Passing out ASA to the "maybe cardiac"

[Medic26]

Each patient has to be decided on a case by case basis, I usually don't give ASA unless I'm pretty darn sure its cardiac in nature. Syncope and N/V is surely not cardiac enough on there own to convince me.

[fiznat]

Each patient has to be decided on a case by case basis, I usually don't give ASA unless I'm pretty darn sure its cardiac in nature. Syncope and N/V is surely not cardiac enough on there own to convince me.

...And yet I have seen patients having MI's with exactly those complaints alone.

It is true that we have a lot of diagnostic equipment. Couple that with a solid understanding of cardiac presentations, atypical presentations, equilivents, and experience: I think it is safe to say that a good number of patients we will be able to make a pretty surefooted decision as to whether a cardiac problem exists or not.

These are not the kinds of patients I am asking about.

I dont think it is fair to say that we should always be able to make a firm decision as to whether an event is cardiac or not. Even with an awesome assessment and the best resources possible (neither of which are always present for one reason or another), STILL there are patients who defy the rules and evade direct diagnosis. If you beleive you dont have these patients ever because your assessment is that good, I'd sure like to learn a few things from you.

These are the ones I'm asking about. The "maybe" cardiacs. Where is your level of suspicion for administering ASA?

...And to the guy who said he bases his NTG decision on " a thorough understanding of the effects it will have on that individual's unique heart and vasculature system," I would ask: how the heck does he obtain that information? PMH can only do so much. ...To presume you can predict in an ambulance individual reactions to these kinds of medicines is borderline hubris imo.

[UMSTUDENT]

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.

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

Half-life and therapeutic effect are often different. Nitroglycerin has an onset of 1-3 minutes with a therapeutic effect of approximately 30 minutes. My point was my point. The risk of building up toxic, potentially harmful levels in individuals who otherwise have no sensitivity to the drug is probably not as high. The body rapidly metabolizes nitro in the liver into two metabolites. The sudden, drastic drop in blood pressure among individuals who are given nitrates is seen is certain populations. Not everyone's pressure is going to bottom out given multiple doses of this medication. This is why ingesting large quantities of nitroglycerin by mouth is often very non life threatening (depending on the form). It succumbs to a tremendous first pass effect!

Basically, nitro is a drug whose use must be tailored to the individual receiving it. As I said before, these are drugs that cannot carelessly be given to individuals blindly based on protocol. The "therapeutic effect" will vary widely among individuals who it is given to. The best advice is to know the drug you’re giving and the potential ill-effects of its use.*

Secondly, my comments on aspirin are based on some reading of my own. My comments were based more on the tendency of some physicians to place their patients on ASA on a daily regime for a variety of ailments. More research has come out indicating that aspirin may have therapeutic effects beyond its traditional uses. I think I'm referencing a TIME article, but I couldn't begin to cite specifics. Type in "aspirin, cancer" though and you'll get a floury of news articles and stories on the research linking it to cancer prevention, specifically in colon cancer.

Hope that helps clarify things.

* Not a pharmacist. Consult protocols!

[UMSTUDENT]

...And to the guy who said he bases his NTG decision on " a thorough understanding of the effects it will have on that individual's unique heart and vasculature system," I would ask: how the heck does he obtain that information? PMH can only do so much. ...To presume you can predict in an ambulance individual reactions to these kinds of medicines is borderline hubris imo.

Education. Understanding and knowing the potential effects of a drug given your patient's detailed history and physical assessment goes a long way.

Hubris? As a paramedic you would be paralyzed with fear or simply stupid to not be able to predict the reactions your medications will have on that individual, especially in a drug like nitroglycerin.

You'd be surprised what you can get out of a patient if you know how to properly question them. For instance, a patient who tells you, "My doctor says my heart only works 30%" is telling you a lot (actual quote). What can we deduce from this statement?

The patient is recalling a comment from a physician. If the patient has an otherwise unknown cardiac history we can presume that he is probably referring to his ejection fraction. Even if you take this statement literally, it still translates to a rough estimate of his/her heart's overall working capacity and the result is the same. Nitroglycerin has a potent effect on the end systolic ventricular pressure (afterload). A patient with a relatively floppy, nonfunctioning heart will probably have a more pronounced reaction to the drug. This is what I'm referring to. Even if your patient simply says, "I get dizzy, lightheaded and pass out when I'm given that drug" you've discovered a lot. Prepare a large bore IV and have fluids available just in case.

Blind implementation of protocols without any thought on the part of the provider is just asking for danger.

[Medic26]

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).

These symptoms alone are not enough for me to give ASA. If we did, ASA would be like Pez in a dispenser and more common than oxygen being administered.

Vague Symtoms + Normal 12-lead = Monitor & Transport in these cases.

[JakeEMTP]

Blind implementation of protocols without any thought on the part of the provider is just asking for danger.

This should be the opening statement of ALL paramedic classes! 8)

Well stated UMSTUDENT! :thumbright:

[aussiephil]

Secondly, my comments on aspirin are based on some reading of my own. My comments were based more on the tendency of some physicians to place their patients on ASA on a daily regime for a variety of ailments. More research has come out indicating that aspirin may have therapeutic effects beyond its traditional uses. I think I'm referencing a TIME article, but I couldn't begin to cite specifics. Type in "aspirin, cancer" though and you'll get a floury of news articles and stories on the research linking it to cancer prevention, specifically in colon cancer.

Sorry, i thought this forum was on the use of ASA in chest pain not for treatment of a variety of illnesses.

* Not a pharmacist. Consult protocols!

No one asks us to be pharmacists but an understanding of the drugs we give & effects they can have on patients allows use to use them effectivley. This should be in conjunction with an understanding of the pathophisiology of the illness/complaint presented to us. Can we also say we are not Orthopods so we cant treat fractures? or we are not cardiologists so we cant treat cardiac illness? If you are entrusted to give a drug, you need to know its uses, effects, indications, contraindications BEFORE you give it.

Phil

[CBEMT]

Syncope? Nausea? By themselves, probably not although I have done it in the past based on the whole picture.

The 74 year-old I had recently with weakness, dizziness, SOB, and "a little pressure up near my chest here," and a recent CABG history?

You bet your ass I did!

[UMSTUDENT]

Sorry, i thought this forum was on the use of ASA in chest pain not for treatment of a variety of illnesses.

No one asks us to be pharmacists but an understanding of the drugs we give & effects they can have on patients allows use to use them effectivley. This should be in conjunction with an understanding of the pathophisiology of the illness/complaint presented to us. Can we also say we are not Orthopods so we cant treat fractures? or we are not cardiologists so we cant treat cardiac illness? If you are entrusted to give a drug, you need to know its uses, effects, indications, contraindications BEFORE you give it.

Phil

I hope that is sincere, LOL. Adding a comment on the general use of aspirin, while not directly related to the topic at hand, is appropriate.

Secondly, I obviously advocate for the proper use of a drugs based on education and training. Unlike some people however, I feel I should not overstate my level of knowledge or rights to practice. While I may have a thorough knowledge of the drug I'm talking about, changing your practice on a universal level based on my statements is not advised. I don't want someone on here telling their medical director they're an idiot because of something I said.

[aussiephil]

I hope that is sincere, LOL. Adding a comment on the general use of aspirin, while not directly related to the topic at hand, is appropriate.

I am hoping that this is not a question of my sincerity or abilities, as you know nothing of me or my skills or abilities.

I agree that adding extra information can be useful, but in this instance,

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.

one would be of the assumption that you were indeed dicussing the use of ASA for cardiac patients as there is no reference to the debate for other ailments.

Phil