Passing out ASA to the "maybe cardiac"

[fiznat]

I've had a lot of patients like this during my preceptorship, just wondering what your take is on it.

Imagine a patient who is presenting in an only vaguely cardiac manner. Something like weakness without ST changes in a female. Syncope in a patient with cardiac history but no other complaints. N/V and diaphoresis coupled with a clean 12 lead in a 65 year old smoker with a history of HTN and high lipids. We see these patients all the time (or at least I do). Basically they will present with one or two of the typical "cardiac equivalents," but will defy clear-cut cardiac diagnosis by denying chest pain/SOB/etc and presenting with clean or unreliable (BBB, pacers, etc) EKGs.

How often will you give ASA?

My preceptor has often suggested that even if I am not convinced that a patient is "cardiac enough" to give NTG, I can still (most times) go ahead with ASA as the drug is fairly benign (save a few circumstances). It is a sort-of "cover your bases, just in case" kind of philosophy.

Personally, the idea kind of rubs me the wrong way. I feel it smacks of sloppy medicine, and it shouldnt be advisable to give medications for conditions we dont clearly see. I'm not sure that it is our place in the ambulance to ever give meds "just in case."

On the other hand, though, I understand of course that we have limited resources to evaluate these patients, and often - especially in ACS - time is of the essence. Perhaps it makes sense to give ASA to these patients simply because the potential benefits may outweigh the risks.

What do you guys do in these situations?

[ericenglund]

Personally, the idea kind of rubs me the wrong way. I feel it smacks of sloppy medicine, and it shouldnt be advisable to give medications for conditions we dont clearly see. I'm not sure that it is our place in the ambulance to ever give meds "just in case."

Agreed. Although your preceptor is probably right, lots of people eat lots of Bayer every day, I dont think its my place to give meds just in case.

You've got a stable trauma patient with no deformity or swelling that just wants to get cleared physically at the ER. Do you give morphine "just in case" they have a femur fracture(or any bone for the purpose of this) that you can't detect?

Or are you gonna give your hx. of CHF pt the CHF workup to someone complaining of a headache "just in case" they're having an exacerbation somewhere in there?

Just my .02

[Dustdevil]

You've got a stable trauma patient with no deformity or swelling that just wants to get cleared physically at the ER. Do you give morphine "just in case" they have a femur fracture(or any bone for the purpose of this) that you can't detect?

Or are you gonna give your hx. of CHF pt the CHF workup to someone complaining of a headache "just in case" they're having an exacerbation somewhere in there?

I'm not sure either of those were stellar analogies for what Fiznat is talking about.

Obviously, this is another case-by-case proposition that cannot and should not be addressed in cookbook fashion, which I believe is the valid point that Fiznat is getting at. Again, this is where education comes in to play to give you the scientific foundation to evaluate each patient individually and come to a reasoned determination of the need for ASA, which, of course, is more for it's anticoagulant value than for analgesia (which is what makes your morphine analogy not such a good one, and why I never have been a fan of the whole "symptom relief" term).

[aussiephil]

If you have a suspicion forsome sort of cardiac event, & the pt has no bleeding tendencies ulcers etc or a know allergy, i would give it.

Will this action hurt them?

Unless they have something undiagnosed, no it wont. Will it benefit them? if they are havin a cardiac episode, yes it will.

I agree with dust that this is where education plays a large part in your judement.

Out protocol actually states to give it if Mcardial Ischaemia is suspected even if you are unsure of the cause, give it anyway!!!!!

Play safe

Phil

[AZCEP]

I truly appreciate the fact that you are questioning the validity of the suggestion fiz. Atta boy.

Is it reasonable? Probably, but it does carry some danger with it. There is no benign medication. They all act in ways to alter normal physiology. If they didn't we wouldn't use them. There are clear indications, contraindications, and suggested times for and against everything we carry.

Your concern for "sloppy medicine" is a good thing to carry with you. Just as you could justify using something, you could also justify not.

Welcome to the gray area. There's plenty of room.

[brentoli]

I prefer the "silver area" it is a bit more shiny.

Some areas basics can give aspirin with out ALS arrival. How do you suppose this is any different. We are not allowed to do it here, however, if a B is giving aspirin they are going by the chief complaints and symptoms. There is no 12 lead, or even 3 lead to guide them in the indication.

No this isn't a basic uplifting post, settle down there Dust

I don't know the physiology behind cardiac care... yet.

What I have seen the last couple of years working and hanging out here, this is the type of situation that can put a spin on what kind of medic you are. Do you trust your skills and observations enough to go with the presentation of the patient, or do you need to fall back on the recipe card to make your way through it.

When someone fights you about why a Basic should be allowed to do medic level things and how a B is just as good as a P, send them to a question like this. It really has me thinking AND intrigued to learn more about the physiology behind it. Anyone got an extra 3k I can borrow? Dust? Rid?

[Dustdevil]

What I have seen the last couple of years working and hanging out here, this is the type of situation that can put a spin on what kind of medic you are. Do you trust your skills and observations enough to go with the presentation of the patient, or do you need to fall back on the recipe card to make your way through it.

I'm afraid I don't have $3k to spare. I have a Europaean honeymoon to pay for soon.

But I will give you 10 points for figuring out, in two years as a basic, what many people never figure out in ten years as a medic. :thumbright:

[kevkei]

Welcome to the world of medicine where very little is black/white! This is the type of question that seperates the good from the not so good. I agree with what has already been said and I don't like giving things to cover your bases. I have to be pretty confident it is cardiac (>80%) before I'll start to look at NTG and ASA. You can do this with a thorough history, assessment and physical exam.

If you don't know what it is, what do you think it might be? (differential diagnosis). Are there false positives and/or pertinent negatives?

When you have your list, go through and rule in what you can and rule out what you can. You are left with a working diagnosis, which if you have done your job right and well, you can treat.

Very few cardiac patients will present like a textbook. Many will present with atypical symptoms (especially females, diabetics and the elderly - sounds like a lot of our patients doesn't it?). This is why understanding anginal equivalents is so importanty. More importantly, these symptoms have ususally been going on for hours, days or weeks so how effective is ASA going to be?

I would lean more towards a conservative approach. Assuming you have done a good history and exam, start with your basics. O2, IV, position the patient, etc. Then re-evaluate and ask, has there been any change? If I feel it is cardiac related, if there are no contraindications and looking at the entire patient (vitals, etc) I may consider a trial of NTG and then re-evaluate again. Has there been any change? If so, was it mild, moderate or significant? If it is mild or moderate, I'll probably repeat again after reassessing. (If it was significant, I'd be cautious and would probably raise a red flag.)

When repeated, go back and reassess again. Was there any change now, if so, mild, moderate or significant? If you see positive results, you are probably on the right track and then I would consider giving ASA. If not, I would with hold the ASA and probably hold off on giving any more NTG.

[UMSTUDENT]

If I remember correctly, Nitro has a very short half-life, somewhere in the range of 1-4 minutes. I think using it during a suspected cardiac event is warranted, so long as you have a thorough understanding of the effects it will have on that individual's unique heart and vasculature system. For instance, I would say a 12-Lead ECG is a good diagnostic tool to implement before just randomly giving nitro. For instance, the presence of an inferior MI may warrant more judicious use of nitro.

Aspirin on the other hand is an anti-platelet aggregator. The immediate advantage of giving ASA in the field is probably negligible, although it does have added advantages of keeping the clot from getting larger. Interestingly enough, there is a huge divide in the medical community about the utility of salicylates in certain aspects of medicine. There is some research to suggest it may help with a variety of ailments, while yet other research suggest its dangers when used carelessly. I think we can all agree on its most basic uses.

I think the take home point of these drugs is to use them when warranted by clinical signs and symptoms with the proper use of available diagnostic tools. Basically, this means utilizing your brain instead of blindly handing out drugs for every patient meeting only the mildest criteria.

[aussiephil]

If I remember correctly, Nitro has a very short half-life, somewhere in the range of 1-4 minutes

Nitro effects last for up to 30 minutes, depending on the patient, this is still a short half life but a little longer than 1-4 mins.

We use is where myocarial infarction or ischaemia is suspected - diagnosed without a 12 lead- cardiogenic pulmonary oedema & autonomic dysreflexia, provided the pt maintains a systolic BP >100mmHg.

Interestingly enough, there is a huge divide in the medical community about the utility of salicylates in certain aspects of medicine

Which areas? I would be curious to read the reference material if provided.

It is also interesting to note that a supliment to the Medical Journal of Australia provided a supliment 'Guidelines for the managment of Acute Coronary Syndromes 2006'

This document was produced in conjunction with the National Heart Foundation as well as The Cardiac Society of Australia & New Zealand with input from 18 seperate Cardiac specialists, professors & Associate Professors.

It states 'Aspirin should be given early (ie, by emergency or ambulance personnel) unless already taken or contraindicated. It further stated that this should be used in conjunction with Glyceral Trinitrate & Morphine.'

Phil