ECG obtained then 12 lead.
Somewhere in there ALS backup was called
Its a 20 min drive to the hosp. and we had to put him into a stair chair to get him out of the 2nd floor apt.

I'm not yet allowed to start a line,(until I finish ACP school), I am allowed to give nitro. ALS will take at least 15 min to get to me.
So to give or not. Should I make this pt wait for ALS? Your thoughts please.

 

[Outbac1]

Maybe it will post now.

 

[Outbac1]

 

[Ridryder911]

NO!

Couple of reasons

First, you did not describe if the patient was complaining of any chest pain at the current time.

Very prominent Inferior and Lateral wall involvement with reciprical changes, verifying such. The patient as well is demonstrating normotensive and even slightly possibly hemodynamically challenged if placed with dilating properties.


Why wait, why not rendezvous with the ALS Unit? Meet them, this will cut down transport time and at the same time the patient will receive the required ALS.

Truthfully, one of the best interventional therapy might be fluids, as Right Sided Infarcts respond to fluid therapy.

R/r911

 

[KEVD18]

Here is an ECG of one I did the other night.
**************55y/o m, supine on floor. pale, cool, clammy, weak. Had been sitting in a chair talking with his friend when he had a sudden onset of c/p and sob.**********
He said it came in waves and the pain was severe. His friend helped him lay down on the floor.
HR 80 - 90
B/P 108/80
RR 20 - 24
B/S clear bilaterly
Allergies to rubbing alcohol, bees and shellfish
No previous cardiac hx
only chronic back pain
Hernia operation a month ago for which he takes tylenol 3s with codeine
Pt given O2 via n/c @ 4L/min, ASA160mg PO, 4 lead ECG obtained then 12 lead.
Somewhere in there ALS backup was called
Its a 20 min drive to the hosp. and we had to put him into a stair chair to get him out of the 2nd floor apt.

I'm not yet allowed to start a line,(until I finish ACP school), I am allowed to give nitro. ALS will take at least 15 min to get to me.
So to give or not. Should I make this pt wait for ALS? Your thoughts please.

i would hope the "somewhere in there als was called" took place between the stars.....

 

[bonedog]

Nitro is a relative if not absolute contra-indication with this pt. Rid is bang on....

It is good to realize that nitro is purely for pain relief for these patients and the vasoactive properties make it extremely dangerous especially with RMI.

Personally I don't prescribe to protocols that lead to more protocols.... especially ones that may end with the patient going in the coroner's wagon.

 

[Outbac1]

I called for ALS early in my assessment.

The pt was having pain that came and went in "waves". Waves were his description. Every time one came it was described as severe. He wouldn't or couldn't give me a number on a scale.

I didn't wait. I finished my assessment and we moved him to a stair chair and headed for the truck. While moving him he had another "wave" of pain. So I took the chance and gave him 1 x 0.4mg nitro SL. The pain went away, but maybe it would have left anyway. When I checked his pressure a minute or so later it was actually up to 118/88. As we got out of the apt. bldg. our ALS arrived. We quickly got him in the truck and headed for the hosp. A line was started and NS hung. Enroute he was given 2 more nitro sprays and morphine was drawn up but not given. 15 minutes after arrival at the ER he was given TNK and moved up to the ICU. Our nearest cath lab is 2 hours away.

His door to drug time was about two hrs. Not too bad considering he waited to call for 45 min and there was 40 mins of travel time involved, and a prolonged extrication.

Next year we are supposed to have TNK on the trucks for this type of call. It will be given in the field by ACPs with online consultation.
Part of me is excited as I should have my ACP tag by then, and part of me wants to stock up on diapers.

As of yesterday pm he was still in ICU and has had no more pain.

Just looking for your thoughts and input on this call. I know everyone would probably run the call a little differently, and everyone has different protocols to live by. I feel by sharing some of our calls everyone has a chance to learn something from each other. Thus the purpose of the forum.
Thanks to all for your input.

 

[Melbourne MICA]

Nasty

Nasty

Inferior with antero-septal ischaemia, maybe posterior and q's and small ST rise in laterals suggestive they might be suffering as well. Nitro aint gonna do much for this man except screw around with his coronary artery/myocardial perfusion.

Morph, fluid, aspirin, Ts - expect arrhythmias esp bradys, a BP dump > CG Shock, have some Epi and Atropine ready and be nice to the man.

Early Ts was a good option.
MM

 

[FLAEMT22]

always IV

You need an IV before you give nitro. I don't care how high the B/P is. You don't want to have that one patient that has a reaction to the nitro and bottoms out on you. Better to be prepared for the worst.

 

[remote_medic]

IV first, then nitro. No ifs/ands/or butts.

Now I'm going to contradict myself...If IV access is not available I would consider giving Nitro if the patient has been perscribed it and uses it on a semi-regular basis. If my patient crumps I can quickly gain central access using the IO drill.

My opinion and my opinion only

 

[rhan101277]

Sorry to drudge up, but didn't want to create a new one.

I am starting at a service that only had 3 lead capability. I can use modified chest lead to get a better picture. Even if I had 12 lead capability an inferior infarct can still be right or left involved or both. I will always start an IV even if pressure is within limits. We were always taught that you can kill a pt. by giving them nitro if its right sided, due to decreased preload, which is going to effect how much blood the heart receives for itself.

Every area except lateral can include right ventricle correct?

 

[MrBrown]

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?