Nitro before IV

[medic_chick87]

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

^_^ Thanks Melbourne. That's my line of thinking. That and I wonder what medics did for how many years before 12-lead? Hmm... maybe some Nitro. Didn’t really want to say anything though because I didn’t want to start anything. After all, I'm just a lowly medic, not a cardiologist.

 

[Ridryder911]

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

YES! Again NTG is prescribed for angina NOT an AMI. Cardiologist will (or should be) the first to recognize that the NTG was NEVER prescribed for an AMI or potential AMI. Patients are placed upon NTG at home again for angina not an AMI hence the reason of teaching the patient if NTG does not work notify EMS.

We for some reason presume that NTG is always "good thing" for all chest pain. Why would one want to administer a medication that could produce severe effects and even potential death, when obtaining a 12 lead should take less than 45 seconds to one minute?

As well one should NEVER blanket treatment any complaint solely based upon s/s alone, especially when one has diagnostic tools to aid to differentiate. Again, the old adage of if NTG works in a chest pain, it is probably not an AMI since most reperfussions are not corrected by NTG alone. Yes, it may allow or increase some blood flow but not enough alone to correct the problem.



R/r911

 

[Ridryder911]

^_^ Thanks Melbourne. That's my line of thinking. That and I wonder what medics did for how many years before 12-lead? Hmm... maybe some Nitro. Didn’t really want to say anything though because I didn’t want to start anything. After all, I'm just a lowly medic, not a cardiologist.

Unfortunately, many were ignorant of the problems as is it still prevalent. I used to perform multi-leads to rule out an inferior by moving my leads around. (Yes, it can be done on a three lead). Ignorance should NOT be tolerable.

After you have seen a patient go into cardiac arrest because a "lowly medic" administered NTG; I would believe your opinion would change. It happened and unfortunately continues to do so as we still encourage EMT's to administer NTG before a detailed exam can be performed.

R/r 911

 

[Melbourne MICA]

12lead

Absolutely we should always use our tools at hand. All meds have both effects and side effects - its a double edged sword. Monitoring is important, even vital, but its not 100% reliable. Sometimes it shows nothing when something exists. It's all up to the skill and "street smarts" of the user to join the dots.

GTN is no blanket therapy - never has been. Its reliable, proven and consistent. And its supposed to be used as part of a careful process of evaluation and Mx that now includes 12lead.

I would never give any type of medication without utilising all the assessment tools first.

Its all about "ACS" now, even for us, Whether you have angina or an acute MI the process is the same, lumen obstruction, its just a matter of degree and risk. We are now expected and trained (some might have a sly grin about that one), to make an attempt to subdivide our pts for direction to services.

Our role in EMS now is certainly more than just symptomatic management and I agree Rider, there is no "blanket" therapy approach that is appropriate. Its about directing the pt to the correct management services - basic pharmacological interventions and GP/cardiologist follow up, CAGS or infarct Mx. Some of our "angina" pts are even OK to stay at home. But their are limits, costs, bed availability, cath lab services availability, staffing issues etc tied into the process as well.

But in the end the EMS guy still has an obligation to treat (with care and prudence). Giving GTN is a standard adopted by all EMS services around the world and before services could afford EKG's or train grunts to work them it still had its place and a certain level of effectiveness without compromising too many pts. But we understand more now and the whole thing is coming together right from the pointy end of EMS to the cathlab table.

BLS types need to always be conservative and ready to bring in ALS types but one thing follows on from the other. They're not separate.

If you give GTN without having monitored the pt its just as bad as not having taken a BP, asked about contraindications/allergies or gotten a decent history. (or if you haven't bothered to look at your books for 3 years!)

Expect side effects to see you in the supervisors office fast if you adopt this approach!!!

MM

 

[Ridryder911]

Expect side effects to see you in the supervisors office fast if you adopt this approach!!!

MM

That's what I do.....

The point I am attempting to make is that patients are not nor should ever be blanketed treatment. Each case is as individual as the person. When we start educating (instead of training) medics, then and only then we will see a medical diagnosis should be made upon history, variable assessments and of course the tools that aid our assessments.

Unfortunately, the EMT (in the U.S.) does not have the required education nor even the training to go into differential diagnosis as only based upon s/s and tx. In which the system has used the "best of the two evils" instead of correctly resolving the problem. Especially in areas where the nearest ED maybe 1-2 hours away per ground or nearest cath lab is 3 hours. Even in some of our larger suburbs 24 hour cath is only a dream, as it is a costly adventure and if "they can make through the night"; we will attempt to cath in the morning!.

There is a far cry though of an AMI or even Prinz Metals Angina and the classic standard Angina caused by coronary occlusion, by which in all rights can and should be treated with standard NTG, even possibility of long lasting, high dose (aka: Nitrobid).

I do believe we agree, possibly miscommunication though on the system we have here. Basics blindly administering NTG as long as the patient is not hypotensive and yes no ACLS follow up for who knows when?

As a Acute Care Nurse Practitioner student, that makes rounds with Cardiologist, I can assure you that NO medicine is routinely blindly given. Would they agree, again if faced between the two evils..?

R/r 911

 

[Melbourne MICA]

That's what I do.....
Basics blindly administering NTG as long as the patient is not hypotensive and yes no ACLS follow up for who knows when? R/r 911

I get where you are coming from. Is it an issue of a perception - the imperative to provide some level of treatment in the public's mind? Perhaps a lack of technological tools. More likely as you say, it's a matter of available definitive services and cost/benefit issues plus practicalities like distance to ED.

But cardiac disease is so rampant. So you may end up needing a basketful of drugs and a hundred assessment toys to treat Pt's on a case by case basis. Facilitating that kind of approach - It's tough one.

Still we all must act with duty of care and empathy for our pt. It's someone else's husband, mother, grandfather we're sticking dangerous drugs in after all.

MM

 

[mycrofft]

Nurse Thumbfingers here. Yo?

As much as I have been learning and nodding at in these highpowered exchanges, (and I am getting some material I need at work, thanks very much), allow me to mention some stuff:

1. Over 70% of MI pt's present with sudden clinical death. ("Sudden" usually means the signs were not recognized by the pt or others). Pt hx then is nonextant. A lot of your "zebras" are going to be dead ones in the field situation, period, sorry, claim yor prize and hit the egress. Old saying: "In house: treat. Out-house: sheet".

2. Project the time needed to perform the evaluations and treatments on the spot, versus on the go, and the relative benefits as considered against transport time to a hospital. I have to frequently get my doctors to cut to the chase and get transport coming to us instead of becoming target fixated and holding off on initiating transport until the pt is "better", when in any event that pt will need a hospital. Multi-task, but get your intel (eval) first and ongoing. I think everyone does this, but in the heat of the forum it gets spun out.

3. In metropolitan areas ALS is available on most responses for this sort of call, no? But in rural areas, or in settings where medical personnel are present and expected to act but are not ALS (for instance, nursing homes or physical rehab facilities) in the immediate case you have to fall back on protocols based on the local realities. This is definitely a tiered situation and as long as one is not violating basic tenets of their level of eduation and practice they are doing "right". The answer is "competent ALS everywhere", but it is not going to happen and eventually still requires hospitalization.

Here's some chum for the scrum. What do you NOT like to see having been done for these pts before you get them at the ALS level? (Maybe that deserves its own thread....watch for it).

 

[MedicPrincess]

I guess my question for those that give the Nitro if the BP is "high enough" is What do you consider "High Enough?"

140/90? Even if they have a 25% drop they will still be at 105/... Is that high enough?

Where do you draw the line? Do you ask your patients if they have had Nitro and what kind of effect it had on them?

I think back to a pt I had whose initial BP was well over 190/ and he refused his third Nitro (at that time his BP was still above 140) because the 3 of the past 5 times he had Nitro, after the third one he ended up in Cardiac Arrest. Being one of our "Snow Birds" he had his medical records with him, and he wasn't mistaken.

So whats considered "High Enough" to give your nitro without a backup plan in place?

 

[EMT-P633]

So whats considered "High Enough" to give your nitro without a backup plan in place?

In my opinion there is no "high enough" to admin nitro with out a back up in place.

 

[mycrofft]

And of course MAP...

Is 140/90 high enough with a pulse of 130/min, or 120/66 with 75/min?
This discussion (and thanks to everyone) has made me upset with my coworkers and medical director. This means (more) war.

 

[marineman]

Looking at it strictly as an EMT-B according to the registry anything over 90 is technically high enough. Now I'll be the first to admit that much of the information in this thread was miles over my head as we haven't hit on cardiology yet but from what I've understood it sounds like it's not the actual end number of the BP that's truely important it's how far it dropped. Say you had a patient go from 180 systolic to 110 systolic vs a patient at 90 systolic dropped to 75 systolic I think the first one is what we're worrying about. That second patient under our protocols wouldn't qualify for a second dose where the first patient technically would but I think I'd make use of the peddle on the right and let the doc give that second dose to either one.

 

[mycrofft]

marineman, how they taught me in emt-Amb to remember it, as rule of thumb...

(Ah, yes, Professor Quartz at old Bedrock U)...
Beware when the heart is working too hard for the BP you get (pulse rate higher than you would generally expect for a given BP). Something's gotta give. Especially so when the rate is irregular (and an irregular rate will throw off some automatic BP machines....did I mention those things? Sorry).

 

[Melbourne MICA]

Looking at it strictly as an EMT-B according to the registry anything over 90 is technically high enough. Now I'll be the first to admit that much of the information in this thread was miles over my head as we haven't hit on cardiology yet but from what I've understood it sounds like it's not the actual end number of the BP that's truely important it's how far it dropped. Say you had a patient go from 180 systolic to 110 systolic vs a patient at 90 systolic dropped to 75 systolic I think the first one is what we're worrying about. That second patient under our protocols wouldn't qualify for a second dose where the first patient technically would but I think I'd make use of the peddle on the right and let the doc give that second dose to either one.

Don't get hung up on BP. The most important things to realise are these.

What is GTN and how does it work? How does GTN fit into the scheme of things for the cardiac pt? Where does GTN fit into your protocol for the management of cardiac chest pain/ACS?

Learn the drug sheet and follow the guidelines on its use. Realise it is a powerful, potentially dangerous drug but is versatile and effective as well.

Also realise that ALL drugs have effects (benefits or uses as a tool to achieve a specific goal) and side effects (concurrent undesireable or counter-productive effects). And on occasion we may exploit either of these things to achieve a goal.

But remember that these chemicals are tools we use, are usually very specific and have limited uses. They are also tested, checked for safety using many medical studies, and distributed for use to various health professsionals (including us) to be used after careful consideration of their benefits to the most number of people the maximum amount of times possible.

But they are neither foolproof nor 100% reliable because everybody is different. No two people have identical medical problems.

So when you pull out your nitro spray or tablet remember that it is a dumb chemical and once it's in, it's in. There is no Naloxone for GTN.

So gather information - as much as you can given the circumstances - use your 12lead, check contraindications AND precautions. Know the onset times and duration of effect. And above all talk to the patient - they know their own condition better than anyone.

If you do all these things but still have doubts or uncertainties you still have several options. Give less than the prescribed dose. Give none and look for alternatives - if its pain and GTN is a worry and you can give Morph then think about it. Check your partner, check your medical controller. If in doubt -transport is still treatment. Give the O2, give the aspirin, rest the patient.
If they are sick call for backup.

Nobody expects you to be a cardiologist but you must still act prudently and with judgement and common sense.

If you are giving an 80yo woman with a Hx of IHD AMI/angina, hypertension etc and she has cardiac pain with a BP of 105sys and a HR of 120/min, (marginal perfusion numbers), a drug that works by dropping preload and after load - blood pressure going in and going out, what do you think will happen and what must you do?

Work the problem - respect the patient.

It all about the margin for error that you have before you. Thats right - its a numbers game. Always stack the odds in favour of the patient.

MM

 

[Ridryder911]

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

 

[MedicMonty]

No 12 Lead, now what?

Another tip for those of us that don't always have 12-Lead available: it IS possible to run Modified Chest Leads, which give similar views of the heart as the precordial leads. Therefore it is also possible to run RIGHT-sided precordial leads (if you're in a hurry, MCL4R is the most useful), which should tip you off to a Right Ventricular Infarct. You should use a machine capable of diagnostic-quality tracings, if available, but any machine capable of a 3 lead tracing can give you these views. It's actually not that difficult, just be sure you know what you're looking at.

To do this, place the positive and ground electrodes (white and black) in their usual positions for lead II, and set the monitor to Lead III. Then, you can quickly place the positive (red) lead in position to view any left- or right-sided precordial lead you like, MCL1-MCL6 or the same leads on the right side.

Again, the disclaimer here is that you know the limitations of what you're looking at:
-it will NOT be as accurate as a true 12-Lead. You cannot call these tracings "V1" - they should be labelled as MCL1
-unless you're using a machine that's capable of diagnostic quality tracings, you will miss some subtle things. You may only see ST elevation when it's huge, or you may miss small q waves, etc. In that case, it may be possible to rule "in" and RVI, but it is even more difficult to rule it "out"

For a better discussion (and instructions on how to get a LP10 into "diagnostic" quality mode), see:
http://www.flightweb.com/forums/index.php?showtopic=1973&st=0

Hope this helps. Be safe!

NJM

 

[rhan101277]

This is difficult for me to understand. Why won't they give us what equipment/training we need to save lives? If its money related get some tax dollars. I mean this doesn't make since. It is like you know what needs to be done but your hands are tied. The 3-lead that is on our ambulance, the resolution is low the paper that it prints out on, I don't see how folks interpret it. Seems like the 3-lead is a simple, do I have any electrical activity. I don't think you could tell whether the pt. was having a STEMI or a non-STEMI with those. Almost every pt. I saw rolled into the emergency room with SOB or chest pain had their blood sent up for testing. How come not have medics ready with some blood from the pt. for testing when they roll in w/ them. I mean medics can start a IV already, how hard is it to get a vial of blood? It just boggles my mind to see what EMS could be doing in regards to training/equipment.

It seems to me like the 3 leads we use on our ambulance are from the 80's, they are so clunky.

 

[JPINFV]

Why won't they give us what equipment/training we need to save lives?

... because you can't simply increase a 110 hour course by a few hours to justify more diagnostic and intervention tools.

 

[MedicPrincess]

This is difficult for me to understand. Why won't they give us what equipment/training we need to save lives? If its money related get some tax dollars.

It's not as simple as just getting some tax dollars. You have to put a proposal out. Try to educate the voters that you really really need that money and why. Counter act all the bad press because someone complains your crew is grabbing something to eat at some nast fast food place (Bk, McD, Wendys, etc) even though its 10 hours into their shift and they have hardly had time to pee let alone get something to et. Continue to try to educate people who can't write their own name, or won't put down their beer long enough to read the literature. Counteract some more bad press because one of your units was blocking up an intersection at 5pm rush hour while working a MVC with entrapment. And if your lucky on election day and actually get your 1/2cent sales tax, you then have to wait until NEXT tax year to get your money. Getting tax dollars is not like going to an ATM.

Almost every pt. I saw rolled into the emergency room with SOB or chest pain had their blood sent up for testing. How come not have medics ready with some blood from the pt. for testing when they roll in w/ them. I mean medics can start a IV already, how hard is it to get a vial of blood?

Whats the point of drawing blood? Hospitals in our area can't/won't/whatever use EMS blood. They claim liability. They can't be sure the blood isn't contaminated.

Heck, there's is one hospital that unless we are going to be potentially giving meds or fluids, we don't start the IV in the field anymore. No more courtesy IV's to save the ER staff time. That hosptial has a policy to pull ANY IV that is not started by one of their staff.

It seems to me like the 3 leads we use on our ambulance are from the 80's, they are so clunky.

What are you using? LP 10?

It just boggles my mind to see what EMS could be doing in regards to training/equipment.

Statement of the year, right there.

 

[rhan101277]

... because you can't simply increase a 110 hour course by a few hours to justify more diagnostic and intervention tools.

Maybe make the training more stringent for basics, make the course a two semester program. Mine is only one semester, Tuesdays and Thursday from 6-9.

I read the jems article where they are nationalizing the basics, going update the SOP where we can use pulse oximeter. Who knows how long this will take to happen.

 

[JPINFV]

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.