FIELD REFERENCE
Full criteria & treatment guidance
Indications
- Suspected cardiac-origin chest pain or the specified CHF/rales pathway. PR-225 separately covers continuation of a prescribed IFT infusion.
Contraindications & local exclusions
- SL-tablet label: PDE-5 inhibitors or soluble guanylate cyclase stimulators, severe anemia, possible increased intracranial pressure, nitrate/nitrite/product hypersensitivity, or circulatory failure/shock. OCEMS also applies indication-specific BP and erectile-dysfunction-drug timing exclusions.
Precautions
- Reassess BP and perfusion before repeat doses. A sublingual tablet label does not authorize starting/titrating an IFT infusion; use PR-225 stop criteria for the prescribed infusion. SO-C-015 chest-pain dosing requires systolic BP above 100 mmHg. SO-M-035 pulmonary-edema dosing uses its own ≥100/≥150 boundaries; PR-225’s infusion stop threshold below 90 is a separate IFT rule. Do not swap these thresholds. The SL product label warns that alcohol can further lower BP.
- These are selected safety checks, not a complete prescribing monograph. Product labeling and OCEMS authorization answer different questions; confirm the actual product, patient population and applicable order.
Check before giving
- SO-C-015 says not to give if sildenafil, vardenafil, or tadalafil was taken within the preceding 24 hours.
- Recheck BP before repeat doses. I-15 and the condition orders use different boundary wording; this page identifies each condition order explicitly.
Use in OCEMS
- Use the chest-pain or respiratory-distress standing order that matches the presentation. Their blood-pressure boundaries differ.
- The available SL forms include 0.4 mg tablets, powder packets, and metered sprays.
Adult / adolescent
| Indication / route | Dose & limits |
|---|---|
| Cardiac chest pain — SO-C-015 | 0.4 mg SL when systolic BP is above 100; repeat about every 3 minutes for discomfort, up to 3 EMS doses while BP stays above 100. Patient self-doses before EMS are not counted in those 3 doses. |
| Suspected CHF/pulmonary edema — SO-M-035 | 0.4 mg SL when systolic BP is at least 100; may repeat twice if it remains at least 100. At systolic BP at least 150, use 0.8 mg SL and may repeat twice while it stays at least 150; reduce to 0.4 mg if BP falls below 150 but remains above 100. |
Pediatric
- No routine pediatric field nitroglycerin regimen is listed in I-20. Do not extrapolate the adult SL rows to children.
- Any pre-existing transport infusion requires the applicable transport authorization and sending-facility orders; it is not a pediatric field initiation dose.
Pediatric dosing availability
- OCEMS does not list a routine pediatric field regimen; do not scale an adult dose by weight.
| Weight | OCEMS pediatric dose |
|---|---|
| Any weight | No general OCEMS pediatric dose is listed; follow the applicable order or medical direction. |
Preparation & reassessment
- Check the formulation: one 0.4 mg dose is not the same as the 0.8 mg pulmonary-edema dose.
- PR-225 governs a pre-existing IFT nitroglycerin infusion; use the prescribed pump rate and its monitoring/stop criteria, not these SL doses.
Interfacility infusion — PR-225
- Verify secure access, a working pump, the sending RN/physician’s prescribed rate, and any prior BP problem. Maintain that prescribed infusion rate.
- Monitor rhythm and vital signs continuously. If systolic BP falls below 90 or obvious poor perfusion develops, stop the infusion and transport to the nearest appropriate ERC.
- Document the rate, monitoring, patient condition, and any stop time/reason at handoff. This continuation pathway is distinct from the SL standing-order doses.
VISUAL FIELD REFERENCE
Sublingual nitroglycerin: two BP-dependent pathways
Adult & pediatric guidance · ALS
Sublingual treatment only. A pre-existing transport infusion is a separate pathway.
Adult cardiac chest pain · SO-C-015
0.4 mg SL when systolic BP is above 100; repeat about every 3 minutes for discomfort, up to 3 EMS doses while BP stays above 100. Patient self-doses before EMS are not counted in those 3 doses.
Adult suspected CHF · SO-M-035
0.4 mg SL when systolic BP is at least 100; may repeat twice if it remains at least 100. At systolic BP at least 150, use 0.8 mg SL and may repeat twice while it stays at least 150; reduce to 0.4 mg if BP falls below 150 but remains above 100.
- SO-C-015 says not to give if sildenafil, vardenafil, or tadalafil was taken within the preceding 24 hours.
- Recheck BP before repeat doses. I-15 and the condition orders use different boundary wording; this page identifies each condition order explicitly.
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. I-15 · I-20 · SO-C-015 · SO-M-035 · PR-225
UNDERSTAND THE CARE
Why indication-specific pressure boundaries must stay visible
The chest-pain and respiratory-distress orders do not use identical blood-pressure wording. Select the clinical branch before choosing the dose or deciding on a repeat. Ask about the named PDE-5 medications and prior nitroglycerin, and document the pressure associated with each treatment decision.
Applying the guidance
Confirm the actual sublingual form and intended amount. A tablet, packet or metered spray should be matched to its labeling. A pre-existing transport infusion is governed by a separate procedure and patient-specific order, not by the SL dose table. Continue reassessing symptoms, circulation and the need for cardiac destination coordination.
Diagram text & teaching checkpoints
- Indication
- Cardiac discomfort, CHF or IFT infusion.
- Eligibility
- The correct BP boundary and drug exclusions.
- Formulation
- SL product versus a prescribed infusion.
- Response
- Pressure and symptoms before every repeat.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.
- I-15 — Adult / Adolescent Standing Order Drug Guide
- I-20 — Pediatric Medication Volume Dose by Weight
- SO-C-015 — Chest Pain of Suspected Cardiac Origin or Suspected Angina Equivalent Symptoms
- SO-M-035 — Respiratory Distress
- PR-225 — Monitoring Nitroglycerin Infusion during Interfacility Transports
- Product label — NITROGLYCERIN tablet
- Name / formulation reference — Medication name and formulation terminology
Carry the pathway into the repeat-dose decision
Write down the indication alongside the blood pressure used for each decision. A number copied from the previous assessment cannot establish that the patient still meets the next dose’s condition. The chest-pain, pulmonary-edema and interfacility-infusion branches remain separate even when the medication name is the same.
For example, a patient with cardiac discomfort has received treatment and is transferred to a second crew. Handoff should identify the standing-order branch, self-administered treatment before EMS, EMS administrations, recent pressure trend and current symptoms. The receiving clinician should not reconstruct the treatment from an empty tablet package or assume an infusion stop threshold is the threshold for another sublingual dose.
If a prescribed IFT infusion is present, reconcile its order and pump using PR-225. The sublingual table does not authorize starting or adjusting that infusion. Continue the broader cardiac or respiratory assessment and destination process; symptom improvement after a nitrate does not by itself establish the cause of the complaint.
Source: Chest Pain of Suspected Cardiac Origin or Suspected Angina Equivalent Symptoms.