NITROGLYCERIN A NEW LOOK FOR AN OLD FRIEND. Casey Patrick MD Jordan Anderson LP, CCP-C Texas EMS November 19, 2018

Transcription

1 NITROGLYCERIN A NEW LOOK FOR AN OLD FRIEND Casey Patrick MD Jordan Anderson LP, CCP-C Texas EMS November 19, 2018

2 OBJECTIVES Review pathophysiology of CHF Differentiate between acute pulmonary edema (APE), chronic CHF and cardiogenic shock Review NIPPV in CHF/APE

3 OBJECTIVES Discuss the utility of nitrates in APE Introduce the concept of IV bolus nitroglycerin in APE patients Present MCHD IV bolus NTG data in APE

4 WHY DO WE CARE?? 5 MILLION CHF patients CHF = Most common hospital admitting diagnosis Aging population no end in sight

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6 CHF TERMINOLOGY Systole/Diastole = Contraction/Dilation Preload = Filling volume Ejection Fraction = % of blood ejected with each beat (normal ~55%) Afterload = Resistance LV ejects blood against

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11 WHAT DOES THE PATIENT SAY?

12 WHAT DO WE SAY? Orthopnea = Worsened dyspnea lying flat Paroxysmal Nocturnal Dyspnea = Waking up at night dyspneic Dyspnea on Exertion (DOE)

13 CHF EXACERBATION - WHAT DOES IT LOOK LIKE?

14 CASE #1 71yo M with acute SOB for 2 hours BP-220/120 HR-131 Sats-83%RA RR-31 Rales noted throughout on exam Trace pedal edema only

15 CASE #2 78yo F - 2 weeks of worsened SOB/unable to sleep BP-150/90 HR-84 Sats-96%RA RR-18 Rales noted throughout on exam 3+ pedal edema, +JVD, out of lasix

16 CASE #3 73yo M called for weakness, SOB and syncope. Progressive for 24hrs HR 67 BP 70/40 Sats 82%RA RR28 Pale, ashen, rales throughout - STEMI

17 Differential??? Treatment??? Workup??? Expected course???

18 CHF EXACERBATION = TOO BROAD

19 CHF MORE SPECIFIC PLEASE Acute Pulmonary Edema (APE) Chronic Volume Overload Cardiogenic Shock History and Vitals are KEY!!!

20 ACUTE PULMONARY EDEMA Flash edema - RAPID onset Often marked hypertension CHF #1 drug =??? Over 50% have NORMAL systemic volume status (volume shift NOT overload)

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22 CHRONIC VOLUME OVERLOAD More insidious onset Hx of CHF and diuretic use Able to track volume status using daily weights Volume overload - non-compliance, diet, heat, arrhythmia

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24 CARDIOGENIC SHOCK MI = most common cause Severe SOB, rales, edema, JVD, AMS Often need intubation BEWARE

25 ACUTE PULMONARY EDEMA

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29 DON T FLOOD THE Plunger = NIPPV BATHROOM!! Open the drain = DECREASE AFTERLOAD Turn off the faucet = DECREASE PRELOAD If there is still too much water then get out the pail and get to work = +/-DIURESIS

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31 DOES NIV HELP?? NNT = 13 (For every 13 APE patients placed on CPAP/BiPAP, one life is saved) 21 trials with > 1000 patients total Side effects = skin damage, gastric inflation, discomfort Vital et al. Non-invasive positive pressure ventilation for cardiogenic pulmonary edema. Cochrane Database 2008, Issue 3.

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34 WHY NITROGLYCERIN? Vasodilator Reduces preload Reduces afterload at higher doses Opens the drain and turns off faucet

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39 NITRO DRIP RIGHT? Often started too slow Pump availability/cost, setup, tubing errors etc

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41 IV NITRO BOLUS Rapid preload and afterload reduction Decreases intubation/icu and LOS Safe

42 IV NITRO EVIDENCE 395 patients - IV bolus (2mg) vs. Drip vs. Combo ICU admission = 48%/69%/83% Hospital LOS = 3.7 days/4.7 days/5 days 80% in bolus group received single dose Wilson SS, Kwiatkowski GM, Millis SR, et al. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):

43 WHO NEEDS IV NTG? Target = Acute Pulmonary Edema SBP >160 and moderate to severe respiratory distress We don t want to give to chronic volume overload with chronic HTN

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46 CAN PARAMEDICS USE IV BOLUS NTG SAFELY AND ACCURATELY?

47 HOW MUCH? 1mg IVP May repeat x1 in 5min if SBP still >160 Don t freak One NTG SL - 400mcg 2mg IV equivalent to 5 SL tablets

48 MCHD DATA 26 patients treated EMS initial SBP = 206 +/- 20 ED Arrival BP = 178 +/- 24 Single episode (<5%) of self-limited/clinically insignificant hypotension (<100mm Hg)

49 MCHD DATA 24/26 (92%) with ED diagnosis of APE CXR results = pulmonary edema and/or pleural effusion 26/26 (100%) protocol appropriate

50 mm HG Initial EMS SBP EMS post-ntg SBP ED arrival SBP

51 PARAMEDIC APE DIAGNOSTIC ACCURACY -APE = 7% +APE = 93%

52 Dr. Kevin Rodgers

53 WRAPPING IT UP CHF includes APE, chronic overload and shock HISTORY/TIMING AND MED LIST!! Unplug the drain and turn off the faucet Use your plunger

54 WRAPPING IT UP NIPPV prevents intubation in APE IV bolus NTG decreases intubation and ICU Paramedics can diagnose APE Our data suggests EMS IV Bolus NTG safety

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58 REFERENCES Vital et al. Non-invasive positive pressure ventilation for cardiogenic pulmonary edema. Cochrane Database 2008, Issue 3. Wilson SS, Kwiatkowski GM, Millis SR, et al. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):