Nitro vs Morphine

Specialties CCU

Published

In a coronary care unit, how do you make the decision to give nitro-vs-morphine for unrelieved cp? The example I am thinking of is a guy who came in thru the ED with CP, no EKG changes, and then continued to have cp. Every two hours he recieved morphine. BP 120s-130s. And what would you expect to see done differently for the same unrelieved cp but with initial EKG changes?

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Unremitting CP gets a NTG gtt and intermittent MS. And a trip to the cath lab.

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Specializes in ER/ICU/Flight.

It depends. Everyone with chest pain obviously doesn't need to go to the cath lab.

Was the pt's troponin elevated? Did he have a NSTEMI? Is the pain reproducible? Aggravation/alleviation?

If he was having a STEMI, then yes absolutely: ntg gtt, prn mso4, cath lab, etc. the usual cardiac workup. But there are many things in your chest other than your heart which can cause pain.

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Specializes in Cardiac, Derm, OB.

Keep a close eye on them and if it does not relieve call the on call cardi to report. Had one of these guys much like yours. Young (38ish), no initial ekg changes, Morphine prn, and BP good. However, still c/o CP. Called my on call cardi and I guess he was afraid I would call him back at 3am :) (hehe) so he swung over and said "lets take him for an investigational cath". Well what do you know he was rolling back through the doors asap and prepping for emergency CABG x 3. So just b/c there is no initial change, does not mean there is not something going on! If the pain does not stop, be vigilant in reassessment and report it!

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It depends. Everyone with chest pain obviously doesn't need to go to the cath lab.

Was the pt's troponin elevated? Did he have a NSTEMI? Is the pain reproducible? Aggravation/alleviation?

If he was having a STEMI, then yes absolutely: ntg gtt, prn mso4, cath lab, etc. the usual cardiac workup. But there are many things in your chest other than your heart which can cause pain.

Not everyone with CP.

But patients with unremitting CP despite NTG and antiplatelet/anticoagulation, yes. Unless they are not a PCI/CABG candidate.

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Specializes in ER/ICU/Flight.
Not everyone with CP.

But patients with unremitting CP despite NTG and antiplatelet/anticoagulation, yes. Unless they are not a PCI/CABG candidate.

what about unremitting chest pain caused by esophageal vasospasms? or costochondritis?

an incomplete assessment and workup can overlook things like that. even though ntg has been documented to alleviate cp from non-cardiac sources, but it hasn't worked at least as many times as it has in those cases.

i'm not arguing with you, just highlighting how many different potential reasons there could be that a) have nothing to do with your heart and b) don't need a cath lab to diagnose.

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what about unremitting chest pain caused by esophageal vasospasms? or costochondritis?

an incomplete assessment and workup can overlook things like that. even though ntg has been documented to alleviate cp from non-cardiac sources, but it hasn't worked at least as many times as it has in those cases.

i'm not arguing with you, just highlighting how many different potential reasons there could be that a) have nothing to do with your heart and b) don't need a cath lab to diagnose.

the OP was discussing patients admitted to a coronary care unit...which means they have made it there on the basis of CP PLUS one of the following- ECG changes, enzymes, angina hx, family hx, or risk factors (to name a few). That is the context of the question.

yes you are free to tease out the multiple causes of noncardiac CP but the OP refers to a pt in a coronary unit, which means they have moderate to high probability.

In real world practice these pts will be admitted and cathed. There is a reason we have so many clean caths- b/c no pretest probability is 100% sens/spec. If it was we'd all (hopefully) be paying lower health insurance premiums.

A cardiologist with a patient who has any of the above mentioned hx/profile and unremitting CP is likely NOT going to sit on them, expose themselves to a neg outcome and liability b/c the pt might have costochonditis. Pts in the coronary unit have already had the "complete assessment and w/u". No w/u is 100% but that is why we study the statistics on these tests in the first place...

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Specializes in ER/ICU/Flight.
the OP was discussing patients admitted to a coronary care unit...which means they have made it there on the basis of CP PLUS one of the following- ECG changes, enzymes, angina hx, family hx, or risk factors (to name a few). That is the context of the question.

yes you are free to tease out the multiple causes of noncardiac CP but the OP refers to a pt in a coronary unit, which means they have moderate to high probability.

In real world practice these pts will be admitted and cathed. There is a reason we have so many clean caths- b/c no pretest probability is 100% sens/spec. If it was we'd all (hopefully) be paying lower health insurance premiums.

A cardiologist with a patient who has any of the above mentioned hx/profile and unremitting CP is likely NOT going to sit on them, expose themselves to a neg outcome and liability b/c the pt might have costochonditis. Pts in the coronary unit have already had the "complete assessment and w/u". No w/u is 100% but that is why we study the statistics on these tests in the first place...

i work in the areas you describe and have for many years. i am very comfortable in my understanding/working knowledge of taking care of these patients. your blanket statements include some patients but not all.

there are many reasons why not all of these patients are taken to the cath lab, namely when they rule IN for a non-cardiac source. a reason which you fail to mention.

thanks for your opinions and good luck in the future.

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I appreciate that- my point is that it's not a blanket statement.

The OP posits a specific scenario- a pt with initial ECG changes and unreleived CP, refractory to initial medical therapy.

The medical necessity aside, there is the medicolegal concern; and even though things look differently in retrospect it is hard to make a case that a pt with ECG changes and unreleived CP should not get an angiogram. I would go so far to say that even with a potential noncardiac source many if not most cardiologists would have diffculty justifying sitting on that pt.

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Unremitting CP gets a NTG gtt and intermittent MS. And a trip to the cath lab.

That's what I say!

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Specializes in PCU.

For unrelieved CP w/initial EKG changes: depending on changes, in our ER we give NTG SL, morphine, O2, ASA, cardiac enzymes, rainbow draw. If stable, cath in AM; unstable, stat cath. May start NTG gtt.

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previous poster wrote 'ruled in from a non cardiac source-? like anemia/shock trauma? -i sense a teachable moment for me please elaborate so i can see ifm thinking along the same lines thanks!

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