I’m reviewing ACLS in preparation for recertification, and aside from it being a great review of stuff I’d pushed to the nether-regions of my mind, because well, adults… it reminded me that many of my pediatric colleagues see adults when they least expect it. An adult with chest pain may or may not have an MI. Reflexively that will lead a lot of us to give 325mg of aspirin and some sublingual nitroglycerin. In most cases both of these are great choices. But there are some contraindications. The purpose of this edition of Briefs is to make sure that you remember them when grandma’s heart is a hurtin’. You may want to also take a look at the 2010 AHA guidelines while you’re at it.

Aspirin

Use: Give nonenteric coated aspirin 160 to 325 mg and ask patient to chew the tablet to hasten absorption.

Contraindications

Salicylate allergy
Recent GI bleed

Nitroglycerin

Use: Give up to 3 nitroglycerin doses (tablets or spray) at intervals of 3 to 5 minutes

Contraindications

Hypotension: initial systolic blood pressure <90 mm Hg or ≥30 mm Hg below baseline
Right ventricular infarction (Inferior wall STEMI): Patients with a right sided infarct require adequate preload. Whereas nitrates reduce preload through vasodilation. FYI, right sided MI has ST elevation in II, III, aVF and reciprocal ST depression in I and aVL. 80% are right carotid and 20% circumflex (but you already knew that).
Patients have taken a phosphodiesterase-5 (PDE-5) inhibitor (sildenafil) within 24 hours (48 hours for tadalafil)