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Bolus dose nitroglycerin for hypertensive acute pulmonary edema

Dr. Casey Patrick and Mike Perlmutter discuss their experiences with implementing IV high-dose bolus NTG in APE patients

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Call this condition what you will – APE, SCAPE or SCRAPE – the most important facets are to recognize these patients and then to work to aggressively lower both preload and afterload.

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Many terms have been introduced in the past few years to describe the decompensated patient with hypertensive acute pulmonary edema (APE). Call this condition what you will – APE, SCAPE or SCRAPE – the most important facets are to recognize these patients and then to work to aggressively lower both preload and afterload.

Patients with APE present with acute dyspnea, tachypnea and severe hypertension. They are often also hypoxic with diaphoresis and rales. Classically, initial treatment in this population has been non-invasive positive pressure ventilation (NPPV) and topical or sublingual nitroglycerin (NTG).

NPPV is on shaky ground these days, due to the concern for aerosol generation in the age of COVID-19. This makes preload and afterload reduction even more paramount in this critically ill group of patients. Topical NTG uptake is too slow to be of any benefit in EMS. In a well person, sublingual NTG is absorbed quickly, but how do APE patients present? They are tachypneic, often requiring positive pressure airflow, both of which dry out the oral mucosa. This makes sublingual distribution suboptimal at best. Are there other options?

The use of IV high-dose bolus NTG has been documented in the literature across the world since the 1970s. More recent U.S. emergency department and ICU data has spurred some to move this therapy to paramedics in the prehospital setting. In this episode of the MCHD Paramedic Podcast, Dr. Casey Patrick and Mike Perlmutter discuss their respective experiences from implementing through to publishing peer reviewed results of IV high-dose bolus NTG in APE patients.

Spoiler alert: this therapy is safe and effective for use by paramedics in the field. If you are in doubt, please have an open-minded listen and prepare to do a 180!

Bolus dose nitroglycerin with Mike Perlmutter

Listen to next: How to safely manage COVID-19 respiratory failure patients

References

1. https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/prehospital-treatment-of-acute-pulmonary-edema-with-intravenous-bolus-and-infusion-nitroglycerin/B7B78C8CC0A32A2E0048AECCC177DF69/share/3b38ce9a134027bde58af415173c72b9f3fe8ac4

2. https://www.tandfonline.com/doi/full/10.1080/10903127.2020.1711834

The MCHD Paramedic Podcast was launched in early 2018 in an effort to provide easily consumable core-content EMS education and insights from prehospital care thought leaders. The Clinical Services Department of The Montgomery County Hospital District EMS service developed the podcast as a tool to better engage and disseminate continuing education to our MCHD medics as well as first responders and EMS professionals nationwide.

Dr. Casey Patrick is the assistant medical director for Montgomery County Hospital District EMS and is a practicing emergency physician in multiple community emergency departments across Greater Houston. His EMS educational focus is on innovative paramedic teaching via the MCHD Paramedic Podcast. Dr. Patrick’s prehospital clinical research involves the investigation of paramedic use of bolus dose intravenous nitroglycerin for acute pulmonary edema and the implementation of lung protective ventilation strategies for intubated EMS patients. Casey and his wife, Alyssa, work and live in Conroe, Texas, and Spokane, Washington. Together they have five children: Mia, Ainsley, Brock, Dean and Will.

Dr. Dickson graduated with honors from the University of Texas Health Science Center San Antonio in 2001 and completed emergency medicine training at Indiana University in 2004. He serves as the EMS medical director at Montgomery County Hospital District EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston, Texas. His academic interests include systems of care in stroke and other time-sensitive emergencies, neurologic emergencies and education. He is board certified in emergency medicine in both the U.S. and Australasia, and has subspecialty board certification in EMS medicine. He has authored multiple professional articles and presented at regional, national and international conferences on emergency medicine and EMS topics.