mo_medic Posted January 28, 2012 Posted January 28, 2012 Let me just start by saying it's not me that wants to treat htn with sl nitro. So we were doing pharmacology in critical care class this week and we had a couple of guys with significant experience sitting in for ceu's. When I say significant experience, I mean critical care guys that have been medics for quite some time, have worked flight here in the US and currently do contract stuff in the big desert for the government both air and ground ambulance. So at some point late in the day one of my regular classmates made what I consider a profoundly stupid statement about wishing her medical director would allow medics to treat htn with sl nitro. She's been a medic for 2 years and I just couldn't believe she would want to treat it with sl nitro. I was always taught in medic school (the same school she went to) that could make things worse and cause rebound htn. Well long story short ... that spurred a very long discussion about treating or not treating htn in the field with nitro. Including these critical care guys who just weren't getting why you wouldn't do this. What were you guys taught in medic and or critical care class? Also, does anyone know if maybe this was an acceptable treatment years ago?
JakeEMTP Posted January 28, 2012 Posted January 28, 2012 (edited) Years ago? Here is a link to the 2009 protocol (our current one) regarding Hypertension. http://www.ncems.org...ypertension.pdf Locally, we have Labetolol as an option for the treatment of HTN. Clearly though, it is in the protocol. I'm not necessarily a fan of it's use for HTN, but it does work. Just be sure to monitor closely. If I had to use nitro for HTN, I would prefer a drip. That way you can stop it. SL Nitro? Not so much. Edited January 28, 2012 by JakeEMTP
paramedicmike Posted January 28, 2012 Posted January 28, 2012 Yes. At one time SL GTN was taught as a treatment for a hypertensive crisis. The first service for whom I worked as a paramedic actually had it written in their protocols as treatment. That's the thing with medicine. Research is ongoing. Treatment modalities change based on the results of that research. It's one of the constants in medicine. Staying on top of the changes is also one of the things that makes medicine a challenge.
DwayneEMTP Posted January 28, 2012 Posted January 28, 2012 I've used it for HTN, and it worked great. This is the first that I've heard of it being a significant issue. What do you know about it rebounding? As I've gained experience the number of patients that I really want to treat for HTN has become really small... More common now, at least where Iv'e worked is Nitro paste...it's really easy, lay it down on your little ruler, monitor, scrape it off if you get more effect than you were looking for, etc. Intuitively I can see where the SL nitrates wouldn't give you a long term effect for HTNm but I'm having a hard time visualizing why it would create a significant rebound without relatively moderate/high doses over relatively extended periods...And I guess even then I'm not really seeing it... But I once thought that Santa was intuitively obvious...so there's that... Dwayne
chbare Posted January 28, 2012 Posted January 28, 2012 Do we have any business treating HTN in the field without solid evidence of end organ damage as a result of said HTN? 1
Bieber Posted January 28, 2012 Posted January 28, 2012 Chbare, not at all! But on occasion you do happen upon patients who are symptomatic with signs of end organ damage, though I'd have to be pretty sure they weren't having a CVA before I treated it. My only concern with nitro for hypertension is the risk of rebound hypertension after administration. Do any of you guys with experience using nitro for such have any comments on this? (Dwayne, it sounds like this hasn't been a problem for you at the doses typically given by EMS?) My service carries labetolol, though we're about to get rid of it. I'd like to have metoprolol, but it doesn't look like that's going to happen.
DFIB Posted January 28, 2012 Posted January 28, 2012 Do we have any business treating HTN in the field without solid evidence of end organ damage as a result of said HTN? I treated a lady with severe epistaxis once. She had lost approx. 500 - 800 ml of blood and her bp was 210/160. Would we consider the bleed to be evidence of end organ damage? Would treating her BP in the field be appropriate assuming i held the certs to do so? I would be afraid of her decompensating from a combination hypovolemia and vasodilation.
paramedicmike Posted January 28, 2012 Posted January 28, 2012 You then run the risk of hypoperfusion of her brain and the end organ damage that would come from hypoxia. It's a delicate balance that I don't think we in the field should attempt to moderate. 2
ERDoc Posted January 29, 2012 Posted January 29, 2012 I treated a lady with severe epistaxis once. She had lost approx. 500 - 800 ml of blood and her bp was 210/160. Would we consider the bleed to be evidence of end organ damage? Would treating her BP in the field be appropriate assuming i held the certs to do so? I would be afraid of her decompensating from a combination hypovolemia and vasodilation. That would not be considered end-organ damage. When we talk about end-organs, we mean the brain, heart and kidneys. I'm not a fan of SL ntg for htn. It causes a reflex tachycardia which can be just as bad as the htn. There are better choices, though you may not carry them. 2
DwayneEMTP Posted January 29, 2012 Posted January 29, 2012 ...though I'd have to be pretty sure they weren't having a CVA before I treated it... Yeah, one of the three patients that I've treated with Nitro was for a CVA. Slightly altered, bad headache, very flushed, BP through the roof, but I don't remember how high. I didn't call it in as it was obvious to me that the extreme BP was causing the headache and altered mentation, so shot her with nitro two or three times in succession. And she did seem to get much better, she 'seemed' to be mentating better (though of course having hoped for that result I my caliberation could have been askew), less flushed, claimed to feel much better. At the ER the doc asked why I had chosen that course, and I explained, in a really long winded way, that it was obvious the BP needed to come down, and obvious as well that she felt better, which meant obviously that I was a rockstar medic stud. Yeah, I know you already know the end of this story, but I didn't then. The doc explained that it was a CVA that was causing her pain, altered mentation, and yeah, driving her HTN. Not the other way around. He was as kind as he could be, but I couldn't have felt like a bigger douche...I was just so certain that I was right about that.... Anyway, when I got smart enough to look at HTN as a possible compensation to a pathologic event as well as a possible pathological even on it's own, or perhaps with it's cousins, (more or less), I've not since found a reason to treat HTN in the field. I'm just not really sure how you separate the HTN Yin from the HTN Yang in the field. Dwayne 1
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