8.5.11 best practices nitro and taser

8/4/2019 8.5.11 Best Practices Nitro and Taser

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sublingual or transmucosal nitroglycerin. The early dosing of sublingual NTGhelps afterload reduction acutely. The intent is for the paramedics to continue toutilize the nitroglycerin 0.4 mg dosing every 5 minutes until there is improvementor stabilization of the CHF. The paramedic should continue to utilize NTG spraysprior to the administration of the NTG paste.

In accordance with our protocol, pretreat the patient with sufficient sublingual ortransmucosal nitroglycerin prior to and during the application of the CPAP mask.Once the mask is in position and the nitroglycerin paste is applied, you can treatwith an additional dose or two of nitroglycerin if the blood pressure allows.Remember, the NTG given sublingually is for the acute treatment of CHF. Try toavoid breaking the seal on the mask to the patient whenever possible. If thepatients systolic blood pressure drops below 100 mm Hg discontinue thenitroglycerin paste immediately. At this point with a hypotensive patient you mayconsider a fluid bolus to obtain a blood pressure of at least 100 mm Hg.

The onset of action for dermally applied nitroglycerin paste is 15 minutes underideal conditions. Many times the dermal absorption is erratic if the patient is inshock or vascular compromise. The NTG paste will be clinically effective (onsetapproximately 15 minutes) for the patient while waiting for the emergencydepartment provider to assume care. The NTG paste is bridge therapy from theprehospital to Emergency Department care.

When patients are experiencing chest pain of suspected cardiac origin, it is notappropriate to start with NTG Paste to relieve the pain. The NTG spray worksmore rapidly and consistently for a patient with ongoing acute ischemia. TheNTG paste is for use in afterload reduction in CHF only. NTG has a synergisticeffect when working with CPAP that is not present with ischemia.

Paramedics need to proceed with caution with STEMI patients and using NTG.Those who are thought to be experiencing an Acute Inferior and/or Inferior-Posterior Myocardial Infarction (MI) can be sensitive to NTG. These patients arevery dependent upon preload. One of the most recent cases in Santa ClaraCounty, the patient was experiencing an Inferior-Posterior MI. Initially paramedicscould not get a blood pressure and during transport obtained a blood pressure of138/82. They administered a sublingual NTG; when the patient arrived at theSTEMI Center, they were in cardiogenic shock and profoundly hypotensive. Thiswas potentially from the NTG decreasing the blood pressure acutely. Thesepatients may potentially not respond to fluid challenges if they in cardiogenicshock from a myocardial infarction.


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(hallucinogens), or even an underlying central nervous system infection?Exacerbation of underlying psychiatric disorders may be another factor.

When law enforcement requests paramedics remove Taser barbs, this is apotentially dangerous situation for both the paramedic and patient who had thedevice applied. The removal of Taser barbs has been in the past interpreted asmedically cleared for jail. This is clearly not the case. When confronted by lawenforcement requesting you remove those barbs, you may state that it is notwithin your current scope of practice.

(1) JEMS Feb 2011, Wesley, MD, Without Warning, 48-55

8.5.11 best practices nitro and taser

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