Effects of prehospital nitroglycerin on hemodynamics and chest pain intensity.

OBJECTIVE: To assess the effects of prehospital nitroglycerin (NTG) on vital signs and chest pain intensity. METHODS: A retrospective review of advanced life support (ALS) run sheets was performed in a suburban volunteer emergency medical services (EMS) system receiving 8,000 annual ALS calls. All consecutive patients who were administered NTG by EMS were included. Standardized forms were used to collect data on patient demographics, history, and physical exam. Patients assessed their chest pain (CP) before and after NTG on a verbal numeric scale of 0-10 from least to most severe. The presence of syncope, dysrhythmias, or profound hypotension [loss of peripheral pulses, a systolic blood pressure (SBP) of <90 mm Hg after NTG, or a drop of >100 mm Hg in BP] was noted. Results. One thousand six hundred sixty-two patients received NTG over 18 months, their mean age was 66 years, and 48% were female. Indications for NTG included CP (83%), dyspnea (45%), and congestive heart failure (20%). After NTG administration, the CP score decreased from 6.9 to 4.4 (mean difference = 2.6; 95% CI = 2.4 to 2.8). The CP completely resolved in 10% of the patients. Mean decreases in SBPs and diastolic BPs were 11.8 mm Hg (95% CI = 10.7 to 13.0) and 4.0 mm Hg (95% CI = 2.9 to 5.1). The mean pulse rate increased by 2.7 beats/min (95% CI = 0.6 to 4.9). There were 12 patients with adverse events [0.7% (95% CI = 0.4% to 1.3%)], including profound bradycardia and hypotension (1), transient drop in SBP of 100 mm Hg responding to fluids (6), post-NTG SBP <90 mm Hg (4), and syncope (1). There were no deaths in the prehospital setting. CONCLUSIONS: Use of prehospital NTG appears safe. While NTG reduces CP, most patients have residual pain.

Evaluation of American College of Surgeons trauma triage criteria in a suburban and rural setting.

In suburban and rural counties, patient transport to specialized facilities such as trauma centers may result in prolonged transport times with the resultant loss of ambulance coverage in the primary service area. We evaluated the American College of Surgeons trauma triage criteria as modified by New York State to determine the ability of these criteria to predict the need for trauma center care in victims of blunt traumatic injury. Blunt trauma patients were retrospectively identified through review of patient care reports for the presence either of mechanism or of physiological criteria for transport to a trauma center. Controls were randomly selected from patients with blunt trauma not meeting any of the criteria. Main outcome parameters were the emergency department (ED) disposition, length of hospital stay, need for intensive care unit (ICU) care, and major nonorthopedic operative interventions. There were 857 patients enrolled. The presence either of mechanism or of physiological criteria increased the likelihood of hospital admission (control, 11%; mechanism, 35%; and physiological, 33%). Relative to patients without any criteria, the presence of mechanism criteria alone did not identify patients who required a prolonged length of stay (67% vs 71%), intensive care unit services (13% vs 19%) or major nonorthopedic operative interventions (0.2% vs 1.6%). The presence of physiological criteria increased the likelihood of requiring all of these services. These comparisons held true for victims of motor vehicle accidents, pedestrians struck by motor vehicles, and people who fell from heights above ground level. Patients with physiologic criteria may benefit from transport directly to a trauma center. Because of the low need for operative intervention and ICU services, patients with no criteria or mechanism criteria at long distances from a trauma center may be initially evaluated at the closest hospital and transferred to a trauma center if hospitalization or ICU care is necessary. Further study to determine the predictive value of certain individual mechanism criteria is warranted.