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The Prehospital Use of Nitroglycerin According to Standing Medical Orders in an Urban EMS System

Published online by Cambridge University Press:  28 June 2012

Linda L. Herman ,
Max Koenigsberg ,
Sharon Ward  and
Edward P. Sloan
Linda L. Herman*
Affiliation:
Emergency Medical Services Fellow, University of Illinois College of Medicine-Chicago, Program in Emergency Medicine, Attending Physician, Emergency Services, Illinois Masonic Medical Center, Chicago, Ill.
Max Koenigsberg
Affiliation:
Assistant Professor of Emergency Medicine, University of Illinois College of Medicine-Chicago, Attending Physician, Emergency Services, University of Illinois Hospital and Illinois Masonic Medical Center, Chicago North EMS System Project Medical Director, Chicago, Ill.
Sharon Ward
Affiliation:
Chicago North EMS System Coordinator Illinois Masonic Medical Center, Chicago, Ill.
Edward P. Sloan
Affiliation:
Assistant Professor of Emergency Medicine, University of Illinois College of Medicine, Attending Physician, Emergency Services, University of Illinois Hospital, Chicago, Ill.
*
Illinois Masonic Medical Center, Chicago North EMS Office, 836 W. Wellington, Chicago, IL 60657USA
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Abstract

Purpose:

The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determin the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia).

Method:

Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, Auguest 1990) to identify all prehospital patient contacts in which NTG was utilized.

Setting:

The Resource Hospital/Telemetry Base-Station a two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.

Results:

There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176±44 mmHg and the repeat mean SBP was 164±41 mmHg with a mean decrease of 12±22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97±24 mmHg, the repeat mean DBP was 92±23 mmHg, a mean decrease of 5±15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resusticated with a fluid bolus of 300 ml normal saline.

Conclusions:

In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.

Keywords

base-stationbradycardiachest paindyspneaEMShypotensionischemianitrogylcerinparamedicsprehospitalpulmonary edemastanding medical orders (SMO)telemetry
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 8 , Issue 1 , March 1993 , pp. 29 - 33
Copyright
Copyright © World Association for Disaster and Emergency Medicine 1993

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References

1. Murrell, W: Nitroglycerin as a remedy for angina pectoris. Lancet 1979;1:80,113,225,284,642–646.Google Scholar
2. Amsterdam, EA, Awan, NA, DeMaria, AN: Sustained salutary effects of oral controlled-release nitroglycerin on ventricular function in congestive heart failure. J Clin Cardiol 1979;2:19–25.CrossRefGoogle ScholarPubMed
3. Armstrong, PW, Armstrong, JA, Marks, LS: Pharmacokinetic hemodynamic studies of nitroglycerin ointment in congestive heart failure. Am J Cardiol 1980;46:670–676.CrossRefGoogle ScholarPubMed
4. Franciosa, JA, Nordstrom, LA, Cohn, JN: Nitrate therapy for congestive heart failure. JAMA 1978;240:443–447.CrossRefGoogle ScholarPubMed
5. Hoffman, JR, Reynolds, S: Comparison of nitroglycerin, morphine and furosemide in treatment of presumed prehospital pulmonary edema. Chest 1987;92:586–593.CrossRefGoogle ScholarPubMed
6. Kaufman, D, Koenigsberg, M, Barrett, J, et al. : The Chicago Emergency Medical Services System Standing Medical Orders. Project Medical Directors Consortium of the Chicago EMS System, Chicago, Illinois, July 1986.Google Scholar
7. Moos, AN, Mohiuddin, SM, Hilleman, DE, et al. : A comparison of sublingual nifedipine versus nitroglycerin in the treatment of acute angina pectoris. DICP, Ann Pharmacotherapy 1989;23:562–564.Google Scholar
8. Valenzuela, TD, Criss, EA, Hammargren, WM, et al. : Thermal stability of prehospital medications. Ann Emerg Med 1989;18:173–176.CrossRefGoogle ScholarPubMed
9. Rottman, SJ, Larmon, B, Mannix, T: Chemical stability of sublingual nitroglycerin tablets carried on paramedic vehicles. Am J Emerg Med 1988:6:681–683.CrossRefGoogle ScholarPubMed
10. Ong, EA, Canlas, C, Smith, W: Nitroglyerin-induced asystole. Arch Intern Med 1985;145:954.CrossRefGoogle Scholar
11. Ong, EA, Bass, S: Nitroglycerin-induced bradycardia and hypotension in acute myocardial infarction. Chest 1980;77:244.CrossRefGoogle ScholarPubMed
12. Khan, AH, Carleton, RA: Nitroglycerin-induced hypotension and bradycardia. Arch Intern Med 1981;141:984.CrossRefGoogle ScholarPubMed
13. Come, PC, Pitt, B: Nitroglycerin-induced severe hypotension and bradycardia in patients with acute myocardial infarction. Circulation 1976;54:624.CrossRefGoogle ScholarPubMed
14. Nemerovski, M. Shah, KP: Syndrome of severe bradycardia and hypotension following sublingual nitroglycerin administration. Cardiology 1981;67:180–189.CrossRefGoogle ScholarPubMed
15. Abrams, J: Nitrates. Med Clin N Amer 1988:72:1–5.CrossRefGoogle ScholarPubMed
16. Gascho, JA, Fanelli, C, Sumner, A, et al. : Effects of posture on the venodilatory response to nitroglycerin. J Applied Physiology 1989;66:2585–2588.CrossRefGoogle ScholarPubMed
17. Wasserverger, J and Balasubramaniam, S: Complications in prehospital use of nitroglycerin. Ann Emerg Med 1982;11:116. Abstract.CrossRefGoogle Scholar
18. Murad, F: Drugs Used For the Treatment of Angina: Organic Nitrates, Calcium-Channel Blockers, and B-Adrenergic Antagonists. In Gilman, AG, Rall, TW, Nies, AS, Taylor, P (eds): Goodman and Gilman's The Pharmacological Basis of Therapeutics, (8th ed). New York: Pergamon Press, 1990, pp 764–774.Google Scholar