Can I administer nitroglycerin (sublingual nitrate) for chest pain suggestive of acute coronary syndrome (ACS) on a plane?

Nitroglycerin Administration for Chest Pain and Shortness of Breath on an Airplane

Nitroglycerin can be administered for chest pain suggestive of acute coronary syndrome (ACS) on an airplane, provided certain safety conditions are met and contraindications are ruled out. 1, 2, 3

Assessment Before Administration

Before administering nitroglycerin, quickly assess:

1. Blood pressure: Must be ≥90 mmHg systolic 2, 3
2. Recent medication use: No PDE-5 inhibitors within past timeframes 1, 2
   • Avanafil: 12 hours
   • Sildenafil/vardenafil: 24 hours
   • Tadalafil: 48 hours
3. Contraindications: 2, 3
   • Hypotension (SBP <90 mmHg)
   • Right ventricular infarction (suspect if inferior wall MI)
   • Extreme bradycardia (<50 bpm) or tachycardia (>100 bpm) without heart failure

Administration Protocol

If no contraindications exist:

1. Dosage: 0.3-0.4 mg sublingual tablet or spray 1, 2
2. Position: Have patient sit down to prevent falls from potential dizziness 2, 3
3. Frequency: May repeat every 5 minutes up to 3 doses total 1, 2, 3
4. Monitoring: Check blood pressure after each dose 2
5. Discontinue if: 2, 3
   • Systolic BP drops below 90 mmHg or 30 mmHg below baseline
   • Severe headache develops
   • Symptoms worsen

Additional Considerations

• Oxygen: Provide supplemental oxygen if oxygen saturation is <94% 1
• Aspirin: If available, administer 160-325 mg (chewed) unless contraindicated 1, 2
• Medical assistance: Request emergency landing if:
  • Pain persists after 3 nitroglycerin doses 3
  • Patient becomes hypotensive
  • Symptoms worsen or change in character

Evidence on Effectiveness and Safety

Research shows nitroglycerin is effective for chest pain relief in suspected ACS with a clinically significant reduction in pain scores 4. A 2019 study found that nitroglycerin administration resulted in a median SBP decrease of only 10 mmHg, which is not clinically significant in most cases 4.

Contrary to common concerns, a 2016 study demonstrated that even patients with inferior STEMI did not show higher rates of hypotension after nitroglycerin administration compared to non-inferior STEMI patients 5. However, caution is still advised as guidelines recommend avoiding nitroglycerin in suspected right ventricular infarction 2.

Pitfalls to Avoid

1. Don't administer if hypotensive: Always check blood pressure first 2, 3
2. Don't give with PDE-5 inhibitors: This can cause severe, potentially fatal hypotension 1, 2, 3
3. Don't have patient stand up immediately after administration 2, 3
4. Don't delay seeking professional medical care: Nitroglycerin is for symptom relief only, not definitive treatment 3
5. Don't continue beyond 3 doses if pain persists - this indicates need for advanced medical care 3

In an airplane setting with limited resources, nitroglycerin can provide temporary relief while arrangements are made for emergency landing and professional medical care.