Skip to main content Accessibility help
×
×
Home

Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension

  • Brian M. Clemency (a1), Jeffrey J. Thompson (a1), Gina N. Tundo (a1) and Heather A. Lindstrom (a1)
Abstract
Introduction

High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed.

Hypothesis/Problem

To assess the protocol's safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied.

Methods

This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing.

Results

One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%.

Discussion

High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field.

Conclusion

Hypotension was rare and self-limited in prehospital patients receiving MSN.

ClemencyB, ThompsonJ, TundoG, LindstromH. Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension. Prehosp Disaster Med. 2013;28(5):1-4.

Copyright
Corresponding author
Correspondence: Brian Clemency, DO Erie County Medical Center Department of Emergency Medicine 462 Grider Street Buffalo, NY 14215 USA E-mail bc34@buffalo.edu
References
Hide All
1.Roger, VL, Go, AS, Lloyd-Jones, DM, et al. Executive summary: heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012;125(1):188-197.
2.Jessup, M, Abraham, WT, Casey, DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016.
3.Herling, IM. Intravenous nitroglycerin: clinical pharmacology and therapeutic considerations. Am Heart J. 1984;108(1):141-149.
4.Cotter, G, Metzkor, E, Kaluski, E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-393.
5.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.
6.Emerman, CL. Treatment of the acute decompensation of heart failure: efficacy and pharmacoeconomics of early initiation of therapy in the emergency department. Rev Cardiovasc Med. 2003;4(Suppl 7):S13-S20.
7.Mebazaa, A, Gheorghiade, M, Pina, 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.
8.Wuerz, R, Swope, G, Meador, S, Holliman, CJ, Roth, GS. Safety of prehospital nitroglycerin. Ann Emerg Med. 1994;23(1):31-36.
9.Wuerz, RC, Meador, SA. Effects of prehospital medications on mortality and length of stay in congestive heart failure. Ann Emerg Med. 1992;21(6):669-674.
10.Mattu, A, Lawner, B. Prehospital management of congestive heart failure. Heart Fail Clin. 2009;5(1):19-24.
11.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.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Prehospital and Disaster Medicine
  • ISSN: 1049-023X
  • EISSN: 1945-1938
  • URL: /core/journals/prehospital-and-disaster-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed