Herman L L, Koenigsberg M, Ward S, Sloan E P
University of Illinois College of Medicine, Chicago, USA.
Prehosp Disaster Med. 1993 Jan-Mar;8(1):29-33; discussion 34. doi: 10.1017/s1049023x00039972.
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).
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.
The Resource Hospital/Telemetry Base-Station and two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.
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.
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.
本研究的目的是量化院前急救中硝酸甘油（NTG）的使用情况，检测与标准医疗指令（SMO）的偏差，确定其给药的有效性以及具有临床意义的不良反应（低血压、心动过缓）的发生率。
回顾性分析1990年6月、7月、8月这三个月内7683次高级生命支持（ALS）遥测基站联系记录，以确定所有使用NTG的院前患者接触情况。
资源医院/遥测基站以及芝加哥北部急救医疗服务系统的两家社区医院/遥测基站。
有445次运行中按照SMO指示使用了NTG。288名患者（64.7%）根据SMO因适当指征接受了NTG治疗，其中203例用于缺血性胸痛（45.6%），79例用于肺水肿（17.7%），6例两者皆有（1.3%）。有157次运行（35.5%）中虽指示使用NTG但未给药。有22名患者接受NTG治疗的指征与SMO不符。对118名患者（40.9%）完成了关于主观症状的重新评估数据，其中92名（45.3%）胸痛患者，26名（32.9%）呼吸困难患者。给予NTG后，21名胸痛患者（10.1%）症状未改善，而13名呼吸困难患者（15.3%）症状改善，13名患者（15.3%）症状未改善，无患者症状恶化。121名患者收缩压（SBP）下降，24名患者（5.4%）血压未变，28名患者（6.3%）血压升高。初始平均SBP为176±44 mmHg，重复测量平均SBP为164±41 mmHg，平均下降12±22 mmHg。87名患者舒张压（DBP）下降，53名患者（11.9%）血压未变，33名患者（7.4%）血压升高。初始平均DBP为97±24 mmHg，重复测量平均DBP为92±23 mmHg，平均下降5±15 mmHg。仅1名患者在使用NTG后出现低血压，经静脉推注300 ml生理盐水成功复苏。
在该急救医疗服务系统中，根据该系统SMO规定的指征，NTG使用不足。重新评估记录较少，但完成时，具有临床意义的不良反应很少见。由于低血压和心动过缓的发生率很低，无法建立静脉通路不应排除使用NTG。
