Nitro

[JM15 386]

I am doing a paper on the uses of Nitroglycerin. I wanted to get a little more background on its uses in pre-hospital care. Also, I would like to get oppinnions from paramedics who use it. If anyone can help out that would be greatly appreciated. Thanks

[50-65 205]

Uses: to give someone a really bad headache.

Seriously, can't help you but good luck with the paper. Let us know how it goes and share any good info you get.

This past summer I worked with a blasting company. Just the vapors from the nitro in the dynamite would give me a headache and that was just from going into the truck to get inventory for the blasters/laborers.

[ckroll 101]

I am doing a paper on the uses of Nitroglycerin. I wanted to get a little more background on its uses in pre-hospital care. Also, I would like to get oppinnions from paramedics who use it. If anyone can help out that would be greatly appreciated. Thanks

Dr. Stamler at Duke has an interesting paper from 2002 on the chemistry of nitro and how it is converted to nitric oxide in the body.

To understand or to explain nitro in a useful way in a paper, I think one needs to go into what conditions it is used for. My limited understanding of NTG's by product, nitric oxide, is that it dilates blood vessels, both arteries and veins. Dilation of the coronary arteries feeding the heart, is the effect that makes it useful for treating angina. That said, I believe that while it relieves symptoms, research has not shown it to improve overall outcome for the patient.

The more profound effect of nitrates is to dilate veins. This is the effect one is looking for in the treatment of CHF/pulmonary edema. At one time, I had the incorrect notion that nitro was useful/dangerous because it dropped BP. While true, it is a too simple a way to think about it. Nitro, by dilating veins, is increasing the spacial volume of the venous system. This reduces how much blood is returned to the heart a.k.a. preload. This is why it is problematic for right sided AMI. If the right side of the heart is already having a hard time getting enough blood moved into the lungs to move on to the left side of the heart, then reducing how much blood the right side has to pump in the first place can be problematic.

My first experience with nitro was a few minutes into my first shift as a medic. I told the person orienting me that I had not done many 12 leads in the field, so we did them on everyone. The first patient was an elderly gentleman who had the flu. He was weak, had passed out, felt achy, threw up. And the 12 lead had honking depressions in II, III, AVF, just classic right side MI. As we were only a few minutes out from the ED, and the patient did not report chest pain [he described tightness in his shoulders] I did skills but skipped the nitro, which the cardiologist immediately ordered.... and before I even had time to feel like an idiot for not giving it..., he was calling for a crash cart. The patient did just fine, but he dropped like a rock for a minute or two.

There are something like 6 different etiologies for CHF depending on what the problem is that is causing fluid to move out of the circulatory system and into the alveoli, so all CHF may not respond in the same way to nitro. In addition, arterial pressures on the pulmonary side can be much different from those on the systemic side. I don't know if the effect of nitro for relieving symptoms of CHF is due to lesser blood volume inbound to the lungs or to larger spatial volume on the pulmonary outbound side.... or maybe something else entirely.

I have heard it suggested, and it sounds reasonable, that not only does high pulmonary pressure cause fluid to move into alveoli, but also that lower blood pressure actually helps the heart beat more efficiently and that is what relieves the CHF. I had a call reviewed where the patient had classic, moderate, CHF, and I had given lasix, but as his BP was 130/80, I had held off on nitro on the assumption that his pressure was not the problem and I was unsure if dropping his pressure was useful. In the resulting discussion, compelling cases were made by learned people on both sides for letting the ED give the nitro in that situation as they can do it as an IV drip which is more effective, and for giving nitro in the field because it can improve the efficiency of the heart independent of the pressure. I was won over to the position that nitro in the field in that situation was the better choice.

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In any event, nitro is used with companion drugs, either with blood thinners for MI or diuretics for CHF, so it should not be considered alone.

There is lots of good literature out there. Let us know what you find and good luck with your paper.

[NWFDMedic 58]

Uses: to give someone a really bad headache.

Seriously, can't help you but good luck with the paper. Let us know how it goes and share any good info you get.

This past summer I worked with a blasting company. Just the vapors from the nitro in the dynamite would give me a headache and that was just from going into the truck to get inventory for the blasters/laborers.

Honestly, we want to bring skills to BLS when EMT's can only tell you that Nitroglycerin (a medication they are allowed to administer) gives you a headache. Ask any paramedic who had to write out drug cards if this would suffice for an explanation for a drug.

[Guest alsfirefighter]

Honestly, we want to bring skills to BLS when EMT's can only tell you that Nitroglycerin (a medication they are allowed to administer) gives you a headache. Ask any paramedic who had to write out drug cards if this would suffice for an explanation for a drug.

LOL. I still have mine bro...

I have utilized NTG with success for CHF and as mentioned as first line for AMI, angine, hypertension etc. One thing that I do notice when training medic students or proctoring newer medics is they often do not follow up their initial NTG admin. As long as the BP holds and the signs/symptoms appropriate for the condition being treated is there, I will continue to give it until the vitals contraindicate its use or I arrive. I also prefer nitro spray over the tabs. There is possibility that nitro tabs will lose some of their potency over time when exposed to air.

Another nitro tool in the kit which I use at a high percentage of time is nitro paste. Not having the ability to administer IV nitro, the paste gives me the ability to maintain some of the vasodilation achieved with sublingual admin.

On a side note, although not a field treatment, nitro paste is also used to improve circulation in lower extremities when applied to the legs or feet. There is also reported uses to treat headaches by applying paste to the legs.

[50-65 205]

Honestly, we want to bring skills to BLS when EMT's can only tell you that Nitroglycerin (a medication they are allowed to administer) gives you a headache. Ask any paramedic who had to write out drug cards if this would suffice for an explanation for a drug.

It was said lightheartedly. Not to offend any medic. As a former student who ran out of money long before the pharmacology class, I do know how hard that course can be. Seriously, I do know that NTG is a vasodialator. I did not know about the other stuff mentioned by ckroll. Very informative.

I look forward to reading more on this subject here. Although I can't do school right now, I still try to learn something everyday.

[NYMedic37 22]

LOL. I still have mine bro...

I have utilized NTG with success for CHF and as mentioned as first line for AMI, angine, hypertension etc. One thing that I do notice when training medic students or proctoring newer medics is they often do not follow up their initial NTG admin. As long as the BP holds and the signs/symptoms appropriate for the condition being treated is there, I will continue to give it until the vitals contraindicate its use or I arrive. I also prefer nitro spray over the tabs. There is possibility that nitro tabs will lose some of their potency over time when exposed to air.

Another nitro tool in the kit which I use at a high percentage of time is nitro paste. Not having the ability to administer IV nitro, the paste gives me the ability to maintain some of the vasodilation achieved with sublingual admin.

On a side note, although not a field treatment, nitro paste is also used to improve circulation in lower extremities when applied to the legs or feet. There is also reported uses to treat headaches by applying paste to the legs.

I agree with ALSFF.....Nitro is a great drug (tabs, spray or paste). Its been used consistantly in EMS for as long as I can remember (back to 1979....maybe even longer). Works great for AMI's, CHF's, HTN & angina. ALSFF is right that Medics need to follow up post nitro administration with an evaluation of vital signs and the chest pain or CHF symptoms. Just have to monitor the BP closely to make sure your patient doesn't bottom out. Headaches are a small price that the patient pays.

[RNMedic08 0]

Nitroglcerin is in a group as classified as a Nitrates, it dilates (widens) blood vessels, making it easier for blood to flow through them and easier for the heart to pump.

Patients are instructed to not use nitroglycerin if you are taking sildenafil (Viagra).

I have used Nitro in the field and I prefer to use the spray to treat chest pain but I caution everyone to take a BP prior to administration. During my Medic ride time i had a situation where although the patient had a BP that do not contradict the use, after my first administration I reassessed her and her BP dropped from 140/80 to palp at 90!!! She appeared to be a Nitro virgin. Luckily I had a line already established at the time and my Medic preceptor right next to me......

As others have stated it is also used to treat acute onset of CHF and topical application works better for a more sustained dosage.

Good luck with the paper.

[WAS967 97]

I've heard a lot of mumbling from some people that NTG Spray shouldn't be used because it's meant to be single patient use only. Ie.....there is a small risk of "off spray" and contamination from using it with multiple subjects. This comes from a Pharamcist BTW. Our QA/QI director is rather keen on eliminating them from our gear but they somehow keep magically coming back.

Thoughts?

[ny10570 745]

Thats a valid complaint, but its also the standard of care and the smallest package that I'm aware of. Unless they want to start issuing it in pill form. I have a hard enough time getting some pts to actually lift their tongue or chew the aspirin. I can see problems with a pill form of nitro.

[Guest alsfirefighter]

I've heard a lot of mumbling from some people that NTG Spray shouldn't be used because it's meant to be single patient use only. Ie.....there is a small risk of "off spray" and contamination from using it with multiple subjects. This comes from a Pharamcist BTW. Our QA/QI director is rather keen on eliminating them from our gear but they somehow keep magically coming back.

Thoughts?

Perhaps, but just as with any multi-dose delivery device...wipe it with a prep pad prior to use. Plus is it really that much different then if you use tabs (one agency I worked PT for only had these and I know its because it was the cheapest way to get it ) and more then one tab comes out..on your non-sterile exam glove that you've only touch god only knows what and you put the extra's back into the bottle. That's dark, moist and warm...hmmm isn't that the best conditions to breed bacteria? I'll take the chance of the spray...well over most of the places we find out patients in and the ambulances we put them in.