Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4-year review

Casey Patrick; Louis Fornage; Brad Ward; Michael Wells; Kevin Crocker; Kelly Rogers Keene; Sara Andrabi; Robert Dickson

doi:10.1002/emp2.13079

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4-year review

J Am Coll Emerg Physicians Open. 2023 Dec 8;4(6):e13079. doi: 10.1002/emp2.13079. eCollection 2023 Dec.

Authors

Casey Patrick¹, Louis Fornage², Brad Ward¹, Michael Wells¹, Kevin Crocker¹, Kelly Rogers Keene², Sara Andrabi², Robert Dickson^{1

2}

Affiliations

¹ Montgomery County Hospital District EMS Service Conroe Texas USA.
² Department of Emergency Medicine Baylor College of Medicine Houston Texas USA.

Abstract

Background: Intravenous nitrates are a primary therapy for hypertensive congestive heart failure (CHF) with acute pulmonary edema (APE) in the hospital setting. Historically, sublingual nitrates are the mainstay of emergency medical services (EMS) pharmacologic therapy for these patients. We aimed to evaluate the safety of prehospital bolus dose intravenous nitroglycerin in patients with APE.

Methods: This is a retrospective evaluation of EMS data between March 15, 2018, and March 15, 2022, where CHF with APE was suspected and bolus-dose intravenous nitroglycerin was administered. Protocol inclusion criteria were hypertension (systolic blood pressure [SBP] >160 mmHg) and acute respiratory distress, with a presumption of decompensated CHF with APE. These patients received 1 mg intravenous nitroglycerin, with the option to repeat once for ongoing distress if the SBP remained >160 mmHg. The primary outcomes were adverse events, defined as hypotension (SBP <90 mmHg), syncope, vomiting, or dysrhythmia.

Results: The final analysis included 235 patients. In patients receiving intravenous bolus nitroglycerin, the median (interquartile range [IQR]) initial and final EMS SBP values decreased from 198 mmHg (180-218) to 168 (148-187), respectively. The median (IQR) pulse decreased from 108 (92-125) to 103 (86-119), and the median oxygen saturation increased from 89% (82-95) to 98% (96-99). Three episodes (1.3%) of asymptomatic hypotension occurred, and none required intervention.

Conclusion: This study supports a favorable safety profile for prehospital bolus-dose intravenous nitroglycerin for decompensated CHF with APE. Blood pressure, heart rate, and oxygen saturation improvements are also demonstrated. Further, prospective studies are needed to confirm these findings.

Keywords: acute pulmonary edema; congestive heart failure; emergency medical services; nitroglycerin; prehospital.