chest pain bad, nitrates good
Posted 16 December 2012 - 06:34 AM
History of bypass surgery some 20+ years prior, AF, hypertension. Had once instance of rapid AF about a year prior that was medically managed. Recently well and reasonably healthy otherwise
Meds were metoprolol, a dihydropyridine ca channel blocker, and was warfarinized. Also had a nitrate spray that was “hardly ever used”
ECG showed rapid AF (ventricular rate between 130-160), hemodynamically stable and well perfused…initial SBP was 160 or so, GCS 15, no evidence of failure/pulmonary oedema, etc etc.
My partner, who was treating, began treating the patient with nitrates as he had chest pain. Aside from dropping his blood pressure over the next to 10-15 minutes, he still remained adequately perfused. The pain marginally decreased.
The obvious concern was that he was at risk of losing his pre-load and was in obvious need of some rate control, but what really surprised me was that the hospital emerg staff continued the nitrate regime.
It never fails to amaze me how the chest pain = nitrate mentality is so strongly engrained into the mind of so many health care workers, both EMSers and non, that it’s almost primeval. I’ve lost count how many times I’ve attended a doctor surgery for a chest pain patient who has received nitrates but no aspirin. More worrying is that one of the most dangerous drugs we carry (in my opinion) can be administered by someone with 115hrs training and is host of a whole cascade of adverse reactions, whilst anti-platelet agents which have a proven benefit in ACS are not in the basic scope.
Note: I work in an upsidedown non-US system with volunteers that can give aspirin but not nitriates
I don’t want to turn this into a ALS vs BLS medication discussion, but just felt like ranting a bit on the topic. Other observations are most welcome
Posted 16 December 2012 - 09:20 AM
We have for example stopped giving O2 to chest pain patients and now give amiodarone and adenosine so we have moved forward. But on the whole, we still manage the majority of chest pain patients with GTN, aspirin and morphine, and have done so for a number of years without really any changes. So maybe its time so research was done on whether this is still the golden standard of chest pain management?
Posted 16 December 2012 - 11:24 AM
I definitely agree that given the original scenario, nitro is not the correct treatment. The chest pain is most likely from the heart that is running a marathon. Slow the rate down first and see what happens.
Posted 16 December 2012 - 12:25 PM
Posted 16 December 2012 - 12:51 PM
I am just about the dumbest motherfucker out there, I mean seriously I had to be shown how to turn on the oxygen and reminded that while ceftriaxone and vecuronium are both powder for resonstitution that you cannot get the two mixed up cos if you do that the bloke with an infection will stop talking and turn awful blue and you will get a finger wagging form the boss ... anyway, if me, the stupidest bastard to ever set foot on the big white van, can figure out the GTN is for myocardial ischaemia (angina) and the primary treatment in AF is rate control doesn't that mean that the rest of you blokes should be able to figure it out?
GTN is a good idea in patients with exertional angina or cardiogenic pulmonary edema. I am not so sure GTN has a role in STEMI or acute myocardial infarction but this remains to be borne out by any evidence; right now it is just a feeling ....
Posted 16 December 2012 - 04:44 PM
Posted 16 December 2012 - 08:07 PM
Fix the rate first dummies... it ain't rocket science.
PS.. for those that are interested, the rate was 37 to 40 afib. Patient had a new prescription for a CA channel blocker after a previous day's admission to the ER for uncontrolled afib (afib RVR for medics here in the wild wild west). Slow push of calcium chloride fixed her right up.
Posted 16 December 2012 - 09:51 PM
So 30 yrs in ems and vol fire...16 yrs as a paramedic....found that a good assessment...and ACS and chest pains...considering your BLS and ALS protocols.....keep it simple....baseline v/s telemetry.12 lead high flow oxygen. Aspirin nitro titrate to blood pressure and morphine ....rapid transport if necessary....confidence in your ability and calming bedside smile......thinking ......what would i do for my own family member...thanks
um ... telemetery? high flow oxygen? rapid transport? supreme fail much?
Posted 16 December 2012 - 10:55 PM
Posted 16 December 2012 - 11:15 PM
Easy Kiwi, he's new here and he may be from NY or NJ. He can only do what is system allows him. Give him a chance.
You didn't give me a chance, you called security on me after I got into a fight with the Surgical Registrar because he was turfing the patient back to Medical because "he didn't need an operation".
I wouldn't want any of my family with chest pain to get high flow oxygen, even if it was in a protocol, not sure about this bloke
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