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Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin

Published online by Cambridge University Press:  07 October 2020

Michael C. Perlmutter Open the ORCID record for Michael C. Perlmutter [Opens in a new window] ,
Matthew W. Cohen ,
Nathan S. Stratton  and
Marc Conterato
Michael C. Perlmutter*
Affiliation:
North Memorial Health Ambulance and Air Care, Robbinsdale, Minnesota USA University of Minnesota Medical School, Minneapolis, Minnesota USA
Matthew W. Cohen
Affiliation:
University of Minnesota Medical School, Minneapolis, Minnesota USA
Nathan S. Stratton
Affiliation:
University of Minnesota Medical School, Minneapolis, Minnesota USA
Marc Conterato
Affiliation:
North Memorial Health Ambulance and Air Care, Robbinsdale, Minnesota USA University of Minnesota Medical School, Minneapolis, Minnesota USA
*
Correspondence: Michael Perlmutter, BA University of Minnesota Medical School 420 Delaware St SE Minneapolis, Minnesota 55455 USA E-mail: [email protected]
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Abstract

Objective:

The study describes the implementation of a prehospital treatment algorithm that included intravenous (IV) bolus (IVB) nitroglycerin (NTG) followed by maintenance infusion for the treatment of acute pulmonary edema (APE) in a single, high-volume Emergency Medical Services (EMS) system.

Methods:

This is a retrospective chart review of patients who received IVB NTG for APE in a large EMS system in Minnesota and Wisconsin (USA). Inclusion criteria for treatment included a diagnosis of APE, systolic blood pressure ≥120mmHg, and oxygen saturation (SpO2) ≤93% following 800mcg of sublingual NTG. Patients received a 400mcg IVB of NTG, repeated every two minutes as needed, and subsequent infusion at 80mcg/min for transport times ≥10 minutes.

Results:

Forty-four patients were treated with IVB NTG. The median total bolus dose was 400mcg. Twenty patients were treated with NTG infusion following IVB NTG. The median infusion rate was 80mcg/min. For all patients, the initial median blood pressure was 191/113mmHg. Five minutes following IVB NTG, it was 160/94mmHg, and on arrival to the emergency department (ED) it was 152/90mmHg. Five minutes after the initial dose of IVB NTG, median SpO2 increased to 92% from an initial reading of 88% and was 94% at hospital arrival. One episode of transient hypotension occurred during EMS transport.

Conclusion:

Patients treated with IVB NTG for APE had reduction in blood pressure and improvement in SpO2 compared to their original presentation. Prehospital treatment of APE with IVB appears to be feasible and safe. A randomized trial is needed to confirm these findings.

Keywords

edemacardiacEmergency Medical Servicesheart failuresystolicnitroglycerinpulmonary edema
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 35 , Issue 6 , December 2020 , pp. 663 - 668
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Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

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References

Sacchetti, A, Ramoska, E, Moakes, ME, McDermott, P, Moyer, V. Effect of ED management on ICU use in acute pulmonary edema. Am J Emerg Med. 1999;17(6):571–574.CrossRefGoogle ScholarPubMed
Edoute, Y, Roguin, A, Behar, D, Reisner, SA. Prospective evaluation of pulmonary edema. Crit Care Med. 2000;28(2):330–335.CrossRefGoogle ScholarPubMed
Wilson, SS, Kwiatkowski, GM, Millis, SR, Purakal, JD, Mahajan, AP, Levy, PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126–131.CrossRefGoogle ScholarPubMed
Uil CA, den, den Uil CA, Brugts JJ. Impact of intravenous nitroglycerin in the management of acute decompensated heart failure. Current Heart Failure Reports. 2015;12(1):87–93.Google Scholar
Cotter, G, Metzkor, E, Kaluski, E, et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998;351(9100):389–393.CrossRefGoogle Scholar
Noonan, PK, Benet, LZ. Incomplete and delayed bioavailability of sublingual nitroglycerin. Am J Cardiol. 1985;55(1):184–187.Google ScholarPubMed
Kelly, RP, Gibbs, HH, O’Rourke, MF, et al. Nitroglycerin has more favorable effects on left ventricular afterload than apparent from measurement of pressure in a peripheral artery. Eur Heart J. 1990;11(2):138–144.CrossRefGoogle Scholar
Hubble, MW, Richards, ME, Jarvis, R, Millikan, T, Young, D. Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care. 2006;10(4):430–439.CrossRefGoogle ScholarPubMed
Dib, JE, Matin, SA, Luckert, A. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure. J Emerg Med. 2012;42(5):553–558.Google ScholarPubMed
Plaisance, P, Pirracchio, R, Berton, C, Vicaut, E, Payen, D. A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary edema: physiological and clinical effects. Eur Heart J. 2007;28(23):2895–2901.CrossRefGoogle ScholarPubMed
Bertini, G, Giglioli, C, Biggeri, A, et al. Intravenous nitrates in the prehospital management of acute pulmonary edema. Ann Emerg Med. 1997;30(4):493–499.CrossRefGoogle ScholarPubMed
Levy, P, Compton, S, Welch, R, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50(2):144–152.CrossRefGoogle ScholarPubMed
Peacock, WF, Allegra, J, Ander, D, et al. Management of acute decompensated heart failure in the emergency department. Congest Heart Fail. 2003;9(s5):3–18.CrossRefGoogle Scholar
Nashed, AH, Allegra, JR. Intravenous nitroglycerin boluses in treating patients with cardiogenic pulmonary edema. Am J Emerg Med. 1995;13(5):612–613.CrossRefGoogle ScholarPubMed
Hsieh, YT, Lee, TY, Kao, JS, Hsu, HL, Chong, CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36.CrossRefGoogle ScholarPubMed
Peacock, WF, Emerman, C, Costanzo, MR, Diercks, DB, Lopatin, M, Fonarow, GC. Early vasoactive drugs improve heart failure outcomes. Congest Heart Fail. 2009;15(6):256–264.CrossRefGoogle ScholarPubMed
Mebazaa, A, Gheorghiade, M, Piña, IL, et al. Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Crit Care Med. 2008;36(1 Suppl):S129–S139.CrossRefGoogle ScholarPubMed
Cotter, G, Moshkovitz, Y, Milovanov, O, et al. Acute heart failure: a novel approach to its pathogenesis and treatment. Eur J Heart Fail. 2002;4(3):227–234.CrossRefGoogle ScholarPubMed
Cotter, G, Kaluski, E, Moshkovitz, Y, Milovanov, O, Krakover, R, Vered, Z. Pulmonary edema: new insight on pathogenesis and treatment. Curr Opin Cardiol. 2001;16(3):159–163.Google ScholarPubMed
Patrick, C, Ward, B, Anderson, J, et al. Feasibility, effectiveness and safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema. Prehosp Emerg Care. 2020. Epub ahead of print.Google Scholar
Team, RC. R: A Language and Environment for Statistical Computing. Vienna, Austria: 2018.Google Scholar
Carey, RM, Whelton, PK; for the 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Int Med. 2018;168(5):351.Google ScholarPubMed
Nieminen, MS, Bohm, M, Cowie, MR, et al. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J. 2005;26(4):384–416.Google ScholarPubMed