Evidence-based use of nitro?

[AZCEP]

To further support ERDoc on this, firefighter523, do you know what percentage of MI's show no ECG changes?

Before you answer consider that NTG is not the first line medication for an acute coronary syndrome. That honor is still held by oxygen. Even with the limited information that has been gathered to date, it is forseeable that NTG will be relegated to the scrap heap of history. If it is in fact worsening the ischemic area, why would we want to continue to use it?

It can be of limited assistance, but it would appear that it is doing more damage than previously thought.

[ERDoc]

It is issues like this (using ntg in MI) that show why we do studies. Things may seem intuitive to one person and not to another. As someone said, ntg is used to vasodilate the coronary arteries to allow blood to flow past the blockage thus perfusing the tissue beyond the block. This seems to make sense, but one could also argue the following. Ntg causes vasodilation such that there is a decrease in forward flow from the reduced coronary perfusion pressure leading to local hypoxia and worsening ischemia/infarction. This seems to make sense too. So, now we have a conundrum. We have two opposing theories that make sense but lead to opposite outcomes. What do we do? We do a study and compare the two. The problem here is that ntg has been so ingrained in cardiac care that you will never get an IRB approval to do a study without it (short of conducting unapproved studies on unwelcomed family members and nosy neighbors in your basement). It is the inability to think past what has been taught to you that makes it hard for someone, like a certain firefighter on this thread, to accept that soomething that we do is not the best medicine. But, that is just my hypothesis and I have no intention of conducting any double blinded, placebo-controlled trials to prove it.

[Dustdevil]

But, that is just my hypothesis and I have no intention of conducting any double blinded, placebo-controlled trials to prove it.

And until such time as somebody does do that, I think we are prudent to go with the current body of knowledge, as well as the empirical evidence, which shows us that when we give NTG, their pain decreases, strongly suggesting that it is helping perfusion more than it could be hurting it.

Of course, this is mildy reminiscent of the MAST controversy, where we assumed that, because the manometer was going up, we were helping the patient, which turned out to be a mistake. While this is not wholly analagous to the NTG scenario, it does illustrate the caution that must be exercised when putting your faith in empirical evidence.

[ERDoc]

And until such time as somebody does do that, I think we are prudent to go with the current body of knowledge, as well as the empirical evidence, which shows us that when we give NTG, their pain decreases, strongly suggesting that it is helping perfusion more than it could be hurting it.

Of course, this is mildy reminiscent of the MAST controversy, where we assumed that, because the manometer was going up, we were helping the patient, which turned out to be a mistake. While this is not wholly analagous to the NTG scenario, it does illustrate the caution that must be exercised when putting your faith in empirical evidence.

I totally agree with you Dust, but in the part of my post you quoted, I was actually referring to where I said, "It is the inability to think past what has been taught to you that makes it hard for someone, like a certain firefighter on this thread, to accept that soomething that we do is not the best medicine." It's late and I may be rambling a little, so I appologize if it doesn't make sense.

[Dustdevil]

I totally agree with you Dust, but in the part of my post you quoted, I was actually referring to where I said, "It is the inability to think past what has been taught to you that makes it hard for someone, like a certain firefighter on this thread, to accept that soomething that we do is not the best medicine." It's late and I may be rambling a little, so I appologize if it doesn't make sense.

:oops:

You mentioned theories twice in there, and when I went back to quote, I just grabbed the wrong one.

And, although I didn't properly address it, your second "theory" was even better than the first.

[reaper]

You also have to keep one thing in mind. For every 10 studies that say something is bad, there are ten studies that say it is the greatest thing in the world. Anyone can make a study work for them!!!

[AnthonyM83]

ER Doc,

You must be a resident still. For one, any experienced doc would not waist his time picking fights, and two. If you aren't aware, nitro is the first round drug for chest pain. If you are having an MI, you are not rushed to a cath lab for nitro therapy, you will recieve therapy to UNCLOG your coronarys, USUALLY a STENT.

My evidence to support the statement is? You are funny!

So, exactly, you have no evidence other than "that's the way we do things here". The POINT of the thread from the start was to FIND evidence for procedures we're already using. So, you're evidence can't be "well, it's the procedure we're already using". The point is that we're questioning the procedure. It's part of critical thinking (another idea why a bachelor's degree would be good for EMS, IMO...to develop those skills).

PS You lose. You made an assumption about ERDoc. You aggressively asked a question about him you didn't already know the answer to and got owned.

[AnthonyM83]

It is issues like this (using ntg in MI) that show why we do studies. Things may seem intuitive to one person and not to another.

And THAT'S why I support studies that support obvious points or things that make people say "duh, we all knew that already". 1 in 100 (or whatever) ends up showing us the obvious truth wasn't actually the truth.