Washington University Emergency Medicine Journal Club- May 2024
Vignette
It’s nine o’clock on a Saturday, and the regular crowd shuffles in (you know…Charles, Tiffany, Jason) when EMS brings Mr. H to TCC-1. Per report Mr. H has a history of congestive heart failure and hypertension and presents with acute onset of shortness of breath while watching the Cardinals game earlier in the evening. He arrives very dyspneic, in severe distress, with a blood pressure of 220/145, O2 saturation 93% on a non-rebreather, and a HR of 113. He has diffuse rales on your exam, denies chest pain, denies recent lower extremity swelling, and reports adherence with his anti-hypertensives and diuretics.
You are concerned for SCAPE (sympathetic crashing acute pulmonary edema) and immediately place the patient on BiPAP and request a nitroglycerin drip, which you start a 100 mcg/min with a plan to uptitrate to achieve blood pressure control and improvement in symptoms. Your attending asks if you would consider an IV bolus of nitroglycerin (which you have never given before) and if you’re sure you don’t want to start the drip at a significantly higher rate.
You continue managing the patient, who improves significantly with BiPAP and the nitroglycerin drip, but continue to ponder your attending’s questions. When your shift ends, you decide to look further into the literature to see what the evidence shows…
PICO Question
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Search Strategy
Article 1: Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007 Aug;50(2):144-52. doi: 10.1016/j.annemergmed.2007.02.022. Epub 2007 May 23. PMID: 17509731. Answer Key.
Article 2: 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 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18. PMID: 27825693. Answer Key.
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Article 4: Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study. J Emerg Med. 2021 Sep;61(3):271-277. doi: 10.1016/j.jemermed.2021.05.011. Epub 2021 Jun 30. PMID: 34215472. Answer Key:
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