If patient had an MI in a non-hospital setting, and it was recognized immediately by a medical personnel, can management begin at the scene? In other words if sublingual Isosorbide Dinitrate and Aspirin were available, can they be given at once, or should we wait until hospital is reached?
If so, what doses can be given? and at what interval until hospital is reached?
On recognition of an MI, both STEMI and NSTE-ACS, one should administer a loading dose of aspirin (300 mg of enteric coated tablet) unless otherwise contraindicated. Isosorbide dinitrate need to be given for symptomatic relief, if relief is not achieved, we can shift to GTN infusion with/without morphine.
Ref : ACC/AHA and ESC guidelines on STEMI and NSTE-ACS.
The most important to give at once is a chewable aspirin 300 mg tab. it has a high mortality benifit.
GTN Spray even better than sublingual GTN but only for symptomatic relief. no mortality benefit.
Yes!
Both chewable non enteric coated high dose aspirin (160-325 mg) and sublingual (0.3-0.6 q5 min. and can be repeated up to three times) or spray nitroglycerin preparation should be administered in any case of ACS unless contraindicated. (AHA, ACC, ESC guidelines)
Approach Considerations
In 2015, the American College of Cardiology/American Heart Association (ACC/AHA) released the guidelines recommendations on the management of non-ST-elevation acute coronary syndromes (ACSs) to assist in maximizing patient outcomes, including the following[18] :
Standard initial medical therapies include supplemental oxygen for arterial oxygen saturation < 90% or respiratory distress; sublingual nitroglycerin; oral beta-blocker therapy within the first 24 hr in the absence of heart failure, low output state, increased risk for cardiogenic shock, or other contraindications to beta-blockade; nondihydropyridine calcium channel blocker for continuing or recurrent ischemia and contraindication to beta-blockade (in the absence of clinically significant left ventricular dysfunction).
Initial antiplatelet/anticoagulant therapy includes 325-mg chewable aspirin at presentation, followed by a daily maintenance dose of aspirin at 81-126 mg daily. A P2Y12 inhibitor (clopidogrel or ticagrelor) should be used in addition to aspirin for up to 12 mo in patients treated with either an early-invasive or ischemia-guided strategy. In addition to antiplatelet therapy, parenteral anticoagulation is indicated with enoxaparin, bivalirudin, fondaparinux, or unfractionated heparin.
http://emedicine.medscape.com/article/1910735-treatment#d1
Best Wishes,
Hi Khozondar,
I would choose Aspirin (160-325 mg) crewable as the most important in this setting. If symptomatic (chest pain or dyspnoea) consider nitrate, carefully with the risk of hypotension.
I am in agremment. I have used chewable aspirin as an immediate therapeutic measure at a loading dose of 300mg stat and repeated twice after initial dose before in-hospital care. It is of immense benefit.
Aspirin is without any doubt, we often give nitrates (sublingual, sprey or oral) even without pain before transportation, because this is some kind of pain prophylactics and vasodilatation. However IV is much better and could be used even in outpatient conditions
i am pretty sure some EMR services in different countries have these kind of protocols in place where the first respondant do a 12 lead EKG, diagnose the MI and give 300 mg ASA. i have never heard of nitrate be given in the pre-hospital setting.
I am pretty sure that could be. In Russia because of the big territory and a long trip to clinic we can give trombolytics in outhospital conditions, and ASA and oral or sprey Nitrates are routine.
specific pre hospital care include :
1-Intravenous access, supplement oxygen
2-immediate administration of aspirin
3-nitroglycerine for active chest pain given sublingually or spray
Aspirin should be given as soon as possible, ideally sublingual to get rapid absorption.
Nitroglycerin, if available, can be given, BUT it could cause hypotension, so ideally you would like to see a BP before giving it.
I agree. Nitro can rarely give hypotension, mostly by IV. Anyway the doses should not be high because it hassle effective threshold and again can cause hypotension and severe headache
In Bangladesh where patients may take long time to reach a cardiac hospital it is advisable to give 300 mg aspirin + 300 mg clopidogrel + s/l nitrate for chest pain. If streptokinase (the only thrombolytic available) can not be given before reaching cardiac facility then iv+ s/c enoxaparin could be started as well.
I believe that aspirin should be given promptly. Nitrate only if the patient is not hypotensive and no history of sildenafil use.
I agree with Prof. Wadud Chowdhury . In a developing country , where the transporting to nearby cardiac centre is time consuming, one may start Aspirin 300 mg in chewable form (in most cases Aspirins are available in enteric coated) as well as Clopidogrel 300mg if ACS is highly suspected ( above 40 years,smoker, hypertensive, diabetic, previosly known IHD ). In fact it is in practice in most remote areas. Guidline on ACS by Bangladesh Cardiac Society also recommended this sort of practice.
I agree with dr Emerson de Albuquerque Seixas: aspirin should be given promptly. Nitrate only if the patient is not hypotensive and no history of sildenafil use.
In Finland ASA and nitro spray have been routine medication for acute chest pain for dozens of years in health care. New national First Aid guidelines instructs also layman to give 250mg chewable ASA to any patient suffering typical acute chest pain, if the patient is not allergic to it.
The ACC guidelines for ACS continue to emphasize early recognition and activation of EMS. Anyone can give 120-325mg ASA for chest pain and nitro--spray or sublingual table--one spray or tablet every 5 minutes, up to 3 doses. Have the victim chew the aspirin.
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