Would you like fries... err ASA with that?

[jwraider]

My drug sheet lists other anti-coagulants as a "relative" contraindication for ASA.

I'm wondering how you run a chest pain call and make the decision to give aspirin because the decision is made during a rapid sequence of events.

My ideal method for a chest pain is as follows:

Initial assessment + (place PT on 02)

OPQRST while monitor goes on and EMT grabs a BP

Complete a 12 lead while asking SAMPLE and giving ASA 324mg PO

Admin Nitro and move to the ambulance... (In the ambulance IV, then possibly Morphine while booking to the cath lab)

So if the PT has taken ASA already do you not give ASA yourself and assume the PT took it correctly? (I wouldn't) If you're able to determine the PT took say 81mg do you give the rest? (I would)

if the PT is on say coumadin do you withold the ASA? (I'm not sure... I believe it also can inhibit some arterial constriction so it still sounds useful)

Thanks !

[mobey]

Someone here is going to give a basic lesson on why you do not withhold ASA just because the pt is on coumadin, that person is not me however because I cannot recall the exact differences. ASA is an antiplatelet and coumadin is an anticoagulant. They do 2 different jobs, but I will leave that to someone more fluent on this subject than me.

One thing I will suggest though is that IV comes before Nitro. Nitro decreases blood pressure, sometimes too much, why not have a line to correct that problem if you should encounter it? If you 12 lead shows ST elevation in leads II III and AVF aren't you scared of bottoming out thier pressure?

The only contraindications to ASA in my books are bleeds, and allergy. Asthma is the only relative contraindication I know of.

Even if they are on daily dose, I still give it.

[AnthonyM83]

I don't like our EMS system at all, but one of perks IS that you sometimes can do all those things at the same time (though realistically they're never that organized...I mean it takes 1 person for d-strick, 1 to strip bandage for d-stick, 1 to prep IV, one to 12-lead, one to interview, one to document, one to read meds off to documenter, one to put on O2, one to critique the ambulance crews...)

But anyway, we usually give O2 as we hook up to EKG & O2 sat, hook up 12-lead and it just runs whenever it's ready, get history, then decide if NTG/ASA is appropriate, administer, then IV, then 12-lead ready, then load.

I've learned on EMTCity how quickly someone can bottom out on NTG and how important ASA is, but my preference would be ASA on-board as soon as possible, then establish IV, then NTG. ASA should probably precede 12-lead even?

And yes, even if they took ASA. we repeat 162 dosage (which is the max we usually give anyway...not sure why we don't give more...ER always asks that....we work in a mother may I system so base tells us this stuff)

[JakeEMTP]

I like to (and it is encouraged by our Medical Director) acquire a 12 Lead prior to the administration of O2. I think it is a more accurate 12 Lead. I would never withhold O2 if they truly were in some respiratory distress, but the time required for the 12 Lead and the administration of O2 is minimal.

324mg ASA would then be administered to the pt. As Mobey mentioned, IV prior to the administration of NTG due to the reasons mentioned.

Anthony, I wouldn't give ASA prior to the 12 Lead. How can we start treating the pt. if we're not exactly sure what is wrong? A 12 Lead is part of the assessment of the CP patient IMHO. Let's see what's going on first. We will treat the patient accordingly, but I like to have a 12 Lead prior to any interventions. Kinda anal that way.

Be safe out there.

[Just Plain Ruff]

I always went this way

Treat lifethreats first - ABC compromised then treat and fix but if I'm able I always got the 12 lead first.

Remember, any intervention we do like ASA, Nitro, IV, Oxygen can ellicit a change in the 12 lead so I always(mostly) got a 12 lead first prior to anything else.

That's why there are two of you all there. One to do the 12 lead and the other to get the other stuff ready to put on the patient. Once the 12 lead is done then truly how long does putting oxygen on the patitnt take?

If you are lucky to have 37 people and a dalmation there to help you out then all your equipment should be ready for the end of your 12 lead.

I do agree that oxygen can change the 12 lead. I've seen a patient's 12 lead change just with the administration of oxygen.

[firedoc5]

It is very important to have your IV before NTG. ASA is probably the only drug I would give before having an IV established, but would still prefer it. If the pt. is having chest pain only and no raspatory distress then go ahead and do a 12 Lead, but if they do have SOB then by all means put on O2 ASAP. If I remember right I was told by a cardiologist that ASA does not have an analgesic effect on the cardiac muscles directly. But acting as a blood thinner and helping the heart to work with a little less stress can diminish the pain, especially if an MI is occurring at that time. I might have someone correct me on that, but that was my understanding from the doc at an ACLS Instructor's seminar.

Be very aware of allergies and asthma. I'm allergic myself and so I can imagine how it could compromise someone having an MI.

[jwraider]

Thanks guys.

Seems like the method around here is Nitro before IV but the IV is coming quickly after. I'll keep what you said in mind though when I'm on my own.

I did some research thanks for pointing out the difference between anti-platelets and anti-coagulants (one limits platelet activity while the other stops the liver from producing coagulating factors if I have it right?)

So just to double check, do you still give ASA if the PT is on some kind of anti-coagulant (coumadin) or anti-platelet (ASA, plavix) or something like heparin or Refludan? (they block thrombin)

[reaper]

I will give ASA, except if they are allergic to it.

If pt tells me they took ASA prior to arrival and can tell me what type, then I change how I give it.

If they take a 325mg, I will give additional 162mg.

If they have taken 81mg, then I give 243mg.

Always try to est. an IV prior to NTG. You may not be able to find one, after you administer the NTG.

[EMS49393]

Blood-thinning agents, down and dirty style.

Aspirin: inhibits platelet formation

Coumadin: inhibits clotting factors II (prothrombin), VII, IX, X

Plavix: blocks ADP receptors, ADP causes platelets to bind

Heparin: binds to antithrombin III

Basically, aspirin is a "platelet slicker" while Coumadin and heparin are anticoagulants.

My former service had the availability of aspirin, heparin, nitro sub-ligual, nitro drips, and retavase. Our goal was obtaining a 12-lead within the first two minutes of patient contact. Rapid assessment and treatment of life-threats and obtaining a 12-lead were paramount over anything. A 15-lead was obtained shortly thereafter. Our basics were trained in proper ECG placement and required little direction freeing the paramedic up for rapid assessment, treatment of life-threats, and if all goes well, obtaining IV access.

The 12-lead determined the course of action to follow. Of course, all of these treatments are contigent on any indications or contraindications. A patient with chest pain, no STEMI present, would get oxygen, aspirin, nitro sub-ligual, morphine, and a nitro drip (if nitro was effective in pain relief) and a call to medical control. If the provider honestly felt the chest pain was cardiac in nature, we could request heparin. The patient presenting with a STEMI, not involving the right ventricle, we could proceed the same as above, and request retavase in addition to heparin, if the patient met the criteria for thrombolytics. A patient presenting with a RVI STEMI would be treated the same as the other STEMI with the exception of sub-lingual nitro. That patient would get a nitro-drip starting at 10 mcg/min and titrated to effect, or blood pressure, whichever comes first. Often heparin would be withheld in instances where the patient was already on Coumadin or Plavix. Aspirin was never withheld, unless it was contraindicated for the patient. I give it regardless of whether the patient takes daily aspirin. As with any home medication, you don't know if it's still in date, has been stored properly, etc.

It's important to get that initial 12-lead, and get it quick. You are the only one that will be able to document that ECG, and our doctors appreciate them. It's also a good habit to run series 12-leads on your patient. I like to perform one a few minutes after an intervention or medication. You give oxygen, aspirin, a nitro, get another 12-lead right before you give another nitro, and so on. Hopefully you'll see a trend, and that information is often invaluable to a cardiologist.

It's also VERY imporant to get IV access before you administer nitro. Nitro drips start at a 10 mcg/min while a sub-lingual nitro is 400 mcg in one dose. Think of a funnel. Once the blood gets to the drain, it's nearly impossible to push it back up. If you put your patient in that situation, you suck. Do a minute of prevention, get that IV.

If you have a patient that has a STEMI and you see cath lab written across their forehead, and you have time in transport, go ahead and get that second line. Doesn't need to have fluid, a saline lock will do. Try hard to get two nice 18 gauge IV's in these patients, the cath lab will thank you, and so will your patients myocardium. Try to get one in the A/C, they need a good proximal IV for any emergency cardiac drugs they may need to administer. If you save the cath lab three minutes by establishing two patent IV's, you will have saved your patients heart muscle three minutes of tissue death.

I wanted this to be a nice, short post. That's difficult to achieve when I start talking hearts. If you have any other questions, I'll do my best to answer them. I may have to dig through years worth of paperwork to find the answer, but I will find the answer.

[saboats]

Aspirin: inhibits platelet formation

Coumadin: inhibits clotting factors II (prothrombin), VII, IX, X

Plavix: blocks ADP receptors, ADP causes platelets to bind

Heparin: binds to antithrombin III

This is all correct, sort of. Asprin does not actually inhibit platlet formation, it inhibits platelet aggregation by blocking the formation of thromboxane A2 (Ta2) {Ta2 causes to aggregate by basically making them sticky, and it causes arteries to contrict}.

ASA is the only treatment, save angioplasty/CABG that has been proven to reduce mortaility is association with AMI. NTG hasn't/GP2B3A inhibitors (integrillin) hasn't, MSO4 hasn't. Only ASA.

Now as far as giving ASA pre/post IV. Give it as soon as your protocols allow as soon as you recognize Chest Pain thought to be associated with AMI. It's onset is 5-30mins, so the sooner you get it in, the better off the patient will be. I can not think of any reason to withhold ASA for IV placement, as it is a BLS skill set in many states, and a true BLS Standard of care in most areas.

?To give when on "other blood thinners" YES, unless local protocols say otherwise, give it, and give it early.

JakeEMT: you stated that you would not give it prior to the 12 lead; I have to ask, why? With it's delayed onset of action, and the pharmacokinetics of the drug, it will have no impact on your tracing (O2 may flatten out ST Elevation, sometimes) but ASA will not have any impact on the tracing. And remember that >50% of all MI patients rule in by enzyme markers in the hospital and have no ititial ECG changes. I would say, give the ASA, the 12 lead won't change...

My 2 Cents.....