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Push-dose medications have become anew hot-button topic in EMS over the past couple of years. But are they really that new? Push dose nitroglycerin has been in the medical literature for quite a while, specifically in 1994 there was a study that discussed the use of push-dose nitro for patient with chest pain. So what applications might push dose nitroglycerin have in EMS? If we look at the standard concentration of NTG, which is 50mg in 250mL (200mcg/ml) we can see that 2ml of this concentration is equal to a sublingual tablet of 400 mcg. The advantage that push-dose nitroglycerin has is that it is far more titratable than a tablet. It also has the advantages of reducing pre-load faster than tablets, and this reduction might be correlated to reduced ICU admissions.

When we see a patient in CHF, the goal is to reduce the amount of fluid in their lungs as quickly and safely as possible. This is not always accomplished with the front-line treatment of CPAP and lasix. In fact, lasix is a drug that we probably should be giving later in the CHF algorithm anyway. Lasix acts as a diuretic, and does not directly reduce the amount of fluid in the patient’s lungs, but instead helps the patient excrete the fluid in the form of urine. Odd are, the patient did not call you because they are having trouble urinating. Anecdotally, I can tell you that push dose nitroglycerin is terrific intervention that works well, and works fast. This intervention is the kind that will have you bringing patients into the E.D. that are a fraction as sick as they once were.

More: Clinical Pearl 70

5 minute refresher- Push Dose NTG