How risky is nitro without a line?

[mobey]

Hey all

Just finished an MI call with a paramedic and we sparked a good conversation on the way home, (yeah it's a long drive). He suggested that giving Nitro spray without an IV is too risky and we should not do it. Note: in my province PCP's cannot start IV's but can spray nitro. Now we are not talking protocols here... I would never withold treatment from any pt. based on personal opinion. Just wanted to know your thoughts. How risky is this? I would be interested to hear some war stories about patients having a negative outcome from this sort of situation.

[mediccjh]

Depends on the B/P and what the EKG looks like.

Personally, I try to get the line first, especially if the patient is not hypertensive. However, if I'm looking at an inferior wall MI, IV first.

[Ridryder 911]

I agree. One should be sure they are not looking at a right sided AMI. That is why it is I am against Basic EMT's giving NTG, without either EKG or hx. of angina.

True, people self adm. NTG all the time without an EKG, but they have been dx. with angina type syndromes.

R/r 911

[Code 8 Paramedic]

People take there own nitro with no ECG or knowing thier BP everyday. So its most likely not gonna kill anyone. If the patients SBP is above 110 i say give them the NTG. My feeling is you could be doing more harm by with holding NTG when the paitent needs it. If the pressure drops, ok you can handle it... drop the head back, elevate the legs. Clearly you need to be aware of whether or not your patient has a right sided infarct, because thats gonna take alot of fluid to counter act the NTG's effect on the BP. But if you dont restore perfusion to heart... larger problems with be down the road.

[Just Plain Ruff]

I have a question that I've always wondered but don't think there's much in terms of studies about this.

The patient is having chest pain. They are having a Right sided MI. WE aren't there yet but they've called 911 or a family member has. they just took their 1st nitro and dropped. They are now coding.

How many of our cardiac arrests do you think are caused by this?

If the number is even 1 then maybe giving nitro without a line is counter productive?

[Code 8 Paramedic]

I have a question that I've always wondered but don't think there's much in terms of studies about this.

The patient is having chest pain. They are having a Right sided MI. WE aren't there yet but they've called 911 or a family member has. they just took their 1st nitro and dropped. They are now coding.

How many of our cardiac arrests do you think are caused by this?

If the number is even 1 then maybe giving nitro without a line is counter productive?

Well I really disagree that if the number is even 1... because the benifits of Nitro in general.. far out way the risk of 1 death.

Codeing with a right sided MI because of the Nitro sounds like a reach... Id say the code was more likely due to the right sided MI...

but maybe someone with far more letters after their name could answer that.

[chbare]

Good topic to debate. Let us ask this qustion. How much are we really helping a patient when we give nitro spray? Does the benefit in fact outweigh the risk of giving this med without a way of treating for side effects?( Well documented and well known side effects.) Are we actually helping our patients and does the evidence back up the practice of giving nitro without IV access? In addition, we must also consider the patient that will receive the nito. True, people take nitro all of the time, however, we must consider the reason our patient calls EMS. We will most likely be dealing with an acute change in the patient's base line condition. Even our chronic angina pt can have acute changes and will call EMS because something is different. We must consider this and never take lightly the fact that we are giving a patient without IV access 400 micrograms of a substance that will interact with our patient's physiology. (nitric oxide in the case of nitro) Remember, if you drop your pressure from nitro, you are most likely looking at a loss of preload. I would not bet my patient's perfusion status on elevating the legs to compensate for a loss of preload. The best treatment will be fluids. (Well known in the case of a right ventricular infarct ) Let's take an objective look at this debate and do what is going to led to the best possible patient outcome.

Take care,

chbare.

[Mastabattas]

Well I really disagree that if the number is even 1... because the benefits of Nitro in general.. far out way the risk of 1 death.

Codeing with a right sided MI because of the Nitro sounds like a reach... Id say the code was more likely due to the right sided MI...

but maybe someone with far more letters after their name could answer that.

Code 8

Why take the chance with one life, when it can quite possibly be protected with a line. Do you still drive without a seatbelt? Because to me...that's what it compares to. You are an EMT-P so surely you are aware of the kinematics of NTG and it's affect on an right sided MI versus left.

My understanding of why we want a line in place is this (this is good for me for review for school too):

First, Nitro = vasodilator. Second, Mechanism of Action = relaxes smooth muscle and causes vasodilation resulting in increased coronary blood flow, decreased preload reducing myocardial workload. Contraindictations include BP < 100.

paraDOc16 from another site explained it best for me:

The right side of the heart is totally dependent on venous return (Preload). Once blood flow gets through the capillary beds, it is pretty much independent of the left side of the heart and the pressure it generates. Venous return is dependent on muscular action around the veins and gravity (stuff like that). So when blood gets to the Right atria, it comes in with a pressure of normally 0 to 8 mmhg! That's hardly anything! So venous return (Preload) is also what is affected by NTG administration. Many medics think you are dilating the coronary arteries to some large extent to get O2 to the cardiac muscle. THAT IS WRONG. You are decreasing preload, so the heart doesn't have to pump as much blood out, and it can rest a little. If you have an ailing right ventricle that is ineffectivly pumping blood due to ischemia, and you knock out the only thing filling it, you don't get blood to the lungs, you don't get blood to the systemic side of the heart, and you end up with less blood in the LV and therefore less blood/pressure in coronaries, and systemically (so BP drops) So NTG in this case makes the muscle more ischemic!

In this situation, a fluid bolus is indicated increasing preload hopefully improving pulmonary flow and ultimately cardiac circulation. But if you can't do a line...then what?

Mobey I'm in AB and so we have to have our line before we can admin NTG. I find it interesting how our provinces can't even agree on something like this. And there is enough controversy in us being allowed to administer it even with a line. To me...the pathophysiology seems to indicate what would be naturally safer...

[Ridryder 911]

Well I really disagree that if the number is even 1... because the benefits of Nitro in general.. far out way the risk of 1 death.

Codeing with a right sided MI because of the Nitro sounds like a reach... Id say the code was more likely due to the right sided MI...

but maybe someone with far more letters after their name could answer that.

Okay, let's remember a few things.. NTG is prescribed for patients at home for anginal episodes NOT an AMI. As well I have seen numerous episodes of just one squirt has caused syncope and pressure to fall. Yes, I administer NTG to a patient without a IV line, if their ECG does not reveal right side, and their normo-to hypertensive. But, administering NTG blindly is asking for troubles.

Having a patient "bottom" out is much more complicated than just treating by raising their feet (which is a proven myth) and giving some fluids. Congrat's and thanks to your action(s) their infarct size has just probably increased ! This is due to an increase workload and demand placed on the myocardium, from the receptors sensing the hemodynamic compromise. Thanks to your actions they now have develop a full thickness wall infarct. Now, we are looking at potential major complications...

This is one of things being re-reviewed and should be changed... even at a Paramedic level.

R/r 911

[Code 8 Paramedic]

Ok just to clear a few things up

Mastabattas

1st of all.. your Paradoc16 guy is wrong on the fact that yes you do give nitro to dialate coronary blood vessles.. AND do decrease preload.. not the other way around...

2nd im very aware of the physiology of a right sided MI, and lots of things beside muscle movement get the blood back to your heart... id recomend NOT listening to that paradoc guy!

3rd i was refering to the unlike event that a pt with is own nitro takes one while having a right sided MI and dies... not me giving it to him.

4th have you ever started an IV? people have died from IV complications but we still do them, medications work differently on many different people.. sometimes they kill people... but if the benifit out weights the risk... you still do it. If everytime someone died from one treatment or another we wouldnt be treating people at all.