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“Just Say Know!”. Pharmacology in ACS. About ME. Julie Williams, NREMT-P, NCEE Beaufort County EMS Training Coordinator. Beaufort. Case #1.

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just say know
“Just Say Know!”

Pharmacology in ACS

about me
About ME

Julie Williams, NREMT-P, NCEE

Beaufort County EMS

Training Coordinator

case 1
Case #1

You respond to a 83 y/o male c/o substernal chest pain (10 on pain scale) throughout the day. Upon arrival you find the patient sitting in his recliner. He is COA and appears pale and diaphoretic. Patient states “all I need is a nitro and I’ll be fine”.

case 1 cont
Case#1 cont.
  • Vital signs
    • B/P - 156/72
    • HR - 56
    • R - 20, non-labored, lungs clear
    • Skin – pale, cool diaphoretic
slide10

M

O

N

A

slide12

2005

2010

what s it do
What’s it do
  • Analgesic
  • Reduces preload
  • Reduces dyspnea associated with LVF and Pulmonary Edema
however
However
  • Myocardial depressant
  • Increases mortality in UA/NSTEMI
  • Cannot be used in CHF
the study
The Study
  • CRUSADE
    • A National Quality Improvement Initiative
    • Duke University Medical Center
  • 57,000 ACS patients admitted to one of 433 hospitals
  • Death or MI with no Morphine 7.1%
  • Death or MI after Morphine 8.7%
rationale
Rationale
  • To correct SaO2 <90%
    • ACC/AHA 2007 guidelines class I
  • ALL NSTEMI/ uncomplicated STEMI
    • Class IIb
  • Increase in O2 = decrease in ischemia
  • Ventilation-perfusion mismatch
  • Pulmonary edema
however1
However….
  • Hyperoxia decreases CBF
  • Increases vascular resistance
  • Increases blood pressure
  • Increases heart rate
  • Decreases myocardial O2 consumption
nitroglycerin1
Nitroglycerin
  • Vasodilator
  • Increases coronary blood flow
  • Reduces ischemic pain
  • Reduces preload
nitroglycerin actions
Nitroglycerin Actions
  • Decrease coronary vasoconstriction or spasm
  • Increase myocardial perfusion
  • Decrease Oxygen demand
  • Decrease preload
  • Tolerance
slide28

Vasodilation

Reduced Preload

Hypotension

DEATH

precautions
Precautions
  • Phosphodiesterase inhibitor
    • Viagra, Levitra <24 hours
    • Cialis <48 hours
  • SBP <90 mmHg
  • HR <50 bpm
  • RVI
tolerance
Tolerance
  • Develops rapidly
  • Blood vessels become desensitized to vasodilation
  • “Nitro-free interval”
  • 10 to 12 hours
aspirin1
Aspirin
  • Platelet inhibitor
  • Used with fibrinolytic therapy
  • Reduced nonfatal MI by 30%
  • Reduced vascular death by 17%
  • Aids streptokinase
precautions1
Precautions
  • “True” allergy
  • Active peptic ulcer
  • Severe hepatic disease
case 1 review
Case #1 Review
  • Oxygen (capnography)
  • Aspirin
  • IV’s
  • Fluid Bolus
  • Dobutamine
thank you
Thank you!!!

Julie Williams, NREMT-P, NCEE

Beaufort County EMS

Training Coordinator

j_williams01@hargray.com