[banbulance]

I'm new to this site and I'm currently studying to be an EMT.
I am interested in nursing and would like to be a traige nurse eventually....

I have a question that I need to clarify because it was discussed in class...
maybe someone can help.

You respond to a call where an elderly man is complaining of cardiac related chest pain and presents with a pulse of 48 beats per minute and a BP of 100/50, resps are 8/minute, pale, cool skin. Your paramedic partner decides against Nitro. Based on your undersanding of cardiac physiology, explain the rational for his decision

Thanks

[KellieNurse06]

ummm...easy..think about it....what does Nitro do???? There you will have your answer.....oh, and throw on some 02 also....

[MomNRN]

After you slap on the oxygen, throw a line in him, and give him aspirin!

[medic2ernurse2b]

Nitro dilates the blood vessels which in turn will lower the blood pressure even more.

[banbulance]

Thank guys ...I guess that was a silly question.
Still new! Still learnin!

[RunnerRN]

You're allowed to learn Just remember that you don't want to give any form of NTG is the BP is at all sketchy. I go so far to say don't even give SL NTG if you don't have an IV in your pt. I've heard too many ghost stories about pts dropping their pressure after 1 SL NTG (the hypotension is very responsive to a fluid bolus, but wouldn't you rather just open up the fluids instead of working your butt off to GET an IV in at that point?)

[canoehead]

Once the airway and breathing is taken care of the BP may come up, chest pain may ease. Airway is always first.

[Aliakey]

Listen to the experience above... they know what they're talkin' about.

As an EMT-Int. with a few years on the street, maybe these bits I had to learn myself will help. I'm guessing that you are studying at the EMT-B level right now?

Remember that oxygen is the greatest medicine that is also the most overlooked. Like mentioned above, get the O2 on that patient. It may be the simplest thing in the book, but is one of the most important. The heart will most likely respond positively to increased oxygenation (your textbook should cite that), and if the patient is truely having an MI, you can help prevent further heart muscle damage simply by oxygenating the patient better. Nitro won't do that directly. It helps get the blood to the heart easier (bigger vessels), but the blood is only as good as the amount of oxygen it carries. The pain the patient feels in his chest is a result of muscle tissue literally dying from lack of oxygen.

And like mentioned above, a good paramedic will have an IV established in the above-mentioned patient before Nitro is ever considered. You cannot predict how much effect one spray of Nitro will have on the blood pressure. With this in mind, a good medic will also use protocols as a guideline and *not* a hard-n-fast rule.

When you are "on the truck" as an EMT, you operate under a physician's license with written protocols that guide what you can and cannot do based on vital signs, signs/symptoms of the patient, etc. Protocols in my area allow you to administer Nitro for chest pain if the systolic BP is above 90. You will NEVER see me give a patient his first Nitro if his systolic BP is anywhere around 90, even 100 or 110. I simply don't know if it will drop only 10, or 50 after that first SL spray. I also don't give Nitro without O2 on board, ASA given, and an IV established first. And, I have never had a physician disagree with my rational for skipping the Nitro on patients similar to your scenerio. As a future medic, you need to look beyond the vital signs and ask yourself: 1. Does the patient's signs/symptoms warrant the treatment, and 2. What will happen (both good and bad) if I give that treatment? You can cause more harm than good. And causing more harm is not why we are out there in the field.

Sadly, some of the new medics out there are anxious to overtreat the patient. "For every ALS skill learned, a BLS skill is forgotten". Remember the basics (oxygen, for example) and save the ALS (IV meds, pacing, etc.) for situations that you know require them to prevent the patient from deterioring.

Anyway, just my two pennies' worth. I know it barely addressed your question on the physiology, but I have a feeling your instructor may be wanting you to look beyond just the Nitro in this case.

[Gromit]

I agree with the above as well.

when I was in EMS, we went with the basics first (least invasive to invasive) Oxygen and aspirin (the oxygen may well take away the pain, if its ischemic in nature -which is also what the nitro is doing (in part, by its vasodilation decreasing the load) but won't drop the pressure. This guys' heart is beating slow (or the pvcs are giving you an artificially low pulse count -if the pulse is weak, and the guy is tossing pvcs, your count is likely off -a monitor would help to determine that).
Back when I was in EMS, we had folks who were always quick to use the most meds -I wasn't one of 'em. You step back, take a deep breath, and do good basic life support (non-invasive care) then ACLS as needed. Your patients' chances of walking out of the facility will be better (one step at a time).

[LMPhilbric]

You also need to remember that symptomatic bradycardia is defined as bradycardia that causes hypotension, chest pain or other symptoms. It's possible that the chest pain is caused by the bradycardia, so if the EKG doesn't indicate ischemic changes, you could try atropine. You can also put on an external pacer. Sometimes just increasing the pt's rate may correct the chest pain. If he's having an inferior MI, ASA, O2, IV ns 250 cc bolus, pacer and get his butt to the ER so they can get him to the cath lab for rescue angioplasty. I would be very nervous about giving Nitro to a pt with a BP 100/50 in this case. If I had to do it, I would probably prefer to use IV NTG which has a half-life of 1-2 minutes. If the pressure bottoms out, you can turn the NTG off. You can't get SL nitro back.