Nitro Question

[EMS_Cadet]

Hey all,

Quick question for all the medics here.

Tonight, we were notified that a family member was sent to the ER for chest pains via ambulance.

I spoke to the nurse who activated 911 and got the following.

83 year old female.

Hx. of diabeties, CHF, TIA's and other things.

The med list is about a mile long.

No allergies.

Vitals: BP- 100/70. HR - 67 Temp - Normal. Pulse ox - Normal. BGL - normal.

Chief complaint was chest pain with shortness of breath. I was unable to find out if the pain was radiating. The nurse did not get a pain scale.

From what the nurse said, the SOB was severe.

The nurse had orders to give nitro tabs for chest pain (as prescribed by her doctor).

The nurse administered (3) nitro tabs without relief.

The nurse took a BP again and it dropped a little (expected that with the nitro).

The nurse proceeded to tell me that the paramedics "hooked her up to the heart monitor and said everything looked fine." I then questioned the nurse if the paramedics preformed a 12 lead, she acted stumped and said, "I don't know." From what medics have told me, you can't confirm a STEMI in just one lead.

My question is...I thought you weren't supposed to give nitro to patients with a systolic <110.

Also, could CHF start off with this presentation? I thought CHF started off with hypertension and patients only presented with hypotension when they started decompenating.

Thanks,

BR

[ERDoc]

This first rule of medicine is that nothing is absolute. You can give nitro at any BP, but should you is another question. There is no hard and fast rule that says what the limit is for ntg. In the field your protocols will dictate at what point you have to stop. There is no enough info given to say what is going on. CHF is in the differential. Not every pt reads the textbook and pts with CHF can be hyper, hypo or normotensive. It all depends on multiple factors including heart condition, resp status, anxiety, etc.

[Ridryder 911]

Ditto to what Doc said. There is no absolutes in medicine, that is why it is part science and part art.

R/r 911

[WelshMedic]

And that's what makes it so beautiful to work in........

But seriously, no nitro at a pressure under 110 mmHg? Seems a bit draconic.....

I was reading an article today about new insights into CHF care. Basically it stated that furosemide should take a back seat mainly because of misdiagnosis (pts with pneumonia were getting lasix and becoming even more dehydrated, for example). I know there's a grey area out there when it comes to diagnosing SOB, but are we really that poor in diagnostics? My gut-feeling tells me no. Any thoughts?

WM

[itku2er]

Our Protocols here you cant give nitro with a BP lower than 100. But some of the squads go with no nitro below a BP of 90 so It goes with what ever your protocol says more or less. I know I am not a medic but I wanted to respond to this any way, Hope you dont mind.

Terri

[NREMT-Basic]

For what its worth, when I started my EMT course, the National Registry said no nitro with systolic pressure less than 90. About mid-way through the course (March 2006) they changed their minds and set the bottom end for nitro administration at a systolic of 100. But, as more experienced providers than myself have said, there is no absolute.

[Just Plain Ruff]

My cutoff has always been a systolic of 90 or higher but there are times when I've given nitro (in the ED) at pressures near 80

remember in your textbooks that what you are learning are the Classic all the time presentations. You read about the illnesses classic presentations yet no book out there presents you with patients who really fall outside of the classic guidelines.

The books do not present material on patients who do not fit the pretty little outlines of a specific illness. The presentations are cookbook in nature and it is up to you to gain the experience or learn more than what is in the books.

Yes the shortness of breath material shows the major illnesses yet not many cover those diagnosis or cases where it could be one thing yet might be another. That is what differential diagnosis and thinking outside the box is for.

You get adverse reaction to medications material in one book yet no where does it cover what a dystonic reaction looks like nor what it's treatment is.

So it takes someone who is dedicated to learning to really delve into learning more about specific illnesses and disease processes.

A good anatomy and physiology book would come in real handy as an adjunct to learning.

[fiznat]

Yup yup, we all believe in the power of evidence based medicine and flexible, assessment-driven intervention but even so:

The nurse got a systolic of 100, gave THREE nitros and THEN checked the pressure? :shock:

Hopefully you got the details wrong on that bit. People react differently to NTG but I think most would agree that we should be a bit more careful than simply dumping that much drug on this patient without reassessment.

[cwilliams17]

In our area NTG is contraindicated with a SBP <100. And if the patient never taken NTG before, we have to start a IV prior to administration. Im sure its different in some places