How risky is nitro without a line?

[akroeze]

Here is a question for people. PCPs in Ontario generally follow the following guidelines for Nitro (your exact mileage may vary):

History of prior nitro use

S/S consistent with either prior angina or s/s consistent with cardiac ischemia

>40kg

Conscious and alert

HR >60 and <160

BP >100 systolic

Discontinue nitro if systolic drops by >1/3

Monitor and O2

We DON'T have an IV established, monitor consists most often of just Lead II and there is a pretty good chance that if they have no nitro use but you have a long transport time you just have to patch and they'll let you go ahead with it.

How do people feel about this?

[AnthonyM83]

If you wait to start a line, then give nitro, would are the negative side effects for the patient?

You give a spray and immediately start on a line, what are the pros?

What are the specific cons? BP dropping too low or is the fear that CP was caused by something else? If the later, then you'll still have the same problem you'd have without giving the nitro, right? Of needing a line?

I guess as a non-medic, I'm just unclear on why people don't want to spray and start line simultaneously. IV takes time and NTG at least gets on board immediately.

[JPINFV]

^

Part of the problem is that if you give nitro and the pressure bottoms out then you will have a harder time starting the line. Furthermore, the risks to the patient's health from hypoprofusion are more time senstitive then the damage from an MI. You can't replace brain or heart tissue, but I'd rather have heart damage than brain damage.

[kevkei]

Here is a question for people. PCPs in Ontario generally follow the following guidelines for Nitro (your exact mileage may vary):

History of prior nitro use

S/S consistent with either prior angina or s/s consistent with cardiac ischemia

>40kg

Conscious and alert

HR >60 and <160

BP >100 systolic

Discontinue nitro if systolic drops by >1/3

Monitor and O2

We DON'T have an IV established, monitor consists most often of just Lead II and there is a pretty good chance that if they have no nitro use but you have a long transport time you just have to patch and they'll let you go ahead with it.

How do people feel about this?

Based on this protocol, what if the HR is 64 and SBP is 108mmHg? Do you give it because it falls within the protocol? (This is why I don't like protocols to be black and white to people)

What if the patient has an inferior infarct but no RVI? The liklihood is their SBP will drop significantly.

To others that say "patients use their own nitro all the time" is very narrow minded and is missing the point. Yes, they do, but typically it is related to an episode of exertional angina (of which they have a history). When they call EMS, it is usually because it is atypical and/or doesn't relieve with rest and nitro, so the argument of personal use should go out the window.

[logos]

I think you are a little off here. Thrombolytics and PCI (angioplasty) both definitely improve survival. I don't know if there is survival data for nitrates, but there is data to suggest that they can limit the extent of an infarct. The mechanism is the same as B-blockers, reduction of myocardial oxygen demand. The whole "dilating the coronary arteries" thing was long thought to be the primary mechanism, but is now thought to be of minor significance, if any.

[Ridryder 911]

Partly true. If one can reduce work load, and increase vasodilation you might decrease potential infarct size, by allowing some blood perfusion. Yes, PCI does increase improvement and survivor rates, as well as thrombolytics in specific conditions. However; more and more research is gearing towards door to cath lab rather in lieu of thrombolytics.

You did point out some significant points that many AMI's are not caused by arterial spasms, and even obstruction in the lumen of the coronary artery, rather releasing of plaque from lining of the arterial walls.

R/r 911

[AZCEP]

I think you are a little off here. Thrombolytics and PCI (angioplasty) both definitely improve survival. I don't know if there is survival data for nitrates, but there is data to suggest that they can limit the extent of an infarct. The mechanism is the same as B-blockers, reduction of myocardial oxygen demand. The whole "dilating the coronary arteries" thing was long thought to be the primary mechanism, but is now thought to be of minor significance, if any.

Nope, I think you may have missed the point. ASA is the only agent to be proven to improve morbidity AND mortality for the patient experiencing an acute MI. FIBRINOLYTICS and PCI do not reduce mobidity, only mortality. Survival data for nitrates is not related to it's use with AMI. Beta blockers reduce the morbidity not the mortality.

I stand by what I said, which was, plainly, many have missed the entire purpose for using nitrates for ischemic chest pain, NOT for acute MI's.

[flopeyeman]

If you give a pt.sl nitro without an IV you run into the possibility of the pt having an allergic reaction to the med then you may run into some even more serious reactions and there hole system may shut down and you wont be able to get a line started at all.I think that it is best to get that line in first after O2 and ecg ect. because you might have a person that has no coronary history and has never taken it before and its better to have it and not need it then it is to need it and can't get it !!

[pinymayu]

Lets also not forget those patients who turn out to be extremely sensitive to NTG and become extremely and refractarily hypotensive from NTG as well, usually without warning. ALso I echo "Rids, Medic001918, AZCEP, Ozmedic's, Chbare's, and many others" comments above as well

Food for thought,

pinymayu

[spenac]

Hey cool another stick person like me =D> . Were just a short 1 1/2 hour to hospital that up till Jan. many times only had PA or NP on duty so not even a DR of any type. Now we get some type of weekend warriors alot of time with no ER experience. For real hospital another 2 1/2 to 3 hours by ground, or wait an hour for helicopter to get to hospital and take them. Protocols here allow nitro with no IV but hey it would be nice to have just in case. In fact every transport here, the patient gets an IV unless only BLS crew.