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?

 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.

In the scenario you describe above, it is unclear if this patient actually received NTG (although they most likely did), but the patient then was not prescribed the medication in follow up nor do they routinely self-administer their own dose. It is possible for instance that the discomfort this patient had experienced turned out to be GI reflux and the MD had tried some NTG initially prior to ultimately reaching that diagnosis.

The patient was then not discharged on NTG. In other words, the patient was not advised/authorized/directed by the physician to take NTG in the future for similar discomfort.

As such, this patient should not be considered to meet the criteria of previous prescribed use and as such would require an IV to be established. Patching remains an option however contacting the BH physician should not routinely be done to over-ride a contraindication to medication administration outlined in the medical directive.

(This answer was revised on: Dec 3, 2014)

Cardiac Ischemia,Cardiac/Circulation

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