Safety of High Dose Nitro in CHF

Our region recently changed our guideline for Nitro SL administration in pulmonary edema from 0.4 mg SL every 3-5 minutes as needed to 0.4-0.8 mg SL every 3-5 minutes as needed.

A new study, Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension in the forthcoming October 2013 edition of Prehospital and Disaster Medicine adds more support for guidelines allowing paramedics to use high dose SL nitro when faced with patients in respiratory distress due to heart failure with hypertension.

In 2011 the New York State Western Regional Emergency Medical Advisory Council issued a new guideline allowing paramedics to give multiple Nitro SL tablets to patients in CHF, including up to 3 tabs (1.2 mg) for patients with systolic BP >200 mm Hg.

Here is the guideline:

Over a six month study period 100 patients received high doses (0.8 mg or higher) of NTG. 68% received two tabs simultaneously (0.8). 31% received three tabs (1.2) at one time. One patient received 4 (whoops) at one time.

Only 3 patients suffered post administration hypotension. All three, who had recieved two tabs, had an improvement in their breathing and all three had their hypotension resolve without further intervention.

The study’s bottom line – high dose nitro in the form of multiple SL tablets appears to be a safe treatment in the prehospital environment.

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See also- NTG and the Hero Medic

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Check out Rogue Medic’s comments on high-dose nitro.

Unreasonable Fear of Hypotension and High-Dose NTG – Part I

7 Comments

  • Christopher says:

    That table is gorgeous, just gorgeous.

    A useful addition to the table would be diastolic cutoffs as well, e.g. “Systolic >200mmHg or Diastolic >140mmHg”.

  • Tom says:

    Cutting edge in 2013? or 1993? we’ve been doing high dose NTG for over 20 years prehospitally. Any yes, we still get the “How many sprays?” question from the newer nurses.

  • Brooks Walsh says:

    Although we just got around to taking furosemide out of the CHF protocol, we’ve also had the multi-dose NTG option for a number of years. Strangely, though, few medics give it. Old ways die hard…

    Personal record – had a patient on 400 µg/minute NTG IV for about an hour. The cardiac unit balked at this dose, since it was right at the “max” set by the pharmacy.

  • Brian says:

    I am all for the above formula, HOWEVER, not until I have a 12 lead ECG in front of me showing me no Inferior wall AMI or RVI. Then , by all means, go for it..make sure you have at least one good PIV and preferable two.

    • medicscribe says:

      With regard to Acute Coronary syndrome, I agree with you. Nitro has shown no benefit. I withhold it in all inferior MIs. In acute CHF, however, NTG is livesaving.

  • Rogue Medic says:

    Brooks,

    You could have a conversation with the pharmacy director about removing this arbitrary limit.

    You could have a more entertaining conversation with the cardiac unit director about the doctors imitation of nursing home nurses who insist that the patient cannot receive another Percocet, since it has been less than the q4 hour/q6 hour/q 8 hour, qwhatever dosing interval is written in the chart, even if only by a few minutes.

    Treat the protocol, not the patient should be inscribed right next to Abandon hope, all ye who enter here.

    I realize that higher doses may increase risk, but it isn’t as if you are giving more serotonin to Libby Zion.

    http://www.epmonthly.com/clinical-skills/emrap/serotonin-syndrome-and-the-libby-zion-affair/

    .

  • Rogue Medic says:

    Brian,

    “I am all for the above formula, HOWEVER, not until I have a 12 lead ECG in front of me showing me no Inferior wall AMI or RVI.”

    An excellent indication that the patient does not have an RVI is acute pulmonary edema.

    Inferior MI is just an indication to look for RVI, but does not otherwise appear to depend on preload.

    Since the study was looking at giving 2 NTG at a time for hypertensive patients (over 160 systolic) and 3 NTG at a time for even more hypertensive patients (over 200 systolic), what is the likelihood that any of them have an RVI?

    There was no requirement to assess V4R mentioned anywhere in the study.

    An excellent series of three articles on RVI from EMS 12 Lead begins with the link below.

    http://ems12lead.com/2009/02/right-ventricular-infarction-part-i/

    .

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Peter Canning

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  • Comments
    Sandy
    The Ideal Medic
    As a 24 year medic, I finally figured out it wasn't me. Thank you for your article. You can't teach that in any classroom. I have always found that empathy is a great tool. Use it to benefit the patient and teach others what it is all about.
    2015-03-24 22:24:30
    Joseph Eriksen
    The Ideal Medic
    As a 30 year, now retired medic I completely agree. There is nothing wrong with second guessing although one should go with their gut. There are times to be aggressive and times to not. Also humor is one of the most powerful pre-hospital tools in the toolbox although it can't be taught. When appropriate it…
    2015-03-24 19:37:25
    Shawn McCormick
    The Ideal Medic
    I totally agree. To me those make great paramedics. I work as a Operation Supervisor and encourage teamwork/backup whenever the situation calls for it. I encourage feedback from a difficult call my crews responded to. 1) they have the chance to recall the events that took place and they may self evaluate the call. 2)…
    2015-03-24 17:14:14
    Sean Fitch
    The Ideal Medic
    Totally agree Peter, For too long I had the same interpretation and like you now, I would by far take your current description.
    2015-03-24 17:05:33
    tom combs - ER doc/author
    The Ideal Medic
    Twenty-five years as an ER doc in level one trauma centers has me in total agreement. I Interestingly what you say regarding paramedics also, in many ways, applies to ER docs. "Tries to learn from each call...puts the patient first." A great post. I salute to your wisdom!
    2015-03-24 17:04:06

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