In the companion document under the medical cardiac arrest directive it lists reasons for early transport. Under here it lists thrombosis (pulmonary and coronary). So to my understanding, if we have a VSA we believe to be caused by a coronary thrombosis (a STEMI) we are to do 1 analyze? In the past it has been said that we are to treat a suspected MI VSA as a medical cardiac arrest and run the entire protocol on scene. Can you please clarify?

In regards to medications with a condition of “unaltered”, should we be administering these if the pt is GCS 15, then has a syncopal episode (or other altered period) in your care and then returns to GCS 15? An example would be a chest pain call where you want to treat with ASA and Ondansetron. Is it a case of “once you’re out you’re out” or would it still be appropriate to treat as they have now returned to an unaltered state? Thanks

Question: Can a paramedic in the field rule out ischemic chest pain and not treat with ASA/Nitro due to the chest pain being reproducible? (eg. worse on deep inspiration but radiating down the left arm/shoulder, and sharp pain in left upper chest and pressure across the lower chest). I recently had this call, and was told that you can rule it out based on it being reproducible, but the history and rhythm strip, clinical presentation was leaning more towards cardiac.

In regards to the cardiac ischemia medical directive, the latest indication is now suspected cardiac ischemia. If you have a pt presenting with all signs and symptoms of cardiac ischemia, have given ASA, established an IV, and have given NTG. If the pt’s symptoms improve after administration of NTG should you continue with the directive to the full amount of doses provided the pt still meets the conditions?

For acetaminophen and ibuprofen, suspected ischemic chest pain is listed as a contraindication. Is this listed mainly to indicate that ischemic chest pain should not be treated with the analgesia directive? Could analgesics be administered to treat a different area of pain that is occurring at the same time as the chest pain that appears to be unrelated? For example, I had a patient with chronic pain that she takes acetaminophen for, but she was experiencing acute chest pain suspected to be ischemic. Would it be correct to withhold acetaminophen in this case and not provide treatment for the chronic pain that she is experiencing at the same time as suspected cardiac ischemia?

Can I attempt the Valsalva on a patient who has chest pain? What if the patient has a clear onset of palpitations, then after onset develops chest pain and or shortness of breath?

Should we consider cocaine induced chest pain as ischemic and be treating with ASA and NTG? Example: 20 year old male patient midsternal chest tightness. Admits to using cocaine and the symptoms occurring after that. I guess my question is, is the cocaine causing ischemia which causes the chest pain?

If a patient is given first time Nitro by a PCP IV but then isnt ever actually prescribed nitro by a doctor does this count as prior hx of nitro use? Could a then PCP non IV give this pt nitro the next time they call?

Hello, How would you like us to proceed with a young pt (say under 30) who complains of chest pain and describes it as ischemic pain, saying all the right things ex; pressure, heaviness etc. But who is vitally stable and doesnt not appear to be in any distress or severe pain. Would you still like us to treat it as ischemia on the side of caution even though its most likely anxiety/stess etc ?

Does a prescription of NTG patch count as previous history of use for NTG spray? Would it be a concern that the medication would be administered through a different route and therefore have a different onset of effect?

Given that rapid atrial fibrillation and other tachydysrhythmias can result from myocardial ischemia; is it wise to provide ASA to these patients as a precaution. I am a PCP, and we dont have a defined treatment for pulsed tachycardia.

Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

Good afternoon, my question is related to current ACS treatment guidelines. I have had several STEMI inter-facility transfers within the last month or so where attending physicians have initiated pain management with Fentanyl. Upon receiving patient handover from these physicians they often request that this treatment modality be continued throughout transfer. Due to the current AMHA research regarding increased mortality in ACS and STEMI patients who are treated with morphine, is there any move to eliminate this contraindication from the fentanyl protocol, or to remove morphine from the ACS treatment guidelines? If a Physician requests this treatment modality (fentanyl) are we able to patch around this contraindication for fentanyl or would this go against the spirit of the protocol patching around contraindications? If the Physician has initiated treatment with Fentanyl and we have exhausted our nitro protocol or it is contraindicated will we suffer repercussions for not initiating morphine treatment even when it was requested that we do not by the sending physician? Would we require a patch to NOT treat this patient with morphine? Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

If a dentist administers nitroglycerin to a patient who has no previous-prescribed use; does this constitute prescribed use at this point?

Wondering what your thoughts are in regards to administering nitro to a patient with atypical angina symptoms and no presentation of chest pain. For example, is it ok for us to administer nitroglycerin if a medic is presented with a female patient who states she becomes nauseated from angina and explains she is prescribed nitro for the symptom? I discussed this question with my colleagues and I have found there is a 50/50 split in regards to those of us who would use nitro or not. I think it is a good question to ask given the differencing of opinion in the field.

If patient receives ASA from a certified provider, such as but not limited to other paramedics, doctors/nurses from clinics, are we required to administer another dose of ASA to the ACS patient. Also, does the patient have to have chest pain to administer ASA?

Question: What are STEMI mimics and their types?

Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 – 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

Question: I am just wondering if ASA is contraindicated for patients taking Pradaxa?

Question: I was faced the other day with a question by one of my fellow peers in regards to the administration of nitroglycerine. As a contraindication, it states that we cannot administer nitro of the SBP drops by one third or more of its initial value after nitro is administered. This can be interpreted in 2 different ways, as brought to my attention by my fellow peer so now ever since, I second guess myself. So my question is, this “initial value,” is it the very first BP we take even before the first dose of nitro, or is it referring to the initial BP you take AFTER the first dose of nitro. It is such a simple answer I am sure but if I can get clarification so I can also relay the message to my fellow peer that would be great.

Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Question: I am a ACP student and was discussing among my colleagues the proper time frame for vitals and drug administration for morphine and NTG in the cardiac ischemia medical directive. I understand that each drug has a 5 minute intervals but someone had mentioned that you could stagger both drugs in 5 minute intervals, for example after administering a third NTG wait 5 minutes then morphine then wait 5 minutes then NTG etc. I was wondering what the preferred interval for vital signs and drug administration would be with two drugs staggered at 5 minute intervals.

Question: My question is in regards to the Cardiac Ischemia protocol. I am currently a PCP student and we had a chest pain call. The patient was complaining of chest discomfort and described it as a pressure starting sub-sternal and going to patients left shoulder. The patient was also experiencing SOB. This pain was a 6/10 when it first came on and went down to a 5/10 with relaxation. The patient did not have a history of angina but had received NTG in the hospital a couple years before and did not know the why. The patient did not have NTG on their own list of meds. We gave 2 81mg ASA and did a 12-lead which was negative for a right ventricular infarct. My preceptor did establish an IV and got a line started set at TKVO before we gave the NTG.

The question is even though the patient did not have NTG on their own med list at the time of the call; does the time the patient was in hospital and was given NTG count as prior history for the Cardiac Ischemia protocol?

I did see a related question on the site but it was related to a doctor giving the NTG before EMS arrival and it was stated that it should be prescribed. So does that mean it has to be a current prescription or can a patient have it in the hospital and it count? I know it does not matter after you get an IV establish but if we weren’t able to get an IV established then would we have been able to give it?

Question: Your partner is preparing O2, obtaining vitals and attaching the monitor for a chest pain patient. You are performing a primary survey, gathering your SAMPLE Hx, ruling the patient in protocol for ASA, giving the ASA and doing the same for Nitro. Vitals are obtained 3-4 minutes earlier than the Nitro administration.

From past experience and following the protocol which states vitals q5 min, nitro q5 min and vitals must be obtained within 5 minutes of medication delivery, is this improper as 3 minutes has lapsed prior to the nitro administration? I have been informed that past deactivation has resulted from this?

Question: I have a question regarding congestive heart failure (CHF) and ASA. If a patient is having acute CHF and is coughing up blood but is also having chest pain are they still a candidate to receive ASA given the active “bleeding”. I would think the blood from back up into your lungs is different than the blood from an ulcer or something. Thanks for your help.

Question: My question is regarding our chest pain protocol. There is a 48 year old male complaining of chest pain. It is substernal, 7/10, onset 1 hour, provoked at rest, radiates to left arm sitting steady.

O/E patient’s history is hypertension; vitals H/R 78 regular and full; breathing 20x / minute; B/P 138/99; conscious and alert x 3. Patient is not allergic to ASA, so he receives ASA.

History of nitro is in question. The patient states he was in hospital once with similar chest pain and doctor “gave me a spray of something for my chest pain”. When asked if it was nitro, the patient did not know name of medication.

Could this patient receive NTG or should we patch?

Question: On a recent ischemic chest pain call with an approximately 60 year old female patient, conscious and alert, 2 nitro sprays prior to arrival. The 12 lead was normal and I gave ASA, but decided to withhold nitro as I had difficulty obtaining a BP on scene. The patient had no palpable radial or brachial pulses bilaterally. My partner and I made 4 NiBP attempts on scene with no reading on either arm and manual BP attempts bilat with no sound on auscultation or deflection of the needle. I was unable to also confirm the HR that showed on the monitor as she was uncooperative while attempting a carotid (although present). After extricating the patient on a stair chair, I decided to continue my care with an IV TKVO in the truck. I did not want to delay scene time any further. While in the truck I continued to attempt NiBPs which was now displaying a reading of hypertension, yet no pulses other than carotid were palpable. Although the monitor was always showing vitals within my parameters to administer nitro, I withheld it, as I was treating the findings with the patient, not the monitor. She had stated her pulses were usually weak. She remained conscious and alert with no signs of hypotension other than weak/absent pulses. My question is€¦ was I ever justified to administer a bolus to this patient?

Question: What position should patients be in when we are doing do a 12-lead?

Question: A nitro virgin patient presenting with chest pain attends a doctor’s office. Doctor administers 1 spray of nitro prior to EMS arrival. Upon assessment by EMS, patient still presents with chest pain. Is the patient still considered a virgin nitro patient as this is the first incident he/she has had with nitro? Or since the doctor administered a spray, does that count as a previous use of nitro?

Question: With reference to the cardiac ischemia protocol. Would it be possible to update the protocol for the administration of nitro (without a BHP consult) for normotensive patient on beta blockers by either: a) lowering the heart rate parameters from 60bpm to 50bpm or b) to lower heart rate parameter from 60bpm to 50bpm when patient is currently taking antihypertensive medications within the beta blocker family with an IV established?

Question: I have a question regarding the order of cardiac ischemia SR medication in the protocol. I have been informed by a source that 0.4mg nitro should be the first SR medication given in a suspected cardiac ischemic event, followed by x2 80 mg ASA. I respectfully disagree with him due to the fact that although nitro is significantly more fast acting, its effects only last 3-5 minutes, hence the spray every 5 minutes stated in the protocol, and although the ASA is slower in its absorption rate, is effects will benefit the Pt. more (in my opinion) than the nitro. The short and sweet version, am I correct in saying that ASA should be administer first before the initial nitro dose is given, if the protocol for both is met.

Question: What are your thoughts on oxygen therapy in myocardial ischemia from a medical evidence standpoint? Even though high flow o2 is regularly administered to PTs with chest pain as per the oxygen therapy and chest pain standards in the BLS standards, there is an increasing body of evidence suggesting that in uncomplicated MI O2 is of no benefit and may cause more harm than good due to ROS and ischemia-reperfusion injury.

The recent ACLS guidelines state to only administer O2 in acute coronary syndromes if the spo2 is < 94% or the PT is in respiratory distress or obviously hypoxic and there are several recent papers and clinical guidelines that suggest a similar course of action in uncomplicated MI. Basically, the evidence is suggesting that titration to spo2 is favorable over high flow o2 due to the risk of oxidative stress injury.

Any thoughts? Obviously you still follow the protocols, but I’m just interested to see if there is any medical opinion on this. Could the standards/guidelines eventually change to reflect the newer evidence?

Question: I am a PCP student, Under the cardiac ischemia medical directive it states that indications for nitro and ASA are “suspected cardiac ischemia” my question is, a patient without chest pain but has other symptoms such as weakness SOB, N/V etc. and a positive 12 lead showing either ST elevation or depression, do they qualify for Nitro under this protocol?

Question: My questions have to do with resolved suspected ischemic chest pain and if we should administer ASA even if the symptoms have resolved.

Question: Do all Phosphodiesterase Inhibitors generic names end in “fil”? Are all drugs that end “fil” Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

Question: I have a few questions about some of the omissions from these protocols that were in the old protocols. The first one is in the event chest pain resolves and re-occurs it is treated as a new episode and nitro protocol repeated. This isn’t stated in the new protocol so if this were to occur can we repeat although it isn’t stated? The other question is regarding the medical arrest protocol. No provision is made in regards to on scene ROSC and re-arresting patient in ambulance. The old protocol says we can pull over and analyze once then continue to receiving facility. With nothing in the new protocol do we follow the same format? Thank you.

Question: When is a patient no longer considered nitro naive? Issue: you have a patient that is suffering chest pain and qualifies for ischemic protocol. You establish a patient IV and give them nitro. The patient accepts the nitro without any adverse reactions and pressure does not fall out of protocol at any time. After your second dose of nitro you check the IV and discover its no longer patent and you have to discontinue it. You attempt your second IV and are unsuccessful. Nitro has been decreasing patient’s pain but they still have active chest pain. Can we still continue with nitro without an IV as the patient has already been given nitro and not had any reaction?

Question: If a patient presents with both chest pain and sudden onset stroke symptoms, can we still give all medications for cardiac ischemia protocol while doing stroke bypass?

Question: Can you clarify a condition in the contraindications for nitro use protocols? Current contraindications listed under the protocol are self explanatory, where as one to me seems to be very vague. The one Im referring to is the use of a “Phosphodiesterase Inhibitors” within the previous 48 hours. They are many examples of this type of inhibitor (including caffeine) and it might reduce confusion if the specific and relevant ones were listed under the protocol specific to cardiac. For example, a patient who has had a cup of coffee prior to your arrival or 48 hours prior to for that matter has ingested a Phosphodiesterase Inhibitor. Under the current directive and the way it is written, could be argued that this patient is contraindicated to receive Nitro.

Question: When treating a patient with suspected cardiac ischemia, should I acquire a 12-Lead ECG before giving nitro or ASA? If the patient is hypotensive, should I bolus at 20 ml/kg, or 10 ml/kg as per the cardiogenic shock directive? And how do I know if the patient has a right ventricular infarct? (Updated)

Question: If I have a patient that appears to be in cardiogenic shock with a STEMI ECG should I be calling for a BH patch to have an order for aspirin after initiating an IV bolus?