Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Is a half a bottle of nitro too much for a single dose?

 
In what I last wrote about the emergency treatment of CHF (Congestive Heart Failure) and furosemide (Lasix – frusemide in Commonwealth countries) being a bad drug,[1] I also mentioned what Peter Canning had written about Hero Medic and a very high dose of NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries).

How much NTG?
 

The hero medic opened the nitro, pulled open the patient’s mouth and poured in what seemed like half the container. The hero medic closed the patient’s mouth, and then told the new medic. “You should be all set.”[2]

 

What seemed like half the container of something we are warned not to give chest pain patients more than one at a time and never more than 3 tabs of – ever!

That does seem like a lot, but how much is half of a bottle?
 

 

How much is a lot?
 

 

For the typical bottle pictured, the label states that the total is 25 of the 0.4 mg tabs.

That is a total of 10 mg. Half of that is easy math – 5 mg.

What seemed like half the container is probably less than half, but it was just such a shocking visual for the narrator, that all he could do was estimate.

Is 5 mg a large dose?

Yes.

Is 5 mg a dangerous dose?

That depends on the patient presentation.
 

a patient in severe pulmonary edema who was circling the drain[2]

 

I would like to know his blood pressure, but even hypotensive CHF patients do well with huge doses of NTG.

The patients below were more than just circling the drain.

All were hypotensive, or pulseless.
 


Click on the image to make it larger.[3]

 

Almost all of the massive dose NTG patients survived.

The highest blood pressure before NTG was 80/70.

The lowest dose of NTG was 1 mg – and that was the only patient who received less than 5 mg NTG.

Almost every hypotensive patient received much more than 5 mg NTG.

Is 5 mg NTG a dangerous dose?

Probably not.

Is 5 mg a scary dose?

Of course. We have been trained to be scared of NTG.

That dose is just much larger than most people are comfortable with, because of fear and inexperience.
 

You can talk about the hero medic acting off protocol and being a cowboy, etc, but the story still resonates for me.[2]

 

Would it be appropriate to just drop in, give a large dose of anything, and then not stick around?

No. If the original medic is not comfortable with that treatment, the Hero Medic should be there to hold the nitrophobic medic’s hand and reassure the medic to follow his assessment, rather than to follow his anxiety. That is the way we learn.

The story of Hero Medic is told through hyperbole – exaggeration to make an important point.

I have done this with others. Look, not only am I giving a much larger dose than you claim is safe – I am going to add a few more tabs – just to make a point.

If the scare stories about NTG were true, the patients would bottom out their blood pressures, but it is only the witnesses who bottom out their blood pressures, due to over-stimulation of their vagal nerves. The patients improve.

Some people learn from this clear demonstration that they have been lied to, but others choose to believe the dogma even after seeing clear evidence that the dogma is a lie.

Doctors, nurses, medics, et cetera. They are equally susceptible to dogma.

Is the Hero Medic a cowboy?

No, the Hero Medic s a teacher.

We need to be smart enough to learn.

Footnotes:

[1] Lasix Kills: Better Therapy for CHF
Wed, 07 Nov
Rogue Medic
Article

[2] NTG and the Hero Medic
Street Watch
November 7, 2012
Article

[3] High dose nitroglycerin treatment in a patient with cardiac arrest: a case report.
Guglin M, Postler G.
J Med Case Reports. 2009 Aug 10;3:8782.
PMID: 19830240 [PubMed]

Free Full Text from PubMed Central

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