Nitroglycerin is used commonly used for angina. Its therapeutic effects were first observed and utilized by Dr. William Murrell in 1878. The drug has been in use ever since. The drug is commonly administered via sublingual means. Nitroglycerin acts as a vasodilator. The drug dilates arteries, of which include the coronary artery. This dilation increases the amount of blood flowing to the heart and also affords a decrease in resistance with which the heart must pump against. “Furthermore, the dilated vessels accommodate more of the blood volume, so less blood arrives in the heart, relieving heart congestion” (Moore, 2013, p. 156).
The use of nitroglycerin in the pre-hospital, or out-of-hospital, setting is not uncommon. In fact, at one point in its journal, Circulation, the American Heart Association spoke of the drug as if it was timeless; a sort of wonder drug. “Newer drugs quickly replace older remedies. This has not been the case with nitroglycerin, now in continuous medical use for more than a century” (American Heart Association). Many people are prescribed nitroglycerin drugs to treat symptoms of angina. Many patients in hospitals suffering from more acute conditions are treated with this drug as well. There have been many positive outcomes of using nitroglycerin drugs. However, these patients suffering severe conditions are in controlled medical hospitals being treated by trained doctors. It is important that the use of nitroglycerin in pre-hospital settings be investigated so the professionals that find themselves delivering medical care outside of the hospital have a basis for what is acceptable in the field.
The administering of nitroglycerin drugs to patients suffering from acute myocardial infarction within a hospital setting is not uncommon. The guidelines developed by the American Heart Association layout recommendations regarding the use of different forms of nitroglycerin drugs in hospitalized patients under cardiac arrest. One very important distinction made within these AHA guidelines is between patients considered to be good candidates for nitroglycerin therapy and those patients that may be at risk under nitroglycerin therapy. “If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered (Yancy et al, 287). Receiving nitroglycerin in a situation in which the body is already prone to low blood pressure (due to the heart not being able to provide the force required to effectively circulate blood) could potentially be fatal. The vasodilating effects of the nitroglycerin could result in a much more severe case of hypotension.
An important question must be asked regarding the vasodilator induced hypotension within patients under cardiac arrest. Are there other symptoms of the patient’s condition that would be alleviated, resulting in mitigation of the threat that the vasodilator induced hypotension poses to the patient? This question was addressed in the early 1980’s, when the investigation on the use of nitroglycerin on patients suffering from acute myocardial infarction was in its infancy. As Epstein states in a paper she released in Circulation, the journal of the American Heart Association, “the concept that nitroglycerin is deleterious during acute myocardial infarction, however, has been untested until very recently” (Epstein, 217). Epstein also indicated that more recent tests were suggesting that the pros outweighed the cons in some cases. “Indeed, results suggest that nitroglycerin-induced hypotension actually augments the degree of ischemia during acute coronary occlusion; its deleterious effects, however, seem to be overridden by other actions that lead to a net reduction in ischemic injury” (Epstein, 218). It seems that when changing the context of a care setting, such as considering out-of-hospital care compared to in-hospital care, the question of using nitroglycerin in cardiac arrest patients must be revisited.
Currently, emergency medical programs that are in charge of first responders like emergency medical technicians provide their technicians with pharmacology reference tables. These reference tables provide guidelines to emergency medical technicians regarding the administering of certain drugs given certain symptoms (and lack of symptoms). For example, the Pharmacology Reference for the New York State EMT-Basic indicates what is allowed of an EMT regarding administering nitroglycerin. “If chest pain is present, and the patient possesses nitroglycerin prescribed by his/her physician, and has a systolic blood pressure of at least 120mm Hg, the EMT-B may assist the patient in the self-administration of their prescribed nitroglycerin as indicated on the packaging” (Pharm. Ref.).
The language used to describe what is allowed of an EMT with regards to nitroglycerin administration is very explicit. The technicians are only allowed to help aid the patient in administering the drug to themselves. This essentially takes the decision making process out of the equation for the EMT. Of course, it is important that such guidelines be in place to protect the patients from receiving care from a person that is not suited to provide such care. However, another question must be asked. Are these guidelines truly protecting the patients from (and legally protecting the institutions that provide the care), or are restrictions like these hindering the caregivers? Would the cardiac arrest patients being cared for in an out-of-hospital benefit more if the emergency medical technicians that were caring for them underwent some certification that would allow them to administer nitroglycerin drugs solely by themselves (without it having to be a situation in which the EMT is just aiding the patient in administration of the drug)? These are very important questions when considering the numbers associated with pre-hospital deaths. “Each year 900 000 people in the United States experience acute MI. Of these, roughly 225 000 die, including 125 000 who die “in the field” before obtaining medical care” (ACC / AHA).
The risk associated with EMTs delivering nitroglycerin is the same as those described in the hospital setting. However, additional risks arise when considering what might happen if the patient does go into severe hypotension. Are the additional treatments available in this pre-hospital setting that could alleviate the symptoms of severe hypotension? If EMTs are allowed to administer this drug, many lives maybe saved on the way to the hospital. I believe that EMTs should be trained in administering these drugs and should also be trained in situations in which nitroglycerin causes severe hypotension. If the physical means of counteracting the negative effects of nitroglycerin are available to pre-hospital caregivers, then trained and knowledgeable medical professional should be allowed to deliver the drugs. Red tape should not stand in the way of a capable person trying to save another person’s life.
- “ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary.”ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary. Web. 30 Mar. 2016.
- American Heart Association. “Nitroglycerin.”Nitroglycerin. 2016. Web. 30 Mar. 2016.
- Hypotension, Nitroglycerin, and Acute Myocardial Infarction STEPHEN E. EPSTEIN Circulation.1973;47:217-219,doi:10.1161/01.CIR.47.2.217 PDF
- Moore, K. L., Dalley, A. F., & Agur, A. M. (n.d.). Clinically oriented anatomy. 2013: Lippincott Williams & Wilkins.
- Pharmacology Reference for the New York State EMT-Basic (follows 11/20/2008 Protocols) http://www.roslynrescue.org/doc/NYS_BLS_Pharm_Table_(3).pdf
