Received a fascinating comment on my 29 Ways to Lift Your Tongue post.

“Check into this but from what I was just told by my mentor is that Nitro Spray doesn’t have to go under the tongue. You can just spray it like breath spray or aim for a cheek. I haven’t checked but it’s even says it on the insert.”

I went to the insert myself and here’s what it said:

“…spray onto or under the tongue.”
and later:

…”preferably onto or under the tongue.”

Here’s a web site for NITROLINGUAL that says the same thing.

But my Emergency and Critical Care Pocket Guide says:

Nitrogylcerin spray (NITROLINGUAL) 1-2 sprays 90.4 – 0.8 mg) under the tongue.

However, the American Heart Association ACS Guideline says nitro “sublingual, spray or IV” which suggests sublingual and spray are not one and the same. It later says, “patients with ischemic chest discomfort may receive up to three doses sublingual or aerosol nitroglycerin…”

I did a random sample of several medics today and everyone told me they spray NTG under the tongue. It’s supposed to be sublingal, they said.

Yeah, that’s what I always thought, but…

While I haven’t talked to a ED doctor yet, the evidence based on the insert and the AHA is pretty clear to me that spraying on the tongue (Lingual)is acceptable.

While I may continue to ask patients to lift up their tongue. If they don’t. I’m just going to spray their tongue. Barring of course any new information or edicts from my medical control. I’ll post an addendum after I’ve had a chance to ask them.

Thanks again to the commentator for pointing this out. You learn something new everyday it seems.

I am curious how many other medics out there knew about this. In the days before the spray everything was always sublingual. When we got the spray, maybe we all assumed Nitro was still sublingual. For you newer medics, what were you taught in school?


  • Peter LoRe says:

    As a current medic student, we’ve been taught that the sublingual tabs have to go under the tounge, but that the spray can go pretty much anywhere, and that it’s more a taste issue than a functionality issue.

  • Anonymous says:

    I’ll let my mentor know that you found this interesting and credit him since I was just as surprised as you. I’ll bring this up as a topic at emtcity dot com as well to see what other people think and do. Keep up the good posts.G

  • Anonymous says:

    I finished medic school just over a year ago. We were taught to use SL for both spray and pill.Where I now work, we can go with as many doses of NTG as necessary. No limit. We have just the pills. No spray. But we also have the paste. The paste works okay. You have to smear it over a big area for it to work well. But, and this is my point, it works through the skin. So if you spray it on the skin or on the tongue, it seems like it woulf work well.Discreetly, give it a shot on yourself. See what happens. Do your BP and the spritz the neck or forearm. Check it and see if you get a killer headache. Theres a good history of NTG in transdermal settings. That’s how its vasodilatory effects were noted back when Noble discovered it.

  • AlisonH says:

    It had honestly not occurred to me, before reading your blog, that I needed to update my MedicAlert to warn that nitroglycerin dangerously divebombs my too-low blood pressure. (Yeah, and tiny doses of metoprolol raises it. I’m weird.) To be sure, do I need to get a new bracelet that explicitly says that about the nitro? Or do you all make that call first when you see a MedicAlert necklace or bracelet? And is one more likely to be noticed than the other?

  • Patrick says:

    We got rid of the tabs a decade ago, and we teach the spray can go anywhere. The tongue is pretty universally porous, so anywhere is fine. The reason the tabs had to go SL is they needed to be trapped where saliva and grinding could break them down.

  • Lucian says:

    we dont carry the spray at all down here (only tabs) but in my paramedic class they just say spray it, they’ve never been specific as to where…ill try to think to ask some people who may know that are teachers, however, we dont use it in or region so i’m not sure too many people around here would even know.LAM

  • Brad says:

    Where I work our protocol says that SL is preferred, but if not possible, you can just spray it in the mouth and it is well absorbed.

  • Eric says:

    Well, in my EMT-B class, the ninth edition(2005) of the orange book says that the spray should also be taken sublingually. It even has a picture in the skill drill to go along with it. And I’m pretty sure that my instructor specifically said to spray it under the tongue as well, so this will be interesting to bring up on Monday.

  • FireResQGuru says:

    I have always gone sublingual, as you do. That was the way I was taught, and simply never gave it that much thought or questioned the instructors, mentors & preceptors I had way back when. But thinking about it now, the mouth being so vascular, it makes sense that it would be absorbed almost as well, if not as well as sublingualy. Hmmmm……

  • Anonymous says:

    I’m an emt-b after consultation with my previous instructor and mentor I have found out that although spray nitro will work when sprayed lingual into the mouth it works better sublingual and also if you do spray into the mouth lingual you should take extreme care to avoid the teeth.Any thoughts on why to avoid the teeth, he couldn’t tell me and I would really like to know

  • PC says:

    Thanks for all the informative comments and please keep them coming. I am investigating further myself, and will post after I have had a chance to talk to my medical control physician and coordinator.

  • Medic09FPC-RN says:

    Well, anatomically and functionally the mucosa under the tongue and in the rest of the mouth cavity isn’t much different. A tablet needs to ‘sit still’ to dissolve – hence, SL. Where else can it sit? A spray attaches and then absorbs almost instantly into the mucosa, so it won’t matter much. There’s a tab form, for instance, that instructs Buccal placement under the upper lip or between cheek and gum (never seen it in use, though). I couldn’t even find Spray in the Davis Nurse’s Drug Guide (what I use at work). In Epocrates, this application appears as “Translingual”. “Spray onto/under tongue.” “Do not rinse mouth for 5-10 min after dose.”mordechai y. schersanta fe

  • Gary says:

    Generally I try to spray sub lingually, but an amazing number of patients can’t seem to figure out how to do that. So, I’ve started spraying on the tongue. It doesn’t seem to be any less effective that way. Gary

  • Rogue Medic says:

    With the tab, chewing (not swallowing) and letting it absorb in the mouth leads to more rapid absorption.As with all titration drugs, we could reassess and determine the need for more. With hypertensive CHF patients it is almost impossible to give too much NTG. For very symptomatic acute pulmonary edema patients one study recommends up to 5 doses of NTG at a time repeated every 3 – 5 minutes until there is a significant change in blood pressure or patient presentation. Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23.Prehospital therapy for acute congestive heart failure: state of the art.Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.IV NTG would be much better for EMS, but few trust us to assess and titrate medicines appropriately.

  • Anonymous says:

    I’m a paramedic in AUstralia where we have only tablets. We can guve S/L or Buccal. No difference really, as long as the tablet dissolves.

  • Anonymous says:

    I ran into this during my internship last year. After trying unsuccessfully for a few minutes of my precious transport time to get my patient to grasp the concept of “lift your tongue” I gave up and sprayed in the mouth. That’s when I looked up to see my preceptor just about falling out of the captains chair in silent laughter. I guess I looked kind of funny doing the “mirror face” thing trying to explain what I wanted to the patient. He afterwards told me that spraying in the mouth is perfectly acceptable and suggested I read the directions on the bottle. Lesson learned.

  • Jason says:

    I asked the question to a pharmacist I ski patrol with and he told me either way works fine but the classic recommendation of SL is still ideal because of slightly quicker absorption however anywhere in the mouth/ on the tongue works just fine.

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