Why not a NTG drip?

[nsmedic393]

I took a transfer from our small community health center to the ICU at our regional hospital an hour away this morning.

This is the patient;

A 79 Y/O female arrived at the health center complaining of sub-sternal chest pain rated 10/10 with pain radiating to her right arm. She had been having this severe pain for 2 days. They gave NTG sprayx3 and did a 12 lead. The 12 lead showed a acute anteroseptal MI. They treated her with 35mg of TNK and we arrived about 15 minutes after to transport her.

Her VS HR 110 BP 142/88 RR20 LS clear=bilat Sinus rithym in leads 1,2 and 3. St elevation in v1-v4.

The st elevation did not subside with lytic therapy and her pain decreased to 5/10 although she was still in quite a bit of discomfort.

They also gave her 3mg of morphine and a 0.4mg NTG patch for the pain she was still having as well as 2.5mg of metoprolol for her rate. Before leaving I asked the Doc if it would be a good idea to start a NTG drip and try to get her pain under control and he told me that the patch was enough and to just get on the road and give her MS prn for the pain.

When I departed her VS were HR 88 BP124/72 RR20 Pain still 5/10. 5 minutes into the trip her pain is still 5/10 and she is quite uncomfortabe, I gave her 2.5 of MS with no relief. So i decided enough was enough and started with the NTG sprays.

I gave her NTG0.4 SL q10mins until we arrived at the recieving hospital. Upon our arrival her pain was 1/10 and she was miling and seemed a heck of alot more comfortable.

So my question is why would the doc not have started NTG before we left? The recieving doc agreed with my TX en-route but didn't comment about why the sending doc wouldn't have started the NTG drip.

[Ridryder 911]

Some Doc's do not prefer NTG post thrombolytic (especially IV form) since occlusion should be somewhat opened up. Since it should not be arterial spasm and partial occlusion, I am sure he was thinking of slow absorption nitrates, he might worried of transfusion enroute. I too am a fan of NTG drips, and still wonder why EMS has not became of age of even initiating them. Morphine definitely has its place, but in arterial spasms and some occlusion, I wonder why the hesitation of not the use in the field? Yes, closely monitored B/P etc.. which should be doene with any medication(s).

I am surprised this has not been investigated further or researched in more detail. Please, the "glass bottles" how to monitor should be eliminated from discussion. There are far more dangerous objects that are carried in the units, and yes IV pumps have to be used. Therapeutic levels could be reached at a faster rate, and closely monitored. I am quite aware that many services are using NTG paste at this time, which is good, but definitely has a slower absorption rate.

I did work at one EMS that did utilize NTG drips, but I have not seen it utilized very much prehospital wise.

R/R 911

[nsmedic393]

I forgot about that glass bottles thread. Here we routinely transport NTG drips. Don't ask me why but it has never been in a glass bottle either.

My thoughts were that this lady had a non recent MI. Her 12 lead had not shown any signs of reperfusion post TNK and as it turned out there were no ECG changes (for the better en route) mind I was only using modified chest leads. I thought pain control should have been the #1 priority since it seemed like the damage had already been done.

Annother question would be; how long after TNK do you usually see positive effects on the cardiogram. I have only seen TNK used a couple of times and the effects appeared almost immediatly after administration.

[Ridryder 911]

Dependent on the extent of the ischemia and possible infarction. We routinely use TNKase, and usually we see immediate changes to changes within one hour after administration, some later again dependent on degree.

R/R 911

[akflightmedic]

Thats what I miss about FL. We routinely intiated NTG drips, glass bottle and all. After doing that for several years, I got lost in my own little world and didn't realize hardly anyone else was doing them. Oh well, I will be back there soon enough....