Nitro is just symptom relief?

[NBPCP]

I hear this all the time, nitro is just for pain, there is no therapeutic value, it doesn't save lives.  Going back to first year anatomy, why wouldn't a medication that dilates the coronary arteries therefore increasing perfusion of the heart leading to less tissue necrosis, and ultimately less strain on the heart, not have a therapeutic value?

[Off Label]

Well even if it were just for pain, why is that not of therapeutic value? Pain causes distress which causes sympathetic discharge which causes, among other things hypertension and tachycardia which increases O2 demand and consumption in the circumstance of a pathologically impaired blood supply.

Beyond that, say for example, the NTG unloads the heart and causes a diastolic pressure of 100 to become 88. That is a direct positive effect on LV subendocardial perfusion. Will it be enough? Who knows? But that by definition is therapeutic. I'm sure you could think of other examples as well.

Do you really hear that all of the time? You gotta pick different people to hang around!

[NBPCP]

here are a few FAQ quotes from our medical director who is a physician, whose license we practice under.  Again this seems to be a reoccurring theme in correspondence from our governing body that less emphasis should be put on Nitro as it is merely symptom 'pain' relief drug...

Question: Are Advanced Care Paramedics expected to perform 15 Lead ECG’s in the field to

rule in/out RVI?

Answer: Not necessarily. Many variables may be present affecting any Paramedic’s ability to

complete certain tasks. The presence of an inferior STEMI alone is enough to support

withholding NTG.

REMEMBER: Nitroglycerin is a “Symptom Relief” drug….not a “Life Saving” drug. ASA is the only

medication in your arsenal that has been proven to improve survival from myocardial

infarctions.

Question: Really? PCPs shouldn’t patch with a BHP for patients with no previous use of

Nitroglycerin and no IV?

Answer: Yes. Again, NTG is a “Symptom Relief” medication only. The Medical Directives are clear

that if a patient does not meet the conditions they should not receive the medication or

treatment.

. 

[paramedicmike]

I don't see the problem with the Q&A as listed above.  It seems pretty straight forward.  In that light I'll have to ask what, exactly, are you wondering? 

[Off Label]

2 hours ago, NBPCP said:

here are a few FAQ quotes from our medical director who is a physician, whose license we practice under.  Again this seems to be a reoccurring theme in correspondence from our governing body that less emphasis should be put on Nitro as it is merely symptom 'pain' relief drug...

Question: Are Advanced Care Paramedics expected to perform 15 Lead ECG’s in the field to

rule in/out RVI?

Answer: Not necessarily. Many variables may be present affecting any Paramedic’s ability to

complete certain tasks. The presence of an inferior STEMI alone is enough to support

withholding NTG.

REMEMBER: Nitroglycerin is a “Symptom Relief” drug….not a “Life Saving” drug. ASA is the only

medication in your arsenal that has been proven to improve survival from myocardial

infarctions.

Question: Really? PCPs shouldn’t patch with a BHP for patients with no previous use of

Nitroglycerin and no IV?

Answer: Yes. Again, NTG is a “Symptom Relief” medication only. The Medical Directives are clear

that if a patient does not meet the conditions they should not receive the medication or

treatment.

. 

Understand that this is a very superficial context in which to view the use of NTG. Pre-hospital care is a microcosm and an entire universe of care exists beyond the ER. In a world of tight protocol and directives where  one size must fit all, as is  totally appropriate for the setting, NTG apparently cannot not be used to it's full potential (see my post above). 

Just know that it's use in the same patients that you transport for care in the ER for myocardial ischemia is far more multidimensional once that patient gets upstairs.

[NBPCP]

11 hours ago, paramedicmike said:

I don't see the problem with the Q&A as listed above.  It seems pretty straight forward.  In that light I'll have to ask what, exactly, are you wondering? 

basically does it increase prehospital survival rates like ASA?  My argument is yes it does, any drug that dilates the coronary vessels, increases cardiac perfusion and workload of the heart like OFF Load stated, should be given more importance than our governing body seems to be giving it.  Another reason why we can't give Nitro unless the BP is above 100 sys or the pt has prior use, even in light of studies have shown there to be little adverse reactions to administering Nitro to these patients, is because it is argued by some that it is not a life saving drug or that it has any therapeutic effects beyond pain control worthy enough to offset the small risk in these contraindicated patients.

Edited October 20, 2016 by NBPCP

[paramedicmike]

Does it increase prehospital survival rates?  What does the research show?  Go do some reading.  I think you'll be surprised.

Your argument is that it does.  Based on what research?  What you learned in anatomy and physiology?

You're upset about something.  The best I can tell from your posts so far is that it sounds like you're upset that your professional governing body and your medical director (you know, the folks who do research on these topics to develop evidence based treatment guidelines for the purpose of actually helping patients and not hurting them) are limiting field interventions within a subset of patients.

Perhaps a sit down with your medical director to review some of the literature would be more productive for you.

[NBPCP]

4 hours ago, paramedicmike said:

Does it increase prehospital survival rates?  What does the research show?  Go do some reading.

I have been.  Don't think online forums is might only source of information.

4 hours ago, paramedicmike said:

You're upset about something.

That's a little presumptuous, this is in response to a CBC national investigative report on the different levels of care you may get when you call 911.  Part of the debate focused on a patient who didn't receive Nitro because a Primary Care crew could not give Nitro, due to no prior hx by the pt and the crew not being IV certified.  So a number of us are asking, should Nitro be given more importance in prehospital settings and is this a shared theme across different EMS jurisdictions to downplay the efficacy of Nitro?  With your training, experience, do you think Nitro increases survival rates, in the 'microcosm' of prehospital emergency care?

[Off Label]

5 hours ago, NBPCP said:

  So a number of us are asking, should Nitro be given more importance in prehospital settings and is this a shared theme across different EMS jurisdictions to downplay the efficacy of Nitro?  With your training, experience, do you think Nitro increases survival rates, in the 'microcosm' of prehospital emergency care?

Since you put it that way, NTG should be used in appropriate patients in the appropriate setting by the appropriate personnel. It doesn't matter what anecdotal evidence anyone can offer...all anyone is able to go on are randomized controlled studies and meta-analyses that control for very specific variables so that some sort of coherent conclusion can be made. Even then, great caution has to be taken with the conclusions.

 

[paramedicmike]

I prefer to base my practice on evidence based medicine whenever possible.  Anecdote and experience do not equate to data.  If you have evidence that shows a clear and statistically significant benefit to preshopital nitroglycerin I'd be happy to consider it.  I'm sure your medical director, as well as your governing body, would be happy to consider it among all the other evidence they review when putting your treatment guidelines together.  As it stands, the current available evidence doesn't meet that.

That being said:

No.  Not every prehospital provider should be able to give NTG.  It is not a benign medication.  It can have some serious consequences if not used appropriately or if used by people who don't know what they're doing or why. 

No.  I don't think NTG should be given more importance prehospitally.  Not until a RCT demonstrates clear benefit to doing so. 

No.  I don't think the evidence supports a clear increase in survival rates in this microcosm of prehospital emergency care.

What's more I would caution against falling into a line of thinking that just because logically something *should* work means that it actually works in practice.

This could be a good chance to make a name for yourself.  Put that first year anatomy class to good use.  Put together a RCT for the use of prehospital NTG and present it to your medical director.  Get your local IRB on board.  Then, when all is said and done get your study published.  Who knows?  You may change the practice of medicine for thousands of providers around the world.