Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

A Comment on Saving Patients from Low Doses of NTG

In response to Saving Patients from Low Doses of NTG, unit12medic writes –

All I can offer to the conversation is over a decade of anecdotal high dose NTG outcomes that matches your anecdotal outcomes. In my early (meaning more scared of the Protocol Nazis) days, I religiously studied, recited, and followed the protocol book.

I ran into some truly idiotic refusals of orders very early as a medic. I have always been one to question teachers, bosses, and other authority figures when they did not make sense. Not necessarily as a belligerent confrontation, but in wanting to know why they came to the conclusions that they did, when I came to opposite, or very different conclusions.

Butch Cassidy: No, no, not yet. Not until me and Harvey get the rules straightened out.
Harvey Logan: Rules? In a knife fight? No rules!
[Butch immediately kicks Harvey in the groin]
Butch Cassidy: Well, if there aint’ going to be any rules, let’s get the fight started. Someone count. 1,2,3 go.
Sundance Kid: [quickly] 1,2,3, go!
[Butch knocks Harvey out]

Are there really any rules of the knife fight rules of decorum, when it comes to what is best for patients?

Many times I was wrong and learned from asking questions. Sometimes I found out that the authority figure had no idea why they were doing something, but were only repeating some mythology they had memorized, but never questioned. While I could have had a much more stable career, if I never questioned authority, I could not have been happy that way.

It was good in the fact that I did intubate a relatively higher percentage of patients than I do now. The good I’m referring to is a young medic getting lots of intubation experience, not anything good for the patients mind you. It’s been too many years for me to recall what the impetus was to re-evaluate my CHF treatment routine, but I did so sometime in the late ’90s early ’00s.

One of the things I first learned in EMS is just how valuable NTG (NiTroGlycerin) can be and just how useless furosemide (Lasix) is, unless I am trying to get the patient to pee on the stretcher. I’m just not that big a fan of Golden Showers and other perversions.

Photo credit

I’m not sure how you did it, but I used the “4 pumps equals 1 spray method” for the longest and did not stop at the prerequisite 3 “sprays”, but usually hit 5 on a normal CHF’er.

I was not using 4 sprays = 1 tab, but I have read somewhere that 2 sprays = 1 tab (that might have been on the label for the NitroLingual).

I get lost sometimes when counting that high.

I know what you’re thinking. “Did he give six NTG or only five?” Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is nitroglycerin, the most effective drug for hypertensive CHF, and under-treating CHF would be very bad, you’ve got to ask yourself one question: Do I give an extra one just to be sure? Well, do ya, punk?

Of course, I would always give the patient one more NTG. I got’s to know that my patient is getting enough. Not enough is what is dangerous.


More NTG is almost certainly not going to make things worse – not giving enough NTG is the real danger to the patient.

I have never seen a hypertensive CHF patient have a significant drop in blood pressure from any amount of NTG – Never.

I have been told repeatedly that maintaining hypertension is impossible with high doses of NTG. It is easy to demonstrate that this certain bottoming of the blood pressure is a lie.

Double the dose of the NTG when the patient’s pressure is higher than 180/x. If the pressure remains very hypertensive, give a triple NTG dose. If the patient has still not come down by any significant amount, give a quadruple NTG dose. If the patient’s pressure still has not moved, give 5 NTG at a time.

At any point where the pressure starts to come down, stay at the last dose of NTG used – 2 or 3 or 4 or 5 at a time, or drop the dose by 1.

Remember that the goal of treatment with NTG is to lower the blood pressure because the pressure is too high and filling the lungs with fluid.

Giving one NTG at a time is just creating the misleading appearance of doing something, when all we are relly doing is keeping busy until the preventable intubation is no longer preventable.

We should be better than that. Our patients deserve better than that.

I noticed that I was intubating fewer and fewer patients and that these fewer intubated patients were in less distress when we arrived at the ER. For a guy that was taught rotating tourniquets in school, I feel like I’ve made some real progress. Of course I could have never done this without the support and even encouragement of the ER docs that I worked with. These guys always took the time to pat me on the back when I did good, or pull me aside and explain what I had done wrong and how to improve upon it. Too bad I didn’t have a medical director that did the same thing, but that is another story all together.

This is one of the failures of the medical direction system. There is a fear that NTG is too powerful for EMS to titrate – even too powerful for emergency physicians to titrate. We have been slow to make the progress that our patients need.

We also need more research and the paper that started this. This is an excellent example of what we need to convince the more fearful doctors that –


The danger is not too much NTG.



Medical NTG is not dynamite, no matter how much some people pretend otherwise.


The real danger is not enough NTG.



[1] Butch Cassidy and the Sundance Kid (1969)
Link to full quote.



  1. A lot of it I think stems from the poor education as to the causes of pulmonary edema. It wasn’t until I took an instructor methodology course and had to develop a lesson plan on pulmonary edema that I realized just how nuanced it is. The classical definitions of “cardiogenic” and “non-cardiogenic” were suitably lacking in helping a provider understand how their treatments affect the individual.

    I’d prefer if there was a push to move to “high pressure” and “high permeability” as the definitions. That way it is clear as to the pathophysiology at play.

    High pressure pulmonary edema? Treat it with the 3 P’s: park it somewhere else, push it forward, and pee it out.

    1. Park it in the distal vasculature with high dose NTG
    2. Push it forward using pressors if necessary or even more fluid (dive deep with Starling)
    3. Pee it out with diuretics only after you’ve made a place to park it and pushed it forward

    I think high dose NTG can be corrected with some simple continuing education, but getting providers on board with pressors and more fluid may be quite the challenge!

  2. As opposed to NO NTG for CHF. To this day I run into residents and even board certified EM physicians who can’t figure out why EMS gives NTG if the patient has no chest pain. I’ve even had some lecture me that I’m “out of protocol” for doing it. Must be a different protocol because mine has been pretty clear since we adopted NTG spray just about the time I became a medic. Systolic pressure above 150 mm/Hg, the patient get double NTG (0.8mg) sprays until the systolic is BELOW 150 mm/Hg, unless there is some contraindication.

    Combine NTG with CPAP and you have a very sick patient becoming a very happy patient very quickly.

  3. Intubation, with or without RSI is far riskier for the patient. Not to mention that it lengthens ICU stays, has the risk of VAP, and lastly drives up costs. It’s the VAP that’s the killer, sometime literally.

    We don’t see intubation in the hospitals for CHF patients very frequently. In fact, they were ahead of us on using CPAP by several years. That angered a lot of the medics because we knew that there was a better way to treat patients.

    I’d love to be able to do IV NTG in the field, but can’t seem to get our medical director interested in it. That might be because someone else has to approve the purchase of the pumps. It sure would help patients, though.


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