“Just Say Know!”

1. “Just Say Know!” Pharmacology in ACS

2. About ME Julie Williams, NREMT-P, NCEE Beaufort County EMS Training Coordinator

3. Beaufort

4. 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”.

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

6. 12 Lead EKG

7. Right Side V4R

10. M O N A

11. AHA

12. 2005 2010

13. Morphine

14. What’s it do • Analgesic • Reduces preload • Reduces dyspnea associated with LVF and Pulmonary Edema

15. However • Myocardial depressant • Increases mortality in UA/NSTEMI • Cannot be used in CHF

16. 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%

19. Can it Hurt???

20. 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

21. However…. • Hyperoxia decreases CBF • Increases vascular resistance • Increases blood pressure • Increases heart rate • Decreases myocardial O2 consumption

23. Pre-admission

24. Admission

25. Nitroglycerin

26. Nitroglycerin • Vasodilator • Increases coronary blood flow • Reduces ischemic pain • Reduces preload

27. Nitroglycerin Actions • Decrease coronary vasoconstriction or spasm • Increase myocardial perfusion • Decrease Oxygen demand • Decrease preload • Tolerance

28. Vasodilation Reduced Preload Hypotension DEATH

29. Precautions • Phosphodiesterase inhibitor • Viagra, Levitra <24 hours • Cialis <48 hours • SBP <90 mmHg • HR <50 bpm • RVI

30. Tolerance • Develops rapidly • Blood vessels become desensitized to vasodilation • “Nitro-free interval” • 10 to 12 hours

31. Aspirin

32. Aspirin • Platelet inhibitor • Used with fibrinolytic therapy • Reduced nonfatal MI by 30% • Reduced vascular death by 17% • Aids streptokinase

33. Precautions • “True” allergy • Active peptic ulcer • Severe hepatic disease

34. Case #1 Review • Oxygen (capnography) • Aspirin • IV’s • Fluid Bolus • Dobutamine

36. QUESTIONS ?

37. Thank you!!! Julie Williams, NREMT-P, NCEE Beaufort County EMS Training Coordinator j_williams01@hargray.com