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Advanced Paramedic Skills
Introduction to Symptom Relief II
Nitroglycerin
 Vasodilator
 Anti-anginal
 Antihypertensive
 Nitrate
Drug Profile
NTG Admin
Nitric Oxide
BNO
c GMP
Dephosphorylization
of muscle -
Vascular Smooth
Muscle Relaxation
Improvement in workload on the heart
Dilation of large coronary arteries
Increased collateral blood flow to heart
Antagonizes vasospasm
Lowers blood pressure with or without a subsequent rise in
CO
Decrease in preload and systemic vascular resistance
Decreases MvO2 and decreases left and right ventricular enddiastolic pressures (preload)
Pharmacokinetics
•very substantial first pass metabolism in the liver
•Intravenous nitroglycerin produces a slightly
greater reduction in preload than SL nitro.
• The HR only rises if the drop in preload causes
the preload to be lower than the bodies needs.
•tolerance to nitrates can develop in humans
Adverse Effects/Overdose
•causes a headache due to dilation of vascular
smooth muscle in the cerebral cortex
• may cause transient but profound dizziness.
•Reflect tachycardia
•most serious adverse effect is hypotension
•Nausea and or vomiting
Therapeutic Uses
 Angina (stable or unstable)
 Acute evolving MI
 Congestive Heart Failure _Pulmonary
Edema
 Hypertension –
 Coronary vasospasm (prinzmetals
angina)
Supplied/Dose
Sublingual Administration
Supplied in 0.4 mg spray
SR Dose is 0.4 mg SL q 5 minutes
to max 6
Vital Sign Parameters must be
met
Sublingual Administration
Special PreHospital Concerns
•light sensitive and a volatile molecule
•IV is an imperative need for safe administration of the drug
•drop in greater than 30 mmHg with the first dose of
nitroglycerin stop administration
Standing Order
 Indications:
– Chest pain or discomfort consistent with
cardiac ischemia
– YOUR HISTORY AND ASSESSMENT is
vital!!!
Conditions
 To receive Nitroglycerin the patient must:
 be alert and responsive
 have used Nitroglycerin in the past (this
includes
Nitroglycerin
spray,
tablets,
transdermal patch)
 NOT have taken Viagra within the past 24
hours
 have a systolic BP which is > 100 mmHg and
a heart rate which is > 60 bpm and < 159 bpm

CHF
 Standing Order for a certain subset of
patients who are not nitrate sensitive
 Presentation of severe or moderate SOB
 Can reduce preload and help both
ventilation and perfusion (V/Q)
 Clinical picture of CHF
Causes of Congestive Heart
Failure
 Conditions that increase preload, e.g. aortic
regurgitation, ventricular septal defects
 Conditions that increase afterload, e.g.
aortic stenosis, systemic hypertension
 Conditions that decrease myocardial
contractility, e.g. MI, cardiomyopathies,
pericarditis, tamponade
S&S of Congestive Heart Failure
 Exertional dyspnea
- fatigue may be the first sign
 Increased respiratory rate and effort
 Orthopnea and/or PND
 Cyanosis and pallor
 Tachycardia
 JVD
 Dependant edema
Categorized
 Left or Right sided heart failure
????????????
 Forward or Backward ventricular failure
 Backward failure is secondary to elevated
systemic venous pressures.
 Forward ventricular failure is secondary to
left ventricle failure and reduced flow into
the aorta and systemic circulation
NTG Administration for CHF
INDICATIONS
 Patient in moderate to severe respiratory
distress.
 Patient assessed by paramedic to be in
acute pulmonary edema.
CONDITIONS
 Patient >18yr
 Previous history of nitro use or IV
 Systolic BP > 140 mmHg (2X)
 Heart rate and/or pulse rate > 60 and
<159bpm
 No history of viagra use in the last 24 hours
1.
Place patient in sitting position.
2. Administer 100% O2 as required. Support
ventilation with BVM as necessary if reduced
level of consciousness.
3. Attach cardiac monitor and continuous 02
sat monitoring if available.
4. Confirm that the systolic blood pressure is
>140 mmHg and the patient has a history of
previous nitroglycerin use.
5. Administer 0.4 mg nitroglycerin (1 spray
sublingual) every 5 minutes if systolic blood
pressure remains > 140. Check blood pressure
before administering each dose of nitroglycerin.
Discontinue nitroglycerin if BP drops below 140
systolic. Maximum number of nitroglycerin
doses is six.
6.
Reassess patient for additional
Nitroglycerin administration. Administer NTG 0.4
mg spray SL every five minutes as needed for
symptomatic dyspnea to a maximum of six
doses.
7. Assess the BP and heart rate after each
dose of Nitroglycerin administration.
8. Discontinue Nitroglycerin should the BP fall
below 140 mmHg, or the heart rate drops below
60 bpm.
9. If either the systolic BP or heart rate falls
outside of the listed conditions, no further
Nitroglycerin will be administered for the
remainder of the call.
ASA
(Acethylsalicyclic Acid)
 Anti-inflammatory
 Platelet Aggregation inhibitor
Review of Events during Acute
MI
 Coronary artery
blockage
 platelet aggregation at
site of blockage
 reduced blood and
oxygen flow to heart
tissue
 subsequent pain and/or
failure of myocardial
function
Platelet Activation
 platelets in the blood respond to chemical signals
that are present in the plasma (cause plts to
activate or not)
 prostacyclin is released from the endothelial cells
 Another factor that prevents platelet aggregations
is low circulating levels of thrombin and
thromboxanes
Thromboxane A2
ADP
Injury
site
Chemical mediators
released by platelets
Action of
ASA
Collagen fibers
Platelets adhere
to injured surface
of
Endothelial cells
Prothrombin
Activation of
clotting factors in
plasma
Thrombin
Fibrinogen
Fibrin
Therapeutic Uses/Adverse
Effects
 Therapeutic Uses;
anti-inflammatory
anti-pyretic
analgesic
 Adverse Effects
neurotoxic - confusion, lethargy, coma
and death
cardiovascular- acidosis, pulmonary
edema, decreased ATP production,
arrhythmia's
Special Prehospital Concerns
 Contraindications;
Allergic to ASA
Allergic to NSAIDS
Recent Head injury
CVA in last 24 hrs
current active bleed
history of asthma
Children + Asa = Reyes
Standing Order
 Indications:
– Chest pain or discomfort consistent with cardiac
ischemia
 Conditions
1. weigh at least 40 kg
2. be alert and responsive
3. NOT have an allergy to ASA or other NSAID
4. not have current active bleeding (GI or othe
disorders)
5. have no evidence of CVA or head injury withi
24 hours
6. have a history of previous use of ASA with n
adverse reaction if a known asthmatic