Nitro before IV

[medic_chick87]

I love seeing the ones that say "their BP was high enough". These are the ones that have never seen a pt with a bp of 170/100 drop to 70/40, after one NTG dose. You have now made the heart work twice as hard, while it is infarcting.

There is a reason why they teach IV first. As Rid stated, you also want a 12 lead before any meds. That way, if the NTG resolved the problem the Dr. can see what was going
on.

If a pt takes their own NTG, they know the risks. We are there to help,not harm.

Well Reaper, you wouldn’t like me too much I'm afraid 'cause I'm one of those who will give the nitro if there BP is high enough. Have yet to have one bottom out on me. But I'm still a newbie.^_^

This is how I usually run it. Thorough assessment (r/o anxiety cp'er). Check BP and other vitals including basic ekg, if high enough one spray nitro. Depending on how severe pt presenting start line on scene or on-route (if fire hasnt already done it for me). Again, depending on pt presentation 12-lead on scene or on route. Continuing care of nitro every 5 and possible morphine if no pain relief if I havnt arrived at the hospital yet.

 

[Ridryder911]

Well Reaper, you wouldn’t like me too much I'm afraid 'cause I'm one of those who will give the nitro if there BP is high enough. Have yet to have one bottom out on me. But I'm still a newbie.^_^

This is how I usually run it. Thorough assessment (r/o anxiety cp'er). Check BP and other vitals including basic ekg, if high enough one spray nitro. Depending on how severe pt presenting start line on scene or on-route (if fire hasnt already done it for me). Again, depending on pt presentation 12-lead on scene or on route. Continuing care of nitro every 5 and possible morphine if no pain relief if I havnt arrived at the hospital yet.

Just because your a newbie is NO excuse. Go back and learn cardiology! Good grief NTG before a twelve lead and maybe an IV? How good are the 12 leads, while enroute? Are you really serious? Like increasing your patients infarct size or just watching them die as they attempt to increase the preload?

I bet you probably give NTG for those in BBB as well? Did you know that if the BBB is wider than 170ms, the patient probably has a poor left ventricular effectiveness? The ejection fraction is going to be reduced and administering NTG can be dangerous?

A patient with a bifascicular block (LBB or RBB w/hemiblock) drugs such as Morphine, lidocaine, procainamide will slow conduction through the ventricles resulting in drug induced heart block, or possibly, ventricular asystole.

Your new.. read more than the initial text. Yes, what and how we do it matters!

 

[TNemt975]

The protocols where I work say 1 NTG allowed prior to IV access, however most of the people here have IV access prior to NTG. In 4 years of working on a truck I have had one pt code on me because no line was established. Granted that was within the first six months of working on a truck and the pt is alive and doing well (4 MIs later), but that is a pretty crappy feeling that can easily be avoided.

 

[ILemt]

Protocol in my area:
BLS
- Oral dose of Asprin (81mg tab)
- Oxygen (6lpm via n/c or 12lpm via NRB )
- If pt has nitro, may assist pt with administration
If pt does NOT have nitro:
- EMT may contact ER to request 1 nitro tab via EMS supply
taking vitals before and after


I/ALS
- Asprin -as above
- Oxygen - as above
-Start line 18/20 gauge to 500ml bag of NS
- Hook up pt to EKG (also does o2 sat and B/P )
- One nitro tablet
- If no change @ 5 minutes administer 2nd nitro
- Contact ER for further

 

[Ridryder911]

Personally, I prefer to treat my patients not my protocols or even the monitor. One of the reasons I will never will work for a "cook book" type of treatment service. Hence, a more detailed assessment and having the knowledge of what is good and bad for the patient. Discussing with the medical director the problems of the written protocols and how they should be changed if wrong.


Just because they have M.D. after their name does not mean they know what is best. As in protocols some may not realize exactly what each step was or how it is performed. Many will review and with a little research will change them to current standards.

R/r 911

 

[EMT-P633]

Personally, I prefer to treat my patients not my protocols or even the monitor. One of the reasons I will never will work for a "cook book" type of treatment service. Hence, a more detailed assessment and having the knowledge of what is good and bad for the patient. Discussing with the medical director the problems of the written protocols and how they should be changed if wrong.


Just because they have M.D. after their name does not mean they know what is best. As in protocols some may not realize exactly what each step was or how it is performed. Many will review and with a little research will change them to current standards.

R/r 911

Hey R/r, was wondering if you would be willing to come to my service and give us a REAL ACLS / cardiology inservice? We seam to have just that problem. too many are treating protocols / monitors, and not the patients.

 

[knxemt1983]

Whats everyone's take on the question.When dealing with chest pain,Do you always start a line before giving nitro SL.I've seen it both ways.I prefer to start one but would like to hear some other schools of thought.

depends on teh situation, our protocols allow us to admin 1 NTG prior to an IV, but I do my best to have a line in place just in case it bottoms the B/P. Many times I will have my partner getting it ready while I start the line or vice versa. Of course 12 lead first, and the b/p must be of adequate level

 

[EMT-P633]

in all seriousness, I agree with R/r 12-lead, IV and complete assessment prior to nitro. However in my neck of the woods. my particular service does not have 12-lead capabilities. Our director feels that performing 12-leads in the field is a complete waiste of time. Says that since the MD's wont even look at them so why have them on the monitors? We have the E series Zoll monitors, fully capable of the 12-lead, but ours are set up for a 3 lead / defib pads only. (yes BP and SaO2 is there as well).

 

[el Murpharino]

By director do you mean your medical director doesn't want you performing 12-leads? Are you still authorized to use them for your own benefit, even though, according to your director, the doctors won't look at the 12-leads and is a waste of time? Your director is truly doing a disservice to the EMS providers and their patients by having this attitude.

 

[Ridryder911]

in all seriousness, I agree with R/r 12-lead, IV and complete assessment prior to nitro. However in my neck of the woods. my particular service does not have 12-lead capabilities. Our director feels that performing 12-leads in the field is a complete waiste of time. Says that since the MD's wont even look at them so why have them on the monitors? We have the E series Zoll monitors, fully capable of the 12-lead, but ours are set up for a 3 lead / defib pads only. (yes BP and SaO2 is there as well).

Might want to suggest not performing them increases liability for litigation. It is the National Standard and has been for a while. It does not not matter if your M.D.'s look at them or not, yes it matters the treatment is NOT always the same!

My EMS Director had the same opinion until we had a 25 year old with a STEMI that could not be seen in the three leads. I also added the final statement...: I would continue to argue that we need twelve leads, but it is obvious you know nothing about cardiology, or we would not be having this discussion".....

You might go to Physio site, they have testimonies as well as references form AHA, etc..

Good luck,

R/r911

 

[Melbourne MICA]

Just because your a newbie is NO Good grief NTG before a twelve lead and maybe an IV? How good are the 12 leads, while enroute? Are you really serious? Like increasing your patients infarct size or just watching them die as they attempt to increase the preload?

Are you advocating that nobody gets nitrates from EMS unless you have a 12lead at hand or if they present with a BBB even those already prescribed them by their cardiologist?

MM

 

[Melbourne MICA]

My EMS Director had the same opinion until we had a 25 year old with a STEMI that could not be seen in the three leads. IR/r911

Are you saying that you cannot identify any ckincial ECG markers of STEMI in a 3lead? And what was the clinical presentation of the patient?

A 25yo infarct would have statistical odds of what? - about 1 in 250000?

MM

 

[Melbourne MICA]

In practical terms and used in accordance with protocols nitrates have proven efficacy. I haven't seen a guideline yet nor any drug manufacturers explanatory notes or PPGuide that lists BBB or 12lead analysis as either a precaution or contraindication for the admin of GTN to the angina?ACS/chest pain pt with ischaemic pain?

MM

 

[Jon]

Are you saying that you cannot identify any ckincial ECG markers of STEMI in a 3lead? And what was the clinical presentation of the patient?

A 25yo infarct would have statistical odds of what? - about 1 in 250000?

MM

Can you?

Sometimes you can see ST elevation in 3 leads... sometimes you can't, right? Remember how Dubin characterizes a 3 lead vs. a 12 lead? Like looking at 3 sides of a car, rather than walking all around it? Can you perhaps not see small amounts of damage with just 3 views?

12 lead has really become the accepted standard. And the cardiology folks WANT STEMI door-to-balloon time to drop. There are many factors that make that happen... but diagnosis of STEMI prior to ED arrival is a HUGE factor to decrease the time.

The only factor, nationally, that decreases average times more is to have a cardiac surgeon onsite 24x7 - which doesn't happen at anything other than huge teaching hospitals.

 

[Melbourne MICA]

STEMI on 3 lead

Can you?

Sometimes you can see ST elevation in 3 leads... sometimes you can't, right? Remember how Dubin characterizes a 3 lead vs. a 12 lead? Like looking at 3 sides of a car, rather than walking all around it? Can you perhaps not see small amounts of damage with just 3 views?

12 lead has really become the accepted standard. And the cardiology folks WANT STEMI door-to-balloon time to drop. There are many factors that make that happen... but diagnosis of STEMI prior to ED arrival is a HUGE factor to decrease the time.

The only factor, nationally, that decreases average times more is to have a cardiac surgeon onsite 24x7 - which doesn't happen at anything other than huge teaching hospitals.

Your'e right to a certain extent - 3lead gives us only partial view of the picture. Sometimes the changes are apparent straight up.

The most obvious example of suspected AMI on 3 lead analysis being ST elevation in leads two and three - the inferior. Most Paramedics would have come across this in at one time or another. Alternatively clinically significant ST depression (reciprocal ischaemia) in any of the limb leads should lead you to include an anterior infarct in your suspicions. Thus noting ST elevation is not the only way to to arrive at a differential diagnosis of infarct.

Lets not forget that "diagnosis" of infarct is made on the basis on three elements and requires at least two of those three to confirm diagnosis and invoke treatment protocols in the ED along those lines. (Though biomarkers now dominate diagnosis with Troponin rises being very sensitive and specific to demonstrating an acute event).

They are: 1. clinical history/presentation i.e. the pts story with S&S attached
2. 12 lead ECG changes. 3. abnormal Bio-chemical markers eg Troponin rises.

Now you could argue technically that with clinical history plus a twelve lead in the filed you can "diagnose" AMI. Having a 12lead in the field is definately a plus - provided the following don't mitigate its effectiveness in the process.

1. The operator is skilled at interpretation. Training, experience etc come in here. It's a pretty good idea to know, for example, the effect a LBBB or anterior hemi block will have your interpretation of AMI.
2. There is the time and practical circumstances to do a thorough analysis - try and do a good 12lead when the pt is throwing up big time as is common in the hypotensive inferior pt.
3. The patient isn't crashing in front of you necessitating a focus on treatment. Inferiors are classically unstable in the field with brady arrhythmia's, hypotension, severe pain etc. Anterior infarcts may cause PO as the LV fails requiring respiratory support.

Typically our most effective tool is clinically suggestive S&S. AMI is more often than not a catastrphic event with profound symptomology. We've all seen them - diaphoretic+++, acute pain++, rhythm disturbance, perfusion changes, anxiety++, SOB etc. (Of course they can also be subtle).

(And lets not forget about non STEMI's - 12lead useful in that?)

In the end the trick is to join up all the dots and recognise that even a singular piece of the pts story may alert you to AMI. For the ALS operator experience is definately a plus. As we all know S&S can be tricky, subtle or confusing.

For example, only recently I had an elderly man with no prior cardiac HX, who presented with severe, sudden onset central chest pain at rest whilst showering. He stated he felt particularly unwell, was frightened by the event and now felt nauseated. The pain apparently changed with deep inspiration.

His 3lead showed a mild sinus tachy. BP was normal. He was pale and "sweaty".

The BLS crew didn't join the dots. They were misdirected because his pain changed with breathing. 15% of AMI pts present to the ED with pain variability on inspiration. But the crew didn't know this, saw a normal ECG and differentiated the wrong way. They also assumed he was "sweaty" because he had just come out of the shower! Oops!!

For me the clue was the sudden onset at rest, the pts sense of impending doom and his description of the pain.

We did just 2 MCL's using our 3lead - 1 and 2 (V1&V2) - tombstones.

The point is I guess that the clinical assessment was useful in and of itself. The ECG tool was another dot joined (a very necessary one no doubt).

I'm not advocating that 12lead is superfluous -indeed it is not. But like so many things we do in the field components of any event create an index of suspicion that we must act upon. Spinal is another example - you know mechanism of the accident etc.

We don't have the time, the tools or the luxury of ED level analysis. !2 lead is an effective tool absolutely. But its also being adopted in the field for very specific reasons. Not just to diagnose AMI but to alert the cathlab/cardiologist to the type. This enables services to be used efficiently and maximally. Throbolysis or plasty. This is also why telemetry is also being added in the truck. With confirmation from both ends we can then introduce treatment even faster - say like throbolysing the pt in the ambulance.

Monitorisis is the way one of my old lecturers called it. Getting transfixed by the screen. I personally think we need to be very careful about getting preoccupied with electronic tools to the detriment of our skills as clinicians.

3lead - works for most pts - MCL's a nice little extra. 12 lead - even better but needs great care.

12lead will be the accepted standard I have no doubt -for equipment that is. But we operators need to be up to scratch to make it trully effective.

Incidentally MICA in Melbourne started out in 1973 as in field cardiac care. We are only just getting 12 leads. (hey - its aussie land - things go a bit slower here because of the gravity). Our time to balloon is worlds best practice.

(You have let us brag about something because we've only ever beaten you at the Americas cup and Michael Phelps didn't share very well with all those gold medals now did he?).

Cheers
MM

 

[FFMedic1911]

Thanks for all that replied.I would like to add one more question to the mix.I've noticed some have replied that sometimes they would and sometimes would not give nitro to a right side MI.So to those that have stated this if you have two pts. both with right sided MI what would be the deciding factor on who would get it and who would not.If you say clinical finding what are they.
PS sorry if this isnt typed properly am tired and goin to bed.Good night

 

[JPINFV]

Now I'll admit that I'm not a paramedic and that I don't have all that fancy applied education, but I have been trolling a few EMS forums for a few years and have picked up a few things. Wouldn't one of the problems with using a 3 lead to infer ECG abnormalities be that a 3-lead isn't as sensitive as a 12 lead and will show exagerated differences? (Can I get CMEs for reading EMTlife and EMTcity?)

 

[Melbourne MICA]

Now I'll admit that I'm not a paramedic and that I don't have all that fancy applied education, but I have been trolling a few EMS forums for a few years and have picked up a few things. Wouldn't one of the problems with using a 3 lead to infer ECG abnormalities be that a 3-lead isn't as sensitive as a 12 lead and will show exagerated differences? (Can I get CMEs for reading EMTlife and EMTcity?)

It's a good point and it would depend on the monitor. Low voltage monitors are notorious for lack of senitivity. 2 or more squares of ST elevation is clinically significant and this may be misrepresented on some monitors whether with 3 lead capacity or twelve lead.

Our old HP's, the Zoll's and even our newer Philips MRX's can give false displays of elevation. Readings may or may not also be affected by dot placment. All electronic tools have their idiosyncracies.

Its the combination of history, clinical findings, S&S and pattern recognition (of the segment rises and other ECG indicators) that matters. For example, if your pt is fit as a fiddle with no symptoms but has gross ST rises its likely to be either a relatively benign dysrhythmmia like anterior hemi block or a monitor testing you out.

In the way of treatment, planning and your sense of urgency not much will change (with the exception of giving GTN and fluids) whether you analyse inferior, anterior, antero-septal, antero- lateral MI or whatever.

You end up managing perfusion, rhythm disturbance and respiratory state like you would with any other patient.

Then you direct your aim at the appropriate receiving facility with a cathlab or good cardiac unit. And what's on the 12lead will matter to them more than us.

Now when we get pre-hospital thrombolysis this will be a different story!

MM

 

[Melbourne MICA]

Thanks for all that replied.I would like to add one more question to the mix.I've noticed some have replied that sometimes they would and sometimes would not give nitro to a right side MI.So to those that have stated this if you have two pts. both with right sided MI what would be the deciding factor on who would get it and who would not.If you say clinical finding what are they.
PS sorry if this isnt typed properly am tired and goin to bed.Good night

Any pt with RV or RA wall MI (R coronary artery structures incl posterior) will likely lose preload and/ or have significant rhythm disturbance such as brady arrhythmias. If you're lucky enough to have a good BP protect it. Don't dump it with GTN. Filling the R side of the heart with fluids or using inotropes to bolster BP and improve CO (and hence coronary artery filling pressures) is now the standard thinking.

GTN's benfits on collateral circulation and reducing injury spread are too marginal and limited and the side effects too potentially destructive to treat a R sided MI with it. Like trauma the definitive care for our infarct patients is in the hospital not the ambulance.

Having said this some cardiologists will try to exploit any benefits from any drugs including giving GTN if available but typically they want a healthy BP before even they drop it. The difference for them is that the pt is just minutes away from the table and they have far more tools to manage cardiac problems than we do.

MM

 

[EMT-P633]

Thanks R/r for the ammo and the advice, I will keep trying to do my best to get our service up to speed. it will be a long row to hoe so to speak........