At EMCrit there is a very important abstract covering the acute treatment of hypertensive crashing heart failure patients. This is a PDF file and it is only the abstract, but it is essential reading for all in EMS and EM (Emergency Medicine).
Results: 41 patients were consecutively enrolled.
Not a lot of patients, but what would be the outcome in a hospital where patients are treated with conventional treatment – the Standard Of Care?
This must be studied in a hospital that follows the Standard Of Care in order to demonstrate just how dramatic the difference is.
I expect that at least half of these patients treated with standard doses of NTG (NiTroGlycerin) and without NIPPV (Non-Invasive Positive Pressure Ventilation) end up intubated.
All patients received NPPV, with initial settings of IPAP 14/EPAP 8.
Remember, some EMS protocols still insist that EMS must never give more than 3 NTG to a patient (and this includes any NTG taken by the patient prior to EMS arrival). The patient took 4 NTG before I got there. I must have violated protocol. đ
The mean number of nitroglycerin boluses required was 4, which corresponded to a mean dose of 1588 mcg (range 800-28,000 mcg).
Translated into NTG tabs or sprays that is a range from 2 tabs/sprays to 70 tabs/sprays.
Clearly, the higher doses killed the patients and probably even killed some of their family in the waiting room. These doses are just too dangerous! Think of the children hypotension!
How bad was the outcome?
None (0%) of the patients required intubation (95% CI 0-7.3%).
But that’s impossible!
This is a violation of the Standard Of Care. This is the greatest evil in medicine. Malpractice lawyers will take away everything you own – Twice!
Patients had marked improvements in their respiratory parameters.
This is all wrong. They aren’t supposed to get better with such dangerous treatment.
Two patients had transitory dips in SBP < 100,
That’s more like it.
which resolved spontaneously;
No! No! No!
We have to be the ones who fix the hypotension. They can’t get better on their own. This is just wrong.
Where are the boluses of fluid that we have been told are essential?
Where is the CPR?
Where is the epinephrine?
both of these patients received additional nitroglycerin boluses.
No! No! No!
This is like a C-section. Once something bad happens with a drug, we can never risk that bad thing again. Don’t think, avoid. Reflexively withdraw from the treatment as if withdrawing a hand from a flame. There can never be any safe use of anything as dangerous as fire.
No patients required additional drugs or fluids for hypotension.
Stop it! I’m not listening! This isn’t happening!
You can’t make me think!
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My anecdotal observations on this – Since I started giving higher doses of NTG over a decade ago, I have not had a reason to intubate a hypertensive CHF patient. That is over a decade without access to any CPAP (Continuous Positive Airway Pressure). Zero cases of hypotension. Over 50 sublingual NTG sprays for one patient (potent NTG confirmed after the call).
Yes, I have pestered a lot of doctors about this, but without research it is difficult to convince someone that the patient was looking like death at initial presentation, but is comfortable now.
We need to stop coming up with excuses for intubating these patients and start treating them with high doses of nitrates, preferably IV NTG, but SL (SubLingual) does work.
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EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema
by EMCRIT on APRIL 25, 2009
Link to Podcast page
Link to page with other evidence supporting this treatment
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I have been asking myself these same questions for the duration of my paramedic class. Everyone seems to have a Nitro horror story, but they’re all:
“My best friend’s sister’s boyfriend’s brother’s girlfriend knows this guy who knows this guy who’s going with a girl who’s a medic and SHE saw someone bottom out from ONE TAB OF NITRO…”
I’ve even had other Medics tell me that they NEVER EVER give Nitro in the field unless the problem is undeniably cardiac in nature. They choose to ignore the very real benefits of Nitro to the CHF patient. In my VERY limited experience Nitro is a wonder-drug. Not to say that it needn’t be respected (it must) or that it can’t be dangerous (it can), but it seems as though everyone’s afraid to use it because of this perceived danger.
I was happy to see this post. It’s a topic I’ve been meaning to get into!
Windy City Medic,
NTG is safe for hypertensive CHF patients. It is also safe for chest pain patients, but that is an entirely different topic. The ignorance of those who think these are the same is killing patients.
We can start with a low dose of 2 SL NTG at a time and increase it to 4 at a time or 5 at a time once we have demonstrated that this patient does not have an exaggerated response to NTG.
As this paper shows, even if the patient does drop his systolic pressure, that goes away quickly on its own and we can give more high doses of NTG.
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All I can offer to the conversation is over a decade of anecdotal high dose NTG outcomes that matches your anecdotal outcomes. In my early (meaning more scared of the Protocol Nazis) days, I religiously studied, recited, and followed the protocol book. It was good in the fact that I did intubate a relatively higher percentage of patients than I do now. The good I’m referring to is a young medic getting lots of intubation experience, not anything good for the patients mind you. It’s been too many years for me to recall what the impetus was to re-evaluate my CHF treatment routine, but I did so sometime in the late ’90s early ’00s.
I’m not sure how you did it, but I used the “4 pumps equals 1 spray method” for the longest and did not stop at the prerequisite 3 “sprays”, but usually hit 5 on a normal CHF’er. I noticed that I was intubating fewer and fewer patients and that these fewer intubated patients were in less distress when we arrived at the ER. For a guy that was taught rotating tourniquets in school, I feel like I’ve made some real progress. Of course I could have never done this without the support and even encouragement of the ER docs that I worked with. These guys always took the time to pat me on the back when I did good, or pull me aside and explain what I had done wrong and how to improve upon it. Too bad I didn’t have a medical director that did the same thing, but that is another story all together.
Love the IV nitro. 50 SL Heck yeah! I would need over a 4 hour long transport for SL dosing to get there though I think? How did you even do that? lol đ
Chris,
Over 50 SL NTG?
5 NTG at a time, repeated every 3-5 minutes, about 50 minutes from initial assessment to on the ED stretcher.
Blood pressure was above 200/X at all times.
Hypertensive CHF patients require much higher doses of nitrates than chest pain patients. NTG has been shown to improve outcomes for these patients, but NTG has not been shown to improve outcomes for chest pain patients.
We limit appropriately aggressive treatment of CHF (which we know works) based on rare side effects with chest pain treatment (which may not even work). We are killing patients with our ignorance and anxiety.
There is not a good reason to stop EMS treatment until ED treatment is begun.
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