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?

 Thanks for the question.  You are correct in that we have tried to answer on this site many times our philosophy as to what constitutes previous NTG administration.

The SWORBHP teaching philosophy regarding NTG and ischemic chest pain has always been previous prescribed use. Meaning, the patient at one point had been advised by a health care professional to take NTG for this suspected ischemic discomfort, and the patient had in fact done so without complication.  This latter interpretation is the most important vs the patient having an actual current prescription for the medication on hand.

In your example, your patient did receive NTG years ago in the ED however was unsure why they required it.  Apparently they do not recall if they ever had chest pain of a suspected ischemic etiology and also does not appear (by your example) to have a history of angina.

Therefore, our interpretation of your specific scenario would be that: if the patient had not been advised or prescribed by the physician to take NTG for their ischemic chest discomfort even though apparently they had received NTG for some reason without complication, then they would not (in your example) qualify for NTG administration by the medical directive without having an IV established.

Cardiac Ischemia,Cardiac/Circulation

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