Blood pressure based Nitro dosing system in CHF pts

[CoyoteMedic]

Hey folks,

A couple EMS areas I've worked in have had a blood pressure based nitro dosing system from CHF patients. For example, if someones pressure is 100-120, they'd get one 0.4mg dose, 120-200, two 0.4mg doses, 200 and above, three 0.4 mg doses, every five minutes, with a max of nine doses or a B/P of 100 systolic, and lasix only in extreme cases.

What I am looking for is any study documentation to a dosing system like this. I am trying to get the EMS agency that I am working in to take a new look at their CHF protocol, and hopefully modify it. As it currently stands, medication wise, you give one 0.4 mg of NTG, along with 40 mg of Lasix if the pt is not taking a diaeretic, or 80 mg if they are.

I'd love to add other medications like nitro paste, but all I have to work with is ntg and lasix due to local pollices with regards to medications.

If anyone knows of any case studies, could you link them to me?

Many thanks

[THEBEAR]

In my region we give 0.4mg ntg every 5 minutes as long as bp remains above 100 systolic. We can also add an inch of ntg paste as an alternative or in addition to ntg spray with the same bp requirements. Lasix is 40 mg or twice the Pt's single dose, up to 160 mg. We used to have morphine in the protcol but they took that out recently. I always thought the morpine really helped with the bad CHF'ers. We are now looking at adding C-PAP.

[Medic26]

The following is part of the PA state protocol on CHF:

Give nitroglycerin dose based upon blood pressure:

a. 3 SL tablets or sprays – for SBP > 180

b. 2 SL tablets or sprays – for SBP 140-180

c. 1 SL tablet or spray – for SBP 100-140

d. For patients on CPAP who do not tolerate SL NTG, may use 1 – 2 inches of topical

nitroglycerin paste, if available.

4. NTG may be repeated every 3-5 minutes as long as blood pressure is greater than 100 systolic.

[Note: One NTG repeated every 5 minutes is equivalent to a NTG infusion of 80 mcg/min]

For the complete protocol follow this link:

http://www.dsf.health.state.pa.us/health/l...ve_07-01-07.pdf

[akroeze]

Ours is very simple:

Nitro 0.8mg if you have a line and it's above 140 systolic

Nitro 0.4mg if you don't have a line and it's about 140 systolic or if you do have a line and it's above 100

Lasix 40mg-80mg IVP at medic's discretion for if they even give it.

[danielir]

NYC protocols:

SL nitro q5 max 3 doses(no nitrates if sbp<100 unless you have a line)

1-1.5 inches of nitropaste

20-80 of lasix

CPAP if your agency has it (most dont)

You can call the Doc for morphine (which can work pretty well)

By the way, I have seen many tubes avoided with the use of the CPAP. It really does wonders with the bad APE's. If your agency is considering it, support it, unless of course you wanna practice your RSI.

[AnthonyM83]

Under Resp. Dist. in upper left:

http://ladhs.org/ems/Manuals/policies/ref800/806-1.pdf

[ccmedic56]

ok..well the Docs these days are getting away from Lasix..period. There is a good use for it, but most will say no..or be very reluctant to authorize it..but the thing nowadays is BIPAP..which works wonders

[Novisen]

Nitro is the first choice of drug when you have AHF with CPAP and Morfin. CHF is treated with Nitro and Lasix. The best study I have seen is on this site: http://www.escardio.org/knowledge/guidelin...t.htm?hit=quick

[ARothenberg]

Our system eliminated Lasix in January based on studies that Lasix does not releave CHF in the acute setting, it works well over time, but not for the field. They also felt that too many medics were pushing Lasix on pneumonia pts because they heard crackles and did not realive that the pt had a feaver and was dehydrated which did not help that issue any.

Now we give 0.4mg NTG SL q. 3-5min w/ no dose limit while SBP is 100 or greater. We also perform 12-Lead ECG and start CPAP if they are alert and SpO2 is 95 or less. The CPAP works wonders for these pts, but we continue to give the NTG w/ the CPAP in order to decrease that preload which needs higher doses of NTG to occur.