I got a question from a listener about a section of the Maryland EMS protocol that seemed to say that captopril (an ACE inhibitor) was a BLS medication. He could not, however find any mention of it in the BLS meds section of the document.

The area of the protocol to which he refers looks at the care of the Respiratory Distress Patient with Pulmonary Edema and Congestive Heart Failure. Here is my response to him that I thought I would share with the rest of you

Nitro is a BLS drug in a limited way. It can only be administered by a bls provider when the med is prescribed to the patient and it is the patient’s medication. The bls provider may not give anyone else’s nitroglycerine to the patient.

The segment of the protocols at which you are looking is an appendix to the protocols to address better diagnosis and treatment of patients with pulmonary edema and congestive heart failure resulting in respiratory distress. This represents a fundamental shift in the field treatment of this problem in Maryland.

Prior to this update, the treatment involved lasix (a diuretic). Lasix takes at least 20 to 30 minutes to take effect and was not a very effective field treatment. The effects of Nitroglycerine to dilate the blood vessels and thus lower blood pressure was a much more rapid acting treatment. Also, many units have enacted the CPAP protocol and this section of the protocol addresses the integration of multiple drug and mechanical treatments.

The addition of choices for ALS providers to administer either low or high dose nitro along with use of CPAP, captopril, and nitro paste to the chest for after the CPAP mask was attached all offer a more complete field treatment regime for the pulmonary edema/CHF patient.

What do your protocols tell you to do to treat this presentation?

I have added a discussion of this over at the MedicCast Forums as well so feel free to head over there and carry on this or other discussions.

Jamie, the Podmedic

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