How risky is nitro without a line?

[Mastabattas]

Ok just to clear a few things up

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...

I completely agree we give NTG for both purposes. But what I understand is that the risk with Rt. Sided MIs comes with the preload aspect more.

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!

I actually listen to my instructors, and textbooks but also seek out others as alternate ways of explaining. Sometimes it takes different wording to get a concept ingrained in the brain. Never said he was the end all-be all of anything. Just another dude...like you...like me...like everyone.

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.

Well gosh darn it...why didn't ya say so in the first place : )

4th have you ever started an IV?

Actually, yes I have.

I fully acknowledged you as having further education... and then went on to say what MY understanding was... Leaving it open for correction/clarification as I AM still a student (aren't we all...always?) and totally want to get a better grasp on all sides of this issue as it's frequently debated. No need to get your panties all up in a knot, we're all here for the same purpose.

Now Rid...you make (as usual) a solid argument for why it's too great a risk. I hear from a lot of other sources the standard "benefits out weigh the risks" but it just doesn't sit as well with me...maybe I'm not as much of a risk taker as some.

[Code 8 Paramedic]

Yeah I just want you to know i wasnt trying to start a fight or anything... just had a few points i thought needed to be cleared up

[Mastabattas]

Code 8 No worries. Life is gooood!

[brock8024]

I understand that on some people we will not be able to get a IV. I have learned that there is always the neck to start a IV in. I know it is not the best place, but if you had to use it I am sure you would.

I am a paramedic student and will graduate in may so take me with a grain of salt.

I was taught that you need to get a med with out a IV. In my acls part of school if we gave nitro without a IV the patient crashed. It taught us to make sure we had our life net in place in case something happened. I mean what if you was to give nitro and they went hypotensive and that caused them to use more O2 due to the strain of having to fight to keep a BP. Now they are going to vasoconstrict I would think due to the fact that their brain is telling the body to do what it has to do to keep it alive. So now are you going to be able to get a IV? I think it would be harder to get a IV after the drop in pressure than before if it was going to happen.

In todays worlds there is a ER very close unless you are in the sticks. Even then there are many sites to choose from. I hope that everyone is taught about EJ's, different sites on the hands and arms. Hell I have even started IVs in the foot on a patient in cardiac arrest. So trust me there has to be something that can be done to get a IV.

I would hate to face a medical director or attorney because I did not have a IV before giving a med. I mean why would you give a med with out a way of treating the possible out comes good or bad.

[mobey]

In todays worlds there is a ER very close unless you are in the sticks.

I would hate to face a medical director or attorney because I did not have a IV before giving a med. I mean why would you give a med with out a way of treating the possible out comes good or bad.[/quote

Out in the sticks?? Oh you mean 1hr drive to small town hospital with GP on-call. 2.5 hrs from major city hospital with trauma center and cardiologist, 1.5 hrs from ALS intercept if I call them immediatly when I get the tones? YEP thats me!!!

That is why I posed the question. :wink:

[OzMedic]

Once again in this thread I see one of the major barriers to EMS being people looking for 'black and white' rules that they can apply in all situations. In this as well as most situations I think individual judgement on a case by case basis is what is called for. Should you give 400mcg to a possible right sided MI with a sys BP of 110 with no IV?............ Probably not wise. What if the sys BP is 160?................. Far less risk of dropping too low with one dose. Whether they are already on GTN or not will also influence your judgement. We also need to be mindful of applying hard and fast rules to acceptable sys BP's for the administration/discontinuation of GTN in the first place. I can assure you that a myocardium that is used to being perfused via it's partially occluded arteries by a chronic sys BP of 160 will not thank you for dropping it and keeping it at 105! (nor will their brain in some instances).

Get as much information as you can, use judgement, Implement you therapies and constantly reassess for positive or negative responses. Treat the individual patient, not the protocol.

[medic001918]

Assuming that the patient is having chest pain, and it doesn't appear to be a right sided MI (determined w/EKG), and that the patient has an acceptable blood pressure, I will generally allow one dose of NTG prior to the establishment of an IV. If the patient is hypotensive or on the lower side of normotensive, I'll often hold off on the NTG (remember the JVD, hypotensions and clear lung sounds can indicate right sided MI). I have had patients that have had rather large drops in blood pressure with the use of NTG. And I have been able to bolus these patients back to an acceptable blood pressure to continue with NTG treatment (the patient was not having a right sided infarct).

It's a grey area, and one that every provider will have their own answer for. I feel much more comfortable giving NTG, especially repeated doses; with an IV line in place. This way should the patient deteriorate, I already have a point of access and means to start to correct the situation rather than being caught behind.

Shane

NREMT-P

[1EMT-P]

I like to start off with Oxygen first, followed by # 4 Chewable 81mg Baby ASA. If the patient's BP is stable then I will consider giving # 1 dose of SL Nitro without a line.

[SC CT]

Don't see a problem with giving the first NTG to a hypertensive or normotensive patient without a line. I can even see giving a second dose without a line if the pressure stays good and there is significant relief after the first dose. Usually if the patient has a decent BP I will get the ASA and NTG on board before I grab the IV and 12 lead anyway. If the pressure is low or looks lower than it should be, I might try to grab the 12 lead first to look for a RVI.

Even then, I don't think a RVI automatically precludes nitrate therapy, just warrants extreme caution, that caution including fluid therapy and thus an IV.

[AZCEP]

Okay, let's remember a few things.. NTG is prescribed for patients at home for anginal episodes NOT an AMI...administering NTG blindly is asking for troubles.

R/r 911

A number of folks have chimed in following this post, and seem to have completely missed it. Please remember why we are using this medication. It is not intended to treat an acute myocardial infarction. It does not reduce the amount of tissue that is destroyed by an occlusive event in the absence of collateral circulation. NTG is intended to manage ischemic chest pain, not the infarction.

The only medication that has been proven to reduce morbidity/mortality following an acute MI is...aspirin, that's it, nothing else. Not even fibrinolytics can claim this. Reduce the discomfort your patient is feeling, perhaps decrease the anxiety that accompanies the pain, maybe reduce the MVO2 by significantly reducing preload, wonderful. Just keep in mind that we are not treating the MI. We are, in fact, treating a symptom of the infarct.