Passing out ASA to the "maybe cardiac"

[UMSTUDENT]

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,

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

Nope, I was right, just a reading comprehension problem. Abrasive are we not?

[BEorP]

Ok, so yes in happy happy land we will all have pts who are amazing historians and able to provide us with every little bit of information we need to decide on cardiac or not. Oh and we can also do 12 leads on them too. In this happy happy land the only people who get ASA are those who actually seem to be having something cardiac going on.

As nice as happy happy land sounds, we're not there. Pts often have problems explaining exactly what they are feeling and often don't even know their medical history but can then sometimes confirm things that you can deduce from their meds. Plus many medics are not able to do 12 leads yet.

Since we are not in happy happy land I think it only makes sense that sometimes we will give ASA on a hunch to someone who seems possibly cardiac. If there are no contraindications to it, why not give it? Yes, I know it is a drug like any other, but let's be reasonable.

[Dustdevil]

Since we are not in happy happy land I think it only makes sense that sometimes we will give ASA on a hunch to someone who seems possibly cardiac. If there are no contraindications to it, why not give it? Yes, I know it is a drug like any other, but let's be reasonable.

I'm with you there on the hunch thing. But I think the concern here is that very fine line between a hunch and an excuse. While some of us are giving ASA to the atypical patient on a hunch, others are giving it to anybody they can find an excuse to give it to. Nausea? Well a lot of MIs have nausea, so let's give ASA since we have nothing else to give! It's the EMT-B mentality here that, thankfully, you don't have to deal with to much up there in Canadia.

[BEorP]

I'm with you there on the hunch thing. But I think the concern here is that very fine line between a hunch and an excuse. While some of us are giving ASA to the atypical patient on a hunch, others are giving it to anybody they can find an excuse to give it to. Nausea? Well a lot of MIs have nausea, so let's give ASA since we have nothing else to give! It's the EMT-B mentality here that, thankfully, you don't have to deal with to much up there in Canadia.

You make a very good point, I wasn't considering how some might be assessing a pt for a reason to give ASA rather than for possible cardiac issues.

[UMSTUDENT]

I'm with you there on the hunch thing. But I think the concern here is that very fine line between a hunch and an excuse. While some of us are giving ASA to the atypical patient on a hunch, others are giving it to anybody they can find an excuse to give it to. Nausea? Well a lot of MIs have nausea, so let's give ASA since we have nothing else to give! It's the EMT-B mentality here that, thankfully, you don't have to deal with to much up there in Canadia.

This is where Dust is absolutely right. Unfortunately, we have an entire group of cookbook paramedics out there looking for reasons to hand out every piece of candy in their drug box. Working on intuition is one thing, but blatantly handing out drugs is something entirely different and I think you see more and more of this in the EMS community to some extent.

[fiznat]

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.

Who is talking about blindly implementing protocols? Uh, I guess you're right we shouldnt do that-- but pick on me, not the straw man.

My point was that we often cannot tell how an individual will react to a certain drug. Yes, we generally know how NTG works and what effects (IN GENERAL) it has in the body, however as you and I and every medic here has probably seen: NTG will tank one person's pressure while another will hardly drop at all. It is also true that SOME patients will have obvious indicators of potentially strong reactions to the drug: preload dependent people, for example. Still, there remains the point that there is no way we will ever be able to determine on every patient how strongly they will react to a 0.4mg spray or tab. I have personally found that very few patients know their ejection fraction by heart. To think that you can reliably predict adverse reactions is just silly, which was my point. Fact of the matter is we have to always prepare for the worst, most dangerous reaction, and understand the potential pitfalls. Get a good history, start a line first, be very aware of changes after giving the drug, etc.

This goes to the point of my original question. ...Which was about ASA, by the way. Knowing about potential pitfalls and a "prepare for the worst" mentality seems to contradict giving any kind of med simply "on a hunch." In general, though, ASA is much more benign with much less potential danger than NTG. ...Does this mean we can be a little more liberal with its use, and lower our necessary index of suspicion for it's administration? If so, how much? That's the question.

[AZCEP]

I notice that it hasn't been mentioned that ASA is able to be given within 24 hours of an ACS event, and still maintain efficacy.

Earlier MAY be better, but there is no good reason to get overly excited about it.

[ERDoc]

With the many different ways that ACS can present I wouldn't fault anyone for giving ASA. There have been plenty of pts where I have thought, "well, I guess it could be an atypical presentation, let's just give the ASA so that we are ahead of the game." The only time you shouldn't give ASA is if you are thinking disection or aneurysm. ACS is a scary thing because of the varied and vauge ways it can present. Even with a 12 lead you can't definitely rule out ACS.

[tniuqs]

With the many different ways that ACS can present I wouldn't fault anyone for giving ASA. There have been plenty of pts where I have thought, "well, I guess it could be an atypical presentation, let's just give the ASA so that we are ahead of the game." The only time you shouldn't give ASA is if you are thinking disection or aneurysm. ACS is a scary thing because of the varied and vauge ways it can present. Even with a 12 lead you can't definitely rule out ACS.

AGREED there ERdoc:

ASA is my wonder drug....I use it EVERY chance I get.

The oldest drug known to man (I believe)

NSAID

Analgesic

Antipyretic

Cardioprotective

In fact beneficial for suspected TIAs as well, not that we carry a CT scanner in most rigs.

The best use is for HA associated with drivel or ....hmmm .... over indulgence (which I endorse on a monthly basis) so just where did I put that cook book again?

Dustdevil wrote: "you don't have to deal with to much up there in Canadia."

sorry to tell you but the past Gap training fiasco, this struck FEAR in the hearts of some BLS providers...so much so that they were afraid to "allow a patient to self administration" it for a cold and flu...good grief batman.

I can find very few documents that associate death or serious side effects with one time dosage... long term is a wee bit different for GI complications. All in All patient benefit vs. risk should be ones guide to the galaxy in my humble view.

I started to post out of sarcasm but then I realized that the other side of the coin was not reviewed: That being "witholding" standard accepted care, approved by protocol. Granted if one cannot find any S/S of ACS as ERDoc states but one "suspects" ACS and witholds ASA....are they held accountable?

cheers