Aspirin

aspirin

I rank Aspirin (ASA) 10 out of the 33 drugs we carry.

We give ASA to patients with suspected acute coronary syndrome. The American Heart Association rates the early administration of Aspirin as a Class I intervention. The literature is overwhelming in support for ASA. It is inexpensive, safe and reduces mortality and morbidity.

I gave it 36 times last year.

Why don’t I rate it higher? It is the same reason I didn’t give it more.

I used to carry the bottle of Aspirin in my pocket and see how quick after I ‘d walked in the door I could say open wide and pop those four little pills in. Now Aspirin use has become so prominent that many of my patients have already self-administered Aspirin before I get there — either they took it themselves, were given it by a friend or coworker or a medical professional on the scene gave it to them. When I do bring them to the hospital, the first question I am asked is “Did they get Aspirin?” If not, the hospital staff are quick to dole out the dose. If I didn’t carry it, they would still all get it in a quite timely fashion.

I do have a recurring issue with Aspirin that I have never gotten a definitive answer on. I don’t think a definitive answer exists. The question is: should someone on Coumadin take Aspirin? Many doctors, most in fact, have told me yes, in an emergency setting in the presence of chest pain, it is fine. Others, and a fair number of others, including a local cardiologist who was handing a STEMI patient off to me, told me no. I think it probably is just a matter of preference. When, and this happens often, a patient tells me they can’t take Aspirin because they are on Coumadin, I just say fine, we’ll defer to the doctor at the hospital. I could bully them into taking the Aspirin, but why in such a stressful moment get them upset.

I know one medic who risked blinding a patient by forcing Aspirin on him after he had experienced chest pain while undergoing a delicate eye procedure at a local doctor’s office. There was a big to-do about this. The I-can-do-no-wrong medic evidently got in a shouting match with the doctor, who ordered him not to give the aspirin because of the extreme danger of bleeding in the eye due to the surgery. You do need to be careful. When in doubt, defer to the hospital.

I gave Aspirin to a patient with a head bleed once thinking she was having an MI. The call was for chest pain, I got tunnel vision. A misread 12-lead (ventricular strain pattern), and habit(get the aspirin in quick), caused me to pop the ASA down the hatch before I did my full assessment and history taking. If there were strings attached to those little orange tablets I would have pulled on them to bring those babies up from her gullet.

Bottom line. Aspirin is a great drug that belongs on every ambulance. I try to cast a wide net when I give it (I don’t have to be 100% certain the patient is having cardiac pain — if it is pleuritic pain, well, the Aspirin will make them feel better anyway), but I never press it on a patient and try to do a full assessment first. If Aspirin wasn’t so widely available to patients, I would give it far more than I do.

***

I recieved an interesting email from a respected reader on the ASA/coumadin issue:


I asked your question to an ED attending that I know well. He’s also toxicologist so she’s a great resource. The short answer is that you can give ASA to someone taking Coumadin. The slightly longer answer is that they do different things. ASA interferes with platelet aggregation, while Coumadin thins the blood. Since they do different things, the only contraindication to giving ASA is allergy to ASA. I also asked him about having 9-1-1 operators instruct patients to take ASA before EMS arrives and he feels that it is very beneficial. In fact, he said that of all the things we do for MI patients none is more important than giving ASA. So, go ahead and give that ASA to chest pain patients that you think are having ACS or an MI.

***

Aspirin (Acetylsalicylic acid)

Class: Antiplatelet

Action: Inhibitor of platelet aggregation

Effects: Decrease clotting time

Indication: Chest pain of cardiac origin

Contraindication: Allergy to aspirin

Dose: 325mg tab or 4-baby aspirin (81mg per tab)

Route: PO

Side Effects: None with field use

3 Comments

  • Supposedly can precipitate bronchospasm in asthma patients with nasal polyps.

    Never seen it, though.

  • medicechic says:

    I’ve read that about broncospasm in asthmatics too, although it didn’t include the nasal polyps.
    Protocols and standing orders definitely don’t cover every situation. For example, our protocol states contraindications for ASA as allergy or GI bleed. Personally I can’t take it due to a clotting disorder. I had a chronic renal failure patient a few days ago that I let the doc make the choice. She chose NTG and morphine (reduced dose due to CRF). ASA is excreted through the kidneys. Why would I give a medication to someone that can’t get it out of their system unless it is absolutely necessary? In the past I’ve deferred it to the hospital when the pt had recent surgery, trauma, etc. Just because protocol says A is happening do B doesn’t necessarily mean you need to do it. We’re not puppets, this is why many protocols include the word consider and we are taught to think for ourselves and if in doubt call medical control.

  • totwtytr says:

    Although ASA has proven benefit in MI patient, like all medications, it has risks. Our triage cards direct 9-1-1 operators to instruct patients to take 325mg of ASA if the caller gives information that indicates ACS. I think that’s a mistake since so many times triage is wrong. In effect, they are blindly directing the patient to take a medication that not only might not help, but might hurt. Our BLS crews can give it, but again, I’m not so sure that it is that beneficial vs the potential harm. I don’t think that the 10 or so minutes delay until an ALS unit arrives and can do a more thorough evaluation and 12 lead EKG is going to be that harmful.

    Something to discuss with the medical director next time we chat.

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Peter Canning

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