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Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension

Published online by Cambridge University Press:  21 August 2013

Brian M. Clemency ,
Jeffrey J. Thompson ,
Gina N. Tundo  and
Heather A. Lindstrom
Brian M. Clemency*
Affiliation:
University at Buffalo, Department of Emergency Medicine, Buffalo, New York USA
Jeffrey J. Thompson
Affiliation:
University at Buffalo, Department of Emergency Medicine, Buffalo, New York USA
Gina N. Tundo
Affiliation:
University at Buffalo, Department of Emergency Medicine, Buffalo, New York USA
Heather A. Lindstrom
Affiliation:
University at Buffalo, Department of Emergency Medicine, Buffalo, New York USA
*
Correspondence: Brian Clemency, DO Erie County Medical Center Department of Emergency Medicine 462 Grider Street Buffalo, NY 14215 USA E-mail bc34@buffalo.edu
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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.

Keywords

congestive heart failureEmergency Medical Serviceshypotensionnitroglycerin
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 28 , Issue 5 , October 2013 , pp. 477 - 481
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2013 

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