title: The prehospital use of nitroglycerin according to standing medical orders in an urban EMS system.
abstract: OBJECTIVE
  The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determine the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia).
  
  
  METHODS
  Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, August 1990) to identify all prehospital patient contacts in which NTG was utilized.
  
  
  METHODS
  The Resource Hospital/Telemetry Base-Station and two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.
  
  
  RESULTS
  There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176 +/- 44 mmHg and the repeat mean SBP was 164 +/- 41 mmHg with a mean decrease of 12 +/- 22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97 +/- 24 mmHg, the repeat mean DBP was 92 +/- 23 mmHg, a mean decrease of 5 +/- 15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resuscitated with a fluid bolus of 300 ml normal saline.
  
  
  CONCLUSIONS
  In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.
authors.affiliation: University of Illinois College of Medicine, Chicago, USA.
authors.forename: L L
authors.initials: LL
authors.lastname: Herman
authors.forename: M
authors.initials: M
authors.lastname: Koenigsberg
authors.forename: S
authors.initials: S
authors.lastname: Ward
authors.forename: E P
authors.initials: EP
authors.lastname: Sloan
mesh_terms: D000368:Aged; D002641:Chicago; D002985:Clinical Protocols; D004363:Drug Utilization; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D005996:Nitroglycerin / Q000627:therapeutic use*; D012189:Retrospective Studies; D013686:Telemetry; D014665:Vasodilator Agents / Q000627:therapeutic use*