Tiens Pour les directeurs m�dicaux de SMU Dans la panoplie de solutions du soulagement des douleurs cardiaques
Outre l'interdiciton syst�matique du Nitro SL En passant par l'acc�s IV obligatoire pr�-administration Incluant : Les seuils inf�rieurs de T/A et/ou Jumel� � la r�ponse d'une premi�re dose et/ou Jumel� � des indicateurs cliniques Ou, Finalement, � l'utilisation encore plus adapt� du Dx du 12 d�riv�es Probl�matique Tr�s bien illustr� ici dans l'�change qui suit ...� not� les indices d'�l�ments historiques autant que g�ographiques Charles Brault > > > > On 22 Mar 2003, at 21:13, Jon Hoerner wrote: > > > My question to you all... do you really believe it is necessary > for > > > a patient to have IV access before NTG administration in the > > pre-hospital setting??? > > Our system addressed this some years ago. We utilize a systolic > BP of 110 as a bottom-end cut-off for standing-order NTG (which > can be given without an IV, and is expected in fact to be done that > > way). As long as the BP remains above 110/systolic, we can > continue to administer NTG, regardless of whether an IV is in place > > or not. We use a systolic BP of 140 as bottom-end for using a > higher loading of NTG (ntg, 2 minutes, ntg, 5 minutes, ntg, then > ntg > q5 minutes, provided BP remains above 140) for pulmonary edema. > > Our bottom-end systolic BPs were set by the medical directors > based on a combination of studies regarding RVI and their > experience (which suggested that even with a RVI, if they have a > BP of >110, the NTG won't drop them too precipitously...but it will > > drop it enough to prevent us from really dumping their BP with a > second NTG). > > It works well. 17 years, I've never had a patient drop their BP < > 90 > with NTG I've given, and a BP of 90, while a drop for some folks, > is > pretty well tolerated if the patient isn't sitting upright or > standing. > > So...yes, provided the patient has a good enough BP to begin with, > you probably have little initial worry with NTG, IV or not. > Besides, > most places seem to hang those little bags with a micro-drip for > hearts...so what's the difference? Like you can really give a good > fluid challenge with that. > > Bob > Bob Ball > Minneapolis, Minnesota > > "I'd tell you more, but suddenly I am run over by a truck" > -Michael O'Donoghue, "How to Write Good", National Lampoon 1971 > > > > > > Hey list buddies. > > > I function under 2 sets of protocols (one for when I work in > Eastern > PA, the other when I'm in Western PA). There are some significant > differences in these protocols. One major difference that I have > recently debated involves the "Chest pain of suspected cardiac > origin" > protocol. > > One protocol states that the patient must have an IV established > before giving any NTG SL. The Western PA protocol states that NTG > should be given prior to attempting IV access (as long as the usual > conditions are met.. BP above 100 systolic, etc.). Similar > differences occur in the CHF/Pulmonary Edema protocol where the one > does not allow NTG SL until IV, and the other has aggressive NTG > treatment even before IV access. > > My question to you all... do you really believe it is necessary for > a > patient to have IV access before NTG administration in the > pre-hospital setting??? Personally, I don't have any problem giving > NTG before IV access if the BP is greater than 120. If it's between > 100 and 120, I'll quick check for a right sided infarct before > giving > NTG. Those I talk to in Eastern PA say it is crazy to give NTG > before IV. I think you are delaying a needed treatment for an > unnecessary reason. > > As for the Pulmonary Edema protocol, I think it is a no-brainer to > allow NTG before IV access. NTG is a rapid treatment for pulmonary > edema, whereas Lasix will take a while to do its job. > > Soooo.. Share your knowledge and anecdotal tales with me :-) > > > *Jon > > > > My question to you all... do you really believe it is necessary for > a > patient to have IV access before NTG administration in the pre > hospital setting??? > > Jon, > > > > I think that if the patient has never had nitro before they should > have an IV established because you do not know how they are going > to > react and I'd hate to dump ones pressure with No IV in place. For > those who have had it with no adverse reactions...... but......if > they are having a certain type of MI it may dump their pressure > whether they have had it before or not. sooooo...... > > Dawn :-) > > > Clinically an IV prior to NTG or MS is only indicated in the > setting > of an Inferior MI (specifically Inferiors with associated RVI). > SInce these patients are pre-load dependent and both NTG and MS > reduces pre-load (and after-load) you run the risk of hypotension > which will make the ischemia worse. The good news is that if you > "tank them up" with fluid prior to giving these meds and give the > NTG > by drip (it is safer in this setting) and MS in small increments > the > effects will be greatly reduced. In the event administration of > these meds makes the patient hypotensive it can be easily corrected > with fluid administration. > > Just my 2 cents worth > > > Lee Richardson, NREMT-P, LP, CCEMT-P > > > > > Jon, > > This will always be controversial, but consider this. Patients are > prescribed NTG for home use all the time, and they don't start an > IV > on themselves prior to administering the drug. If they have used > NTG > before without any problems, and their pressure is >100, then there > is no reason to delay treatment. On the other hand, the absence of > RVI is no guarantee that the patient will not bottom out with NTG. > Other medical conditions can predispose the patient to sudden > hypotension. > > I agree with you that patients in pulmonary edema, particularly the > hypertensive ones, are not likely to bottom out with NTG. What if > you > are unsuccessful at obtaining IV access? You need to weigh the > benefits of NTG against the risk causing an adverse reaction. For > all > you know, the patient is experiencing chest discomfort, perhaps > even > acute myocardial infarction, secondary to acute coronary vasospasm > that could be totally reversed with NTG. > > That's my take on it. > > Best regards, > > Tom > > > > We had the difference of opinions at my service with most; if not > all > medications given, and what it came down to quite honestly, was; > 'are > you willing to forego the medication in an effort to initiate the > IV?' > > The question arose about the Pulmonary Edema patient, and "what if > you cannot get IV access" after you have administered the NTG? > Excellent question, but it rolls both ways. What if you withhold > the > NTG to get an IV and you are unsuccessful? The AMI patient is the > same, "Time is muscle", we have all had that drilled for years now, > the longer we wait to treat the problem, the more damage that is > constantly occuring. It may take you the duration of the transport > to > finally get an IV, G** knows we have all had one of those patients. > Muscle is deteriorating for the duration, be it 5 minutes or in our > case, nearly 40 minutes. > > If they are hypersensitive to NTG, the half life of NTG is about 1 > to > 4 minutes, raise the feet, and get a line started, the BP will > normalize on it's own, in the meantime, even a BP of 70/- is > acceptable for a short time, (permissive hypotension in medical and > trauma patients). > > My thoughts are that if the patient is within the hemo limits, NTG > should be given without IV access. > > Just my 0.02 wirth....:) > > Mike > > Michael 'TJ' Hatfield EMT-P > > "I would rather you call me and not need me, than need me and not > call me." quem di diligunt > > > > > Jon, > > I think you are right on. I have not ever personally encountered a > patient who is "sensitive to NTG" (20 plus years as EMT-P) but I > suppose like anything else it could and does happen. Recent > studies > (trauma) are indicating that the legs up (trendelenburg or shock > position) really doesn't do a whole lot and probably isn't worth > the > effort. Current stats show about 30-32% of inferior MI's are > associated with RVI. As you say, it seems like a reasonable mode > given the odds. Performing a rapid baseline 12-lead EKG will > provide > you with the most definitive answer but, if you do not have access > to > one then I would have to add that a good clinical assessment may > help you make an educated desicion re: the IV before or after. Due > to > the pathophysiology of an inferior MI patients usually present with > the " oooh he looks sick!" or the "fixin to die" look, that is, the > very pale/ashen/diaphoretic skin with or without the other typical > presentations. > > Lee > > > > > > > __________________________________________________ > Do you Yahoo!? > Yahoo! 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