No more IV NTG in my ED - what else fo CHF?

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paramed2premed

paramed2premed

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And don't tell me NTG paste or Lasix!

I'm talking the severely hypertensive patient who is sucking on the BiPAP. I'm a big fan of starting IV NTG at stout doses, and downtitrating as things improve. But our hospital is fresh out - I took the last two bottles last night. Had to steal the last one from the ICU!

So what else are people using for these patients? Nipride? Nicardipine? 12 inches of NTG paste?

Weingart says clevidipine, but not sure if that's made it out to the country here...
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Nicardipine/clevidipine or nitroprusside.

Clevidipine has the shorter half-life than nicardipine and will behave more like your nitroglycerin gtt. Rather expensive, though.

Nitroprusside shouldn't scare away anyone –*takes days of infusion to become toxic.
 
Not too worried about that - I'll just run hydroxocobalamin in at the same time. Compatible?

Nipride intuitively seems like the next best choice, and at least some of the RNs have given it before.
 
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paramed2premed said:
Not too worried about that - I'll just run hydroxocobalamin in at the same time. Compatible?
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You don't have to run it at the same time. Again, takes days to get toxic. You're not going to be running it for days (likely).
 
Dr.McNinja said:
You don't have to run it at the same time. Again, takes days to get toxic. You're not going to be running it for days (likely).
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Ah, my wry (or just faint) sense of humor didn't come through. Perhaps if I used some of those funny faces or something...
 
2 nitro tabs every 3 minutes then 1 tab, then none :)
Not that I've tried that nor would it be easy given the need to keep poppin the mask off.
 
Rendar5 said:
2 nitro tabs every 3 minutes then 1 tab, then none :)
Not that I've tried that nor would it be easy given the need to keep poppin the mask off.
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PR

(joking -- but it would probably work)

HH
 
Rendar5 said:
2 nitro tabs every 3 minutes then 1 tab, then none :)
Not that I've tried that nor would it be easy given the need to keep poppin the mask off.
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Instead of taking the entire mask off, just take off the hose, then hit them with sprays of nitrospray. It's easier than trying to put the straps back on, etc.
Just make sure they're getting in in the mouth and not inhaling it, although I'm sure it would work from that membrane as well.
 
Nitro-paste

I use it for my rectal fissure once in a while.

Trust me, it works systemically.
 
Jarabacoa said:
Nitro-paste

I use it for my rectal fissure once in a while.

Trust me, it works systemically.
Click to expand...

Speaking of fissures, we had a surgeon come do an botox injection in the ED on a patient that had severe discomfort from an anal fissure that did not resolve with NTG paste. I have never seen a patient go so easily from cursing our existence before the procedure to shaking our hand, apologizing, and expressing his deepest gratitude after the procedure. It worked great.
 
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I use ntg paste for the occasional "Um, I was playing with my buddy's epi pen, and stabbed myself in the finger..."

We're pretty much out of IV nitro as well, but I use the sublingual.
I look at it sort of like the 2mg morphine vs 2 mg dilaudid debate.
I have nurses who don't bat an eye at 400 mcg (1 sl tab!) of ntg, but freak out if I want to start the ntg gtts at 20. You have RT there for a reason - although once the mask straps are adjusted, it's pretty easy to pop it off and then back on.

I love SL ntg. Cheap, effective, and much higher dosing than the nurses realize. It also works faster than the drip. Just take the make off and put it back on. And it's not like you're doing it anyway - your nurse/RT is dealing with it.
 
We have a ton of untreated ESRD with hypertensive emergency/pulmonary edema, and the efficacy and dose of the SL nitro tablets – and what rate to start the drip*– are some of the first things I teach our interns.
 
dchristismi said:
And it's not like you're doing it anyway - your nurse/RT is dealing with it.
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After the initial bolus dose maybe. I have yet to be able to get the nurses to give 6 sprays of nitrospray in succession. I'm sure I would be met with resistance to a SL NTG q5min x 1 hour. Hell, I'd be lucky to get q5 BPs (which I would have to get, because "I'm not going to lose my license,etc etc").

I usually stand in there for the first few minutes (and often hose them down with spray prior to CPAP getting there), it makes the critical care easier to document.
 
no automagic bp machine cycling? and why is their license in question out of curiosity?
 
migm said:
no automagic bp machine cycling? and why is their license in question out of curiosity?
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It's not. But that's the first thing they teach in nursing school. I think there's an entire course on how to say "I'm not going to lose my license for ... !" It's pretty much the only thing NYC nurses will say to med students and residents.
 
Dr.McNinja said:
After the initial bolus dose maybe. I have yet to be able to get the nurses to give 6 sprays of nitrospray in succession. I'm sure I would be met with resistance to a SL NTG q5min x 1 hour. Hell, I'd be lucky to get q5 BPs (which I would have to get, because "I'm not going to lose my license,etc etc").

I usually stand in there for the first few minutes (and often hose them down with spray prior to CPAP getting there), it makes the critical care easier to document.
Click to expand...

I wonder if you could pour the spray bottle into a bubbler and hook that in line with the CPAP circuit?

Kinda tough to titrate, but if you took the volume x concentration / time, could approximate the infusion rate and at least get some basal rate. The PK of trans-pulmonary v. sublingual shouldn't differ too much.

Thoughts?

Sent from my DROID BIONIC using Tapatalk
 
Daiphon said:
I wonder if you could pour the spray bottle into a bubbler and hook that in line with the CPAP circuit?

Kinda tough to titrate, but if you took the volume x concentration / time, could approximate the infusion rate and at least get some basal rate. The PK of trans-pulmonary v. sublingual shouldn't differ too much.

Thoughts?

Sent from my DROID BIONIC using Tapatalk
Click to expand...

I hear a study pending.

"Nebulized nitroglycerin as a potential treatment for CHF"
 
With the last acute CHF patient, I borrowed the medic's spray NTG, and was hitting the patient with 3 sprays q 2-3 minutes. The scribe (a medic student) wrote it down, but the nurses didn't even realize what I was doing.

Probably didn't matter, because they didn't balk at my order for 400µg/minute, although the ICU nursing staff said the rate was to high to come to the ICU. Weird.

Anyway, it's sounds like we're in the same boat. I'm going to be carrying the SL NTG in bandoliers across my chest, and my pilfered NTG spray in the ankle holster. If things get hairy, I'll try some advanced SL dosing..

Thanks all!
 
Wait, what is wrong with nitro paste and why are you not considering using it? Load with sublingual, and maintain a "drip" using nitropaste. I do it all the time. It really simplifies nursing care. If you are still having elevated pressure problems, you could bolus some vasotec or something in addition to BiPAP and lasix. This shouldn't impact your clinical practice much.
 
Jarabacoa said:
Wait, what is wrong with nitro paste and why are you not considering using it? Load with sublingual, and maintain a "drip" using nitropaste. I do it all the time. It really simplifies nursing care. If you are still having elevated pressure problems, you could bolus some vasotec or something in addition to BiPAP and lasix. This shouldn't impact your clinical practice much.
Click to expand...
If you've got them about where you need them with the oral load, it's likely OK. However,

http://www.acep.org/content.aspx?id=39692
Matthew Strehlow said:
"I see that slapped on a lot," he observed. "What's the problem with nitro paste? Basically, it doesn't absorb well," he said. "These patients are often peripherally clamped down, and it's not going to start for 20 minutes. These patients are either going to get better or get worse - probably very rapidly."
Click to expand...
 
Jarabacoa said:
Wait, what is wrong with nitro paste and why are you not considering using it? Load with sublingual, and maintain a "drip" using nitropaste. I do it all the time. It really simplifies nursing care. If you are still having elevated pressure problems, you could bolus some vasotec or something in addition to BiPAP and lasix. This shouldn't impact your clinical practice much.
Click to expand...

I've read about IV enalapril, but I try not to be too outside the group practice - no one else is doing it so far.

As for the paste, I have concerns about the kinetics. Onset, offset, how to "dose" a product that comes in inches. (Seriously, inches?) My question regards the patient who is spectacularly hypertensive, already on CPAP by the medics, and looking like they're going to crump soon. As I mentioned already, I haven't seen the SL tabs getting absorbed so well in these patients, so I'm not sure paste will be reliable either.
 
Nipride, vasotec or sublingual captopril.

The only downside to nipride is you need an art line pronto. Also there is another drug called fenoldopam which is in all the EM textbooks...unfortunately not stocked where I work.
 
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