Dropping pressures with nitro. Anyone experience this??

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Specializes in Emergency Medicine.

This just might be a fluke experience that happened in two days but the drops have been substantial that it kinda makes me wonder if this is commen to drop to these extremes or indeed just a freak two day experience. Heres the low down............

Day one: Fairly healthy older gentlemen came in with substernal CP. NSR, vitals in the 130/90 range. Gave 4 81mg asa and ordered SL nitro 0.4, x3 q.5 min for CP. Hold if systolic

Day two: Covering another pt while nurse goes to lunch. Substernal cp. Sinus tach on the monitor. BP 120/something. Give one SL nitro with not much relief. 5min later cycle pressure. Still around 110/something. 2nd SL nitro. Pt states he is lighteheaded. Lay pt supine, bump up o2, cycle pressure. 74 systolic. DAMNIT! DR. notified, nurse's now laughing at me, pt gets a 500 fluid bolus.

I have worked in the ER for almost two years, pre hospital almost 15 years. I have never had this happen before. I understand it is a vasodilator but geesh. No other medications were being administered other than asa. No obvious infarct going on, no ST changes before or after. Just drastic dropping of the pressures easily reversed by fluid boluses.

So, any other experiences like this? This is why I NEVER given nitro without iv access.

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Specializes in ER, Trauma.

Some people are hyper sensitive to NTG. Experienced staff are careful not to give NTG till there's an IV established so you can give a fluid bolus if there's a big BP drop. I see it a few times per year, and found out by experience that a single dose of nitro drops my own systolic by 40 points. Then I think back to how casually I've handled NTG paste!

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Specializes in Emergency & Trauma/Adult ICU.

Not uncommon in my experience ... and it explains the reason why I would never give NTG without having IV access already in place ... not "putting in a line" but the line is there and ready to go.

This is the intended purpose of NTG after all ... reducing preload. Relief of CP with NTG is helpful in a diagnostic sense, but that's not the reason that we use it.

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It's common with right sided involvement. I've gotten into the habit of assessing V4R prior to GTN.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.

Some people are just more sensitive to it, but for your Knowledge:

If you do a 12 lead EKG and it shows an inferior MI (elevation II, III, and AVF) ALWAYS ALWAYS ALWAYS do a right sided EKG or at least V4 on the right to make sure they are not infarcting there right ventricle!

The right ventricle is dependent on preload and afterload and just one tab of NTG can turn even a mildly hypertensive patient into a severely hypotensive patient if they happen to be having a right ventricular infarct. You can have isolated right ventrcular infarcts, but it is extremely rare. Hense the treatment for hypotensive patients with right sided involvement is fluid, thsese patients may need up to 3 liters!!

Also watch the amount of fluids you are giving these patients (aside from the R infarct patients), especially if cardiac is a likely causee of their chest pain/discomfort. Just because there is no St segment elevation on the EKG doesn't mean they are not having an MI, so to much fluid could put them into heart failure. Remember NTG SL is very self limiting so usually placing them supine if they can tolerate it and a small bolus will fix them.

Happy

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Very common and also a reason to ask if the patient has taken Viagra prior to administering it.

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Specializes in ER, Family Practice, Free Clinics.

+1 saying yes, not uncommon. have seen it enough to not be surprised anymore. Also, unknowingly came into contact with some paste once and wound up on the floor-its a way way ugly feeling. Very yucky.

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Nitro in any form (SL,TD,IV) is a vadodilator, which in turn has a side effect of dropping BP. Any patient recieving nitro should have cardiac monitoring/BP monitoring.

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Specializes in Home Health.

I didn't realize nitro could be so volatile, as concerns dropping the b/p. Am in Home Health and a number of patients have the 0.4 mg SL tabs in the home for use. I can't imagine what might happen to one of these elderly, frail patients home alone if their b/p dropped so rapidly. My husband has the SL nitro tabs, had MI 2 years ago with stenting and been well since then. Looks like I'll have to do some teaching this weekend. Thanks for the info.

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Specializes in Med Surg, ER, OR.

Good job for picking up on this golden point!

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Specializes in ED, ICU, Education.

Right sided MI. Nitroglycerin is contraindicted. Study up!

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Specializes in tele, oncology.

I'm one of those people who is sensitive to it...if I get any on my fingers when gooping up the patches at work and don't immediately wash it off, I'll drop my SBP by about 15. And that's just with a squidge of it!

I'm also really sensitive to morphine. Post-op they had to take my PCA away b/c even with fluids @ 125/hr, I couldn't keep my systolic greater than 80.

I joke that if I ever have chest pain, I'll end up in ICU on pressors just b/c of what the morphine/NTG combo would do to me.

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