What are the rules if your patient has never been prescribed nitroglycerine before? What are the rules?

• In the current Cardiac Ischemia Medical Directive, to receive nitroglycerin by any Paramedic in Ontario, the patient must have either:​
• Prior history of nitroglycerin use ​

-OR- ​

• IV access obtained
• In the current Acute Cardiogenic Pulmonary Edema (ACPE) Medical Directive, to receive nitroglycerin by any Paramedic in Ontario, the patient must have either:​
• SBP ≥ 140mmHg* OR​

•  If SBP is between 100-139mmHg:​
• Prior history of nitroglycerin use ​OR
• IV access obtained ​
• *If SBP ≥ 140mmHg the dosing changes based on whether or not they have IV access OR history of previous nitro use

Why an IV?

• In the absence of previous/prescribed use, or in the setting of ACPE with SBP ≥ 140mmHg an IV needs to be established​
• Rationale: The effects of nitroglycerin could cause a hypotension ​
• IV access allows for administration of a fluid bolus to correct the issue​
• In the setting of ACPE with SBP ≥ 140mmHg a drop in BP is unlikely to result in SBP <90mmHg

So, who attends once the IV is in?

• Once the IV is established, the IV certified paramedic must be the attendant for that patient​
• Rationale: In the event the patient deteriorates, the IV certified paramedic has been trained to manage the situation​
• Please see the SWORBHP Policy: "PCP vs. PCP Expanded Scope Crew Configuration – Division of Responsibilities" for more information on division of responsibility

Summary

• An IV is required to give nitroglycerin in the setting of Cardiac Ischemia if there is no history of prior nitro use​
• An IV is required to give nitroglycerin in the setting of Acute Cardiogenic Pulmonary Edema with SBP between 100-139mmHg, if there is no history of prior nitro use​
• The presence of an IV can alter the dose of nitroglycerin administered per the Acute Cardiogenic Pulmonary Edema Medical Directive if the SBP is ≥ 140mmHg​
• Rationale: Nitroglycerine may cause hypotension in the nitro naive patients. ​
• If this occurs, paramedics must be prepared to manage this complication with IV fluid bolus​
• Once an IV is established, the IV certified paramedic must attend the call

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