Nitroglycerin or "Nitro" is a generally encountered medication because that EMS, yet it might not work the way you think or do what friend think the does

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What is nitroglycerin offered for?

Nitroglycerin (NTG), also known together glycerine trinitrate (GTN) is a nitrate medication frequently administered to relax anginal chest pain and also manage blood pressure through vasodilation. Different preparations the nitroglycerin may also be administered for therapy of renal issues, liver issues and even together an ointment for anal fissures or tears.

Nitroglycerin deserve to be administered with a wide range of methods, including:


once administering spray nitroglycerin, beware not to accidentally inhale the medication. (Photo/Rommie Duckworth)
Sublingual (under the tongue) tabletsSublingual powderSublingual sprayTransdermal (through the skin) pasteTransdermal patchRectal ointmentIV infusionExtended release oral tablets Names and dosages vary depending on the route of administration.

This write-up will concentrate on the creates of nitroglycerin most typically encountered through EMS; sublingual tablets and sprays, transdermal paste, transdermal patches and IV infusions.

Nitro administration routes

Nitroglycerin dosage, management routes and trade names include:

Nitroglycerin sublingual tablets: Nitrostat, separation, personal, instance tablets, 0.3 mg, 0.4 mg or 0.6mgNitroglycerin sublingual spray: Nitrolingual, 1 metered spray, 0.3 mgNitroglycerin transdermal paste: Nitro-Bid, used with a measure paper, 7.5mg per half inchNitroglycerin transdermal patch: Nitro-Dur, pre-measured self-adhesive patch, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr, 0.8 mg/hrNitroglycerin IV solution: glyceryl trinitrate IV, pre-mixed solutions, generally 25 mg/250mL, 50mg/250mL, 100 mg/250mL that may be administered together loading boluses of as much as 600 mcg adhered to by maintain infusions start at 5 mcg/min together dictated through patient conditions

The creates of nitroglycerin typically administered by EMS service providers of different levels include sublingual tablets or sprays; transdermal paste; and, because that some advanced providers, IV nitroglycerin solutions.

The develops of nitroglycerin supplied by patients typically encountered by EMS service providers in the field incorporate sublingual tablet computers or sprays and also transdermal patches.

Nitroglycerin mechanism the action

Nitroglycerin is a vasodilator the has specifically strong result on vascular smooth muscle found in peripheral veins. Arterial vasodilation may also occur at higher doses that nitroglycerin.

Nitroglycerin forms totally free radical nitric oxide (NO), which in turn activates chemistry in the blood that reason smooth muscle come relax, bring about vasodilation. Nitroglycerin is primarily metabolized by liver enzymes.

Sublingual develops of nitroglycerin are soaked up quickly, in one to 3 minutes, with peak impacts in around five to 10 minutes. Sublingual sheep of nitroglycerin continue to work-related for around 30 minutes, but with less effect.

Sublingual nitroglycerin is typically administered one tablet or spray every 5 minutes up to 3 doses. Part prehospital protocols recommend proceeding dosage and even administering greater dose nitroglycerin two to 3 sublingual doses together in cases of hypertensive congestive heart failure.

Sublingual nitroglycerin is frequently discontinued as soon as the wanted effect is accomplished (typically lessened anginal chest ache or relieved symptom of congestive love failure) or if contraindications are encountered.

Transdermal develops of nitroglycerin work an ext slowly, yet maintain therapeutic levels over a lot longer period of time, generally 12 come 24 hours. Transdermal nitroglycerin is typically used by patient to prevent the breakthrough of anginal chest pain and by EMS suppliers to assist maintain consistent therapeutic level of nitroglycerin in the field after management of sublingual nitroglycerin.

IV options of nitroglycerin may be administered because that a range of purposes, however are most frequently used through EMS carriers for patients who room intolerant the or unresponsive to sublingual nitroglycerin, or that require higher doses that nitroglycerin than have the right to be detailed sublingually or transdermally.

Desired effects and indications that nitroglycerin

Vasodilation to reduce myocardial preload and also afterload and also decreasing blood pressure. This to decrease in press reduces the workload of the heart and helps to relieve heart failure.

For EMS providers, common nitroglycerin indications encompass chest ache or discomfort linked with angina pectoris or doubt acute myocardial infarction, as well as pulmonary edema v hypertension.

For patient at home, indications commonly include avoidance or treatment of chest pain, or discomfort connected with angina pectoris or suspected acute myocardial infarction.

Contraindications the nitroglycerin

ABSOLUTE: Discontinue nitroglycerin management or do not provide nitroglycerin to patient who:

have actually a recognized sensitivity come nitrate medicationsAre hypotensive (typically Are kids under 12 years oldAre experiencing boosted intracranial pressureHave severe anemia

RELATIVE: Nitroglycerin management may be considered with caution to patients who:

have a known or suspected ideal ventricular infarct and also are thus greatly dependent on maintaining pre-load (although current studies have found few complications with management of nitro in RV infarcts)Are bradycardicAre tachycardicAre at this time taking antihypertensive medications, including beta-blockers, phenothiazines or other nitratesAre under the impacts of alcohol gulp down or intoxication

Nitroglycerin side impacts include:

HeadacheDizzinessHypotensionFlushingNauseaReflex tachycardia

Nitroglycerin precautions:

proper storage of nitroglycerin is essential. Nitroglycerin is rapidly inactivated through light, heat, waiting contact and moisture.Patients have to not chew or gulp down nitroglycerin tablets.Alcohol usage prior come or concurrent v nitroglycerin usage may rise the vasodilating and hypotensive results of nitroglycerin.Patients may construct a yongin or resistance to nitroglycerin over time and may require boosted dosages because that therapeutic effect.When administering the spray type of nitroglycerin, beware that no suppliers accidentally be breathing the medication because of close proximity through the patience or a poorly command spray.Nitroglycerin indigenous transdermal spot or paste may be absorbed through any contact through the skin. Always wear gloves once handling, using or removing. Once removing, clean the area by wiping v gauze and also disposing the carefully.

Nitroglycerin myths and misconceptions

Like many commonly encountered prehospital treatments, some of the common knowledge surrounding nitroglycerin contains much more myths and misconceptions 보다 evidence-based facts. Right here are some of the height myths and also misconceptions about nitroglycerin treatment:

If the patient does not react to nitroglycerin it can not be cardiac pain. MYTH: while nitroglycerin is an reliable prophylactic against and therapy for anginal chest discomfort, nitroglycerin will certainly not relax all cardiac signs and also symptoms.Administration of nitroglycerin to a patience with ideal sided love failure will certainly kill the patient. MISCONCEPTION: when patients experiencing from right-sided heart fail are specifically dependent on their preload, which administration of nitroglycerin reduces, that is not commonly considered an absolute contraindication in these patients. Any kind of patient administered nitroglycerin who develops hypotension must receive a trial management of IV fluids. Normal precautions for management of fluids come patients with any form of love failure, including monitoring the blood pressure and lung sound apply.You have to start one IV prior to administering nitroglycerin. MYTH: when intravenous accessibility is regime for any type of patient v suspected acute coronary syndromes, patients frequently take multiple doses of nitroglycerin at residence with no IV accessibility in place. As with any kind of medication, nitroglycerin management should be guided by local protocols and also medical direction.If a patient responds to nitroglycerin, they must be having actually a cardiac event.

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MISCONCEPTION: As a smooth muscle agent, nitroglycerin will often relieve symptoms linked with bitterly bladder obstruction or spasm, as well as esophageal irritation and also spasm.

Take the opportunity to share this write-up with your other providers. Powerful treatments like nitroglycerin demand well-informed responders.