
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. 🙄
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!
–
–
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.
–
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
.
Subscribe to RogueMedic.com