For ischemic chest pain the directives are clear that"If a patient’s vital signs fall outside the medical directive’s parameters (i.e.: hypotension), the patient can no longer receive THAT medication (i.e.: nitroglycerin or morphine) even if the patient’s vital signs return to acceptable ranges. It also states that "Morphine is only to be considered following the third dose of nitroglycerin (unless nitroglycerin is contraindicated) and where pain is severe in nature (≥ 7/10)". If the Pt SBP was to fall by 1/3 this is a contraindication for further NTG would it be acceptable to proceed with morphine if the pain was ≥7? The confusion is the wording of "that" med which would refer to the specific one just administered .Also in the contraindications the NTG one refers to a drop of 1/3 post NTG admin and morphine refers to a drop of 1/3 post morphine admin.
Safety maximums in the ALS PCS are established based on possible or actual adverse outcomes and ceiling limits of a specific medication.
In the example provided where the patient is presenting with cardiac ischemia and throughout patient care, that the BP fall by 1/3 after nitro administration and prior to morphine administration, where pain is ≥7, it is acceptable to proceed with morphine.