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.
On an ambulance call as a new EMT about 30 years ago the paramedic gave the patient NTG. Then we had to carry her down a flight of stairs. At the bottom of the stairs SURPRISE!!! unconscious patient. We picked up the foot end of the stretcher for a minute or two and the patient came to and we went on with the transport.
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.
I would hope that patients that have been prescribed NTG at home have been tested in their PMD's office for excessive sensitivity to its side effects. Doesn't mean that they won't drop their BP the next time they use it, though.
Here in NJ, basic EMTs can give patients their own NTG tab or spray SL x 3 PRN for continued pain and SBP >= 110. The federal curriculum standard for EMT-B is 90!! The EMT protocol was set where it is here because the ALS standing order for paramedics is 110 and they wanted to avoid confusion. With EMTs giving this, there is NO IV, NO EKG beforehand. The criteria is the NTG is prescribed for the patient, it is not expired, their systolic pressure is >= 110, they have pain in their chest, and they have not taken either an ED drug or 3+ NTGs already.
As a medic in the field and as an RN, I've had a few patients seriously dip their pressure after giving NTG, but always had a line in place. Lay them flat, open the fluids up and they seem to come back around pretty quickly. These were always naive patients, though, that is, patients that have never had NTG before. Never had one do that who was prescribed NTG for use at home.
So to the poster that stated nitro is contradicted in Right sided MI and I'm to "study up". First off, ekg showed NSR, no ST changes, and showing no old or new infart. The first gentleman I gave the nitro to had never had it before, so this was all new to him. I always make sure that the male pt's have NOT taken viagra because that does have contradictions. I think this was just two pts, two days apart that were just sensitive to it. When I am applying nitro paste, I always wear gloves to avoid it touching my hands.
And in regards to EMT's in the field assisting pt's with their own Nitro, mostly in my area we are all ALS so usually it is the medic giving it and never without a line in place first. But it is in the scope of practice for EMTs to assist pt with taking their own nitro.
I'm quite sure Gila wasn't asking how to diagnose a RVI given his expertise. I'm equally sure he was responding to a snarky remark from another poster.
+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.
Ugh! Absolutely awful feeling! I learned the hard way on my 3rd day working as an RN to ALWAYS, ALWAYS, ALWAYS wear gloves when handling NTP Never made that mistake again...
Everyone is different and people tolerate ntg differently. I have seen people with pressure of 110 sys tolerate tng x3 with no change then some people with pressure of 180 sys drop to 90. It just happens, no biggie, usually an easy fix;)
NTG will cause hypotension and bradycardia. The effects of this are almost always transient, and will go away on their own. So while having a line and opening the fluids up might make US feel better, the 50-100mls of fluid infused before the next BP takes doesn't really have much effect.
This is NOT the case for preload dependent MIs however.
no surprise with the hypotension. You know this can happen. It does happen... often. Who would be laughing at you? No one would ever laugh that I know, because it happens... to all of us... You can and DO expect this. Were they on Viagra or Levitra? This precipitous drop has happened to me when the EMT's prehospital gave NTG then the BP dropped so on arrival, I ask this question as well... don't worry, you have an IV....
GilaRRT
1,905 Posts
How exactly do you know this? Not every hypotensive chest pain following GTN will be a RVI.