chest pain bad, nitrates good

[paramatt_]

I recently attended an 89 year old patient in bed at home presenting with palpitations with associated with chest discomfort. The onset of symptoms woke him up.

History of bypass surgery some 20+ years prior, AF, hypertension. Had once instance of rapid AF about a year prior that was medically managed. Recently well and reasonably healthy otherwise

Meds were metoprolol, a dihydropyridine ca channel blocker, and was warfarinized. Also had a nitrate spray that was “hardly ever used”

ECG showed rapid AF (ventricular rate between 130-160), hemodynamically stable and well perfused…initial SBP was 160 or so, GCS 15, no evidence of failure/pulmonary oedema, etc etc.

My partner, who was treating, began treating the patient with nitrates as he had chest pain. Aside from dropping his blood pressure over the next to 10-15 minutes, he still remained adequately perfused. The pain marginally decreased.

The obvious concern was that he was at risk of losing his pre-load and was in obvious need of some rate control, but what really surprised me was that the hospital emerg staff continued the nitrate regime.

It never fails to amaze me how the chest pain = nitrate mentality is so strongly engrained into the mind of so many health care workers, both EMSers and non, that it’s almost primeval. I’ve lost count how many times I’ve attended a doctor surgery for a chest pain patient who has received nitrates but no aspirin. More worrying is that one of the most dangerous drugs we carry (in my opinion) can be administered by someone with 115hrs training and is host of a whole cascade of adverse reactions, whilst anti-platelet agents which have a proven benefit in ACS are not in the basic scope.

Note: I work in an upsidedown non-US system with volunteers that can give aspirin but not nitriates

I don’t want to turn this into a ALS vs BLS medication discussion, but just felt like ranting a bit on the topic. Other observations are most welcome

[HarryM]

I personally feel (and I haven't actually done any research on this, it's just observations of both ambulance and hospital staff) that the treatment of chest pain has not had a whole lot of really good research done on it until very recently. Which is why there is still a widespread mindset of chestpain = nitrates. It's really only recently for example that we introduced a requirement whereby GTN can only be administered to a chestpain patient with a HR between 40-150. And pre-hospitally, we have only in the past couple of years started pushing the maxim of checking for right sided involvement on a 12-lead before giving GTN.

We have for example stopped giving O2 to chest pain patients and now give amiodarone and adenosine so we have moved forward. But on the whole, we still manage the majority of chest pain patients with GTN, aspirin and morphine, and have done so for a number of years without really any changes. So maybe its time so research was done on whether this is still the golden standard of chest pain management?

[ERDoc]

I don't know where the OP works, but aspirin is pretty much standard of care for cardiac chest pain. Sometimes I think it is given too much without thought. It's probably not the best idea to give it to someone who you think has a disection/aneurysm. I do agree that nitro is given way too much, but this I mostly see from the prehospital providers and the nurses working off their protocols in the department.

I definitely agree that given the original scenario, nitro is not the correct treatment. The chest pain is most likely from the heart that is running a marathon. Slow the rate down first and see what happens.

[Curiosity]

The rate may very well be the reason for the pain. What do you have on board that will control rate of a hemodynamically stable Afib pt? What cause cardiac pain? What does nitro do? Do you think the patient will benefit from nitro providing he/she remains hemodynamically stable until he/she can get the meds needed to definitively end this pain? Did your patients pain decrease after nitro administration?

[Kiwiology]

I wonder if this bloke works in Western Australia? There are no other Australian states that use volunteers to my knowledge and here in New Zed an Emergency Medical Technician can give both aspirin and GTN whereas an Ambulance Assistant (First Responder) can give neither so that counts him being a Kiwi out.

I am just about the dumbest motherfucker out there, I mean seriously I had to be shown how to turn on the oxygen and reminded that while ceftriaxone and vecuronium are both powder for resonstitution that you cannot get the two mixed up cos if you do that the bloke with an infection will stop talking and turn awful blue and you will get a finger wagging form the boss ... anyway, if me, the stupidest bastard to ever set foot on the big white van, can figure out the GTN is for myocardial ischaemia (angina) and the primary treatment in AF is rate control doesn't that mean that the rest of you blokes should be able to figure it out?

GTN is a good idea in patients with exertional angina or cardiogenic pulmonary edema. I am not so sure GTN has a role in STEMI or acute myocardial infarction but this remains to be borne out by any evidence; right now it is just a feeling ....

Carry on.

[georgethomas1960]

So 30 yrs in ems and vol fire...16 yrs as a paramedic....found that a good assessment...and ACS and chest pains...considering your BLS and ALS protocols.....keep it simple....baseline v/s telemetry.12 lead high flow oxygen. Aspirin nitro titrate to blood pressure and morphine ....rapid transport if necessary....confidence in your ability and calming bedside smile......thinking ......what would i do for my own family member...thanks

[Kaisu]

I ran into a similar situation with a bradycardic patient who's BP was so low the automatic cuff didn't register it. The first responders on scene were in a dither because they couldn't get a large bore IV, their intention being to support the BP with a shit ton of fluid. They looked at me non-plussed when I insisted a small cath, which I obtained in 3 minutes, was plenty large enough to administer meds.

Fix the rate first dummies... it ain't rocket science.

PS.. for those that are interested, the rate was 37 to 40 afib. Patient had a new prescription for a CA channel blocker after a previous day's admission to the ER for uncontrolled afib (afib RVR for medics here in the wild wild west). Slow push of calcium chloride fixed her right up.

[Kiwiology]

So 30 yrs in ems and vol fire...16 yrs as a paramedic....found that a good assessment...and ACS and chest pains...considering your BLS and ALS protocols.....keep it simple....baseline v/s telemetry.12 lead high flow oxygen. Aspirin nitro titrate to blood pressure and morphine ....rapid transport if necessary....confidence in your ability and calming bedside smile......thinking ......what would i do for my own family member...thanks

um ... telemetery? high flow oxygen? rapid transport? supreme fail much?

[ERDoc]

Easy Kiwi, he's new here and he may be from NY or NJ. He can only do what is system allows him. Give him a chance.

[Kiwiology]

Easy Kiwi, he's new here and he may be from NY or NJ. He can only do what is system allows him. Give him a chance.

You didn't give me a chance, you called security on me after I got into a fight with the Surgical Registrar because he was turfing the patient back to Medical because "he didn't need an operation".

I wouldn't want any of my family with chest pain to get high flow oxygen, even if it was in a protocol, not sure about this bloke