Episode 40: Rules for Sublingual Nitro

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You can also use the code Cardiopalm1MO at the time of sign up for a one-month grace period applied to your new account . Thanks again , jane . Hello , hello and welcome to today's episode of Talking All Things Cardiopalm . I am your host , dr Rachel Barisi .

Today we're going to be talking about understanding sublingual nitro and this is an important concept when we're talking about the MPTE , because now we're talking about safety and we know safety is a hard hitter on the MPTE . So let's just jump right in Our overall view of today .

What we're going to talk about is mechanism of action of the drug , some side effects . Some need to know things as a PT and just in general need to know information about the drug and how that patient is taking the drug and what you need to educate your patient on for safety , the rule of threes .

And then we're going to wrap up some safety considerations so we can keep everyone safe . If you see sublingual nitro , primary thought trigger word is angina . Sublingual nitro is fast acting to combat angina . It is an anti-anginal med , primary indication , primary problem for safety .

The way that nitro in itself works is that nitrates are converted to nitric oxide in the vessels and nitric oxide is a potent vasodilator .

So nitric oxide is known as an endogenous endothelial relaxing factor and it decreases the sensitivity of the contractile proteins of calcium and we know , calcium causes contraction , so it decreases the sensitivity to allow relaxation of the blood vessels .

Put that in plain English it is a potent systemic vasodilator , meaning we're going to have dilation of the arterials as well as the venous system . It causes a decrease in preload , which is that venodilator . It causes decreased afterload , which is that arterial dilator .

And , most importantly , in the world of angina , it's increasing blood flow to the coronary arteries . So it works fast , quick onset , potent vasodilation . Because of that , we can assume the main side effect is hypotension and dizziness . Fact we're going to talk about it in a second .

But if your patient has to take sublingual nitro , they should be in a seated position because they are going to become hypotensive Period . We are vasodilating everything . When you are hypotensive you tend to feel dizzy , so those two go hand in hand . And then the third most common side effect with sublingual nitro is headache .

They might also get reflex tachycardia , nausea and vomiting and flushed feeling in the skin . When you have a patient that you are caring for and they have a history of heart attack , they have a history of angina . We need to be asking certain questions .

We need to be thinking about what types of meds are they on , because , likely , at some point they have been prescribed nitro . And the question is do they have nitro on board now ?

If they do , if they're prescribed nitro , it must be carried on their person at all times , not just while they're with you in your PT session , at all times , because if they overexert themselves , if they start to have angina , they need to have that medication ready now .

So it needs to be on their person , which means on their being with them , not in the car , not in their wife's purse , not at home , on their physical being carrying it . And then there are some rules attached to this , and that is it needs to be in its original container . So there's an original bottle that it comes in .

It is dark and typically opaque in color . It should be kept in that bottle for a number of reasons , but one of the reasons is to ensure that it's not expired . Expired nitro is less effective , it's less potent . So if that patient has nitro and they have the bottle on them , check the expiration . It is sublingual , which means it goes under the tongue .

Place the tablet under the tongue . They should not chew it . They should not swallow it . Typically , when they place it under the tongue , they may feel a burning sensation . There is some suggestive research that states if you feel the burning sensation , that ensures that there's potency to that med .

The other side of the coin is some of the research says if you don't feel it , it doesn't mean it's not working . So just kind of have that in mind . They might have that sensation . That is normal .

It should almost be happening every time they are to take it and then , just like I said before , before taking the nitro they should sit down because they're going to become hypotensive and they are going to get dizzy . On top of all that , if they're having active angina , we are sitting down because now we're actively resting . Okay , ooh , went too far .

Last super important education point If your patient has nitro on board , they should not be taking an erectile dysfunction med like Viagra or Cialis , because it can cause profound hypotension and sometimes you will see that a patient has both prescribed .

In the event that they do have both meds prescribed , it is important to educate them that if they were to take Viagra or Cialis , that they should then not take Nitro if they were to have angina . Both medications work very similarly and will cause hypotension to profoundly drop and can cause very serious complications . Okay , rule of threes .

If your patient has angina , known history of angina , they have nitro on board . They have it on their person . They sit down , rest . The angina persists , they can take angina . They can take their nitro . They place the nitro under their tongue and they wait five minutes .

If the angina does not go away , they can take a second nitro , place it under the tongue , wait five minutes . At this point you're calling 911 . If the angina still does not resolve after the second nitro , they can take a third nitro . So the rule of threes means patient can take up to three nitros five minutes apart .

Excuse me , it is important that you do follow the rule of after the second nitro , call 911 . Because the faster you have that EMS response activated . If this is an active heart attack , if this is progressing by the time EMS comes or by the time they get to the hospital , it'll be a shortened period of time . I've worked with patients for over 14 years .

Sometimes they don't want you to call 911 . This is the point in your career where you have to make that decision . On a test , you 100% will be calling 911 if you're in an outpatient clinic . So to recap , you're working with a patient , they have a known angina . They have stable angina in their history . They're prescribed sublingual nitro .

They have it on their person . You are actively exercising . During your session they have onset of angina . You have that patient sit down and rest and start getting that nitro out . If that angina has not resolved with rest , they're taking one nitro .

In this process you are taking vitals and assessing your patient because you have to be aware that this could progress . After five minutes time , if the angina has not resolved , they can take a second nitro . After that second nitro has been taken , you are calling 911 . If the angina still has not resolved , they can take up to three .

They should not take more than three . Make sure that you're actively monitoring vitals throughout and writing them down so if you do have to call EMS , you have the information ready to go .

Okay , some additional safety considerations . Like I mentioned before , if your patient has a history of angina , it is your job to ask do you have nitro prescribed ? If they do , you should be educating them to have it on their person , especially if they don't currently have it on their person . Monitor vitals throughout in case there's progression of symptoms .

If that patient takes the second nitro , you're calling 911 . And if you have to take nitro during your session and that angina does resolve and the patient feels fine , do not resume exercise . That patient can become profoundly hypotensive if you were to continue .

Make sure your patient is safe and asymptomatic , with good vital sign response , before sending them on their way . The last thing I wanna mention is that is a typical outpatient scene . In the inpatient environment , the patient is not allowed to have their own medication on them .

You would have to notify the nurse and then the nurse would give the medication , just a technicality . Okay , I hope that was helpful for you . If you have any questions , please reach out to me . You can reach me on Instagram , gmail , text message and , if this was helpful and you are actively prepping for your NPT-E , check out my website .

I have a prep course available , eight hours of prerecorded material and every NPT-E I'll be hosting a two hour live question based review session . So check it out , reach out and whatever you have to do , get after it .