Nitro Drip for CHF

[Brandon O]

I'm not sure if this is the case for the typical "nursing home pt with significant history of CHF having an exacerbation" type of patient, but a number of sources state that "the most common cause of CHF is ischemic heart disease". Probably something to do with this?

Doesn't mean the most common cause of EXACERBATIONS is ischemia. Which it may be, but I doubt. But it might be common enough that throwing some aspirin down the hatch isn't a bad idea.

 

[Household6]

"Not a bad idea" and "sooner than later" was always the basis of the answer that I received.

 

[fma08]

Pt crashed 10 minutes later.... Oops

Think you got your answer on whether or not your care was appropriate.

Dropping that BP would go a long way towards relieving symptoms. Nitro is easily titrated as a drip. If you're confident in your skills to set it up and manage it (seems like you were) then excellent.

 

[Jason]

There's no issue with it. And 5 mcg/min is only a sniff anyway. The problem with the ER is that they look at the patient as they present and don't appreciate how they were. Guarantee you that if the pt had been pushed in wheelchair into the ER as they presented to you they would have started a drip.

I agree with Merck. I think you did well.
I don't have NTG drip avail to me for the field, but wish I did. CPAP and NTG is very appropriate, and NTG drip would be better for continuous treatment - as apposed to SL or Paste. Maybe an initial SL right before CPAP is applied. And I agree not to take CPAP off once started.
Sometimes ... the hospital, like sometimes in our forum ... we need to remember, we were not there to accurately see what you (the provider) assessed and witnessed. I too have been questioned "Why", and had to thoroughly explain and paint the picture of how the Pt was on death's door.
I think you did well.

 

[Nova1300]

The amount of ego they manage to squeeze into these tiny little emergency departments may be one of the great wonders of the world.

I have not been on a bus in a long time, but I yearn for it. Some of that is a function of really missing EMS. Some of it is me waiting for an ER nurse/doc to get nasty with me so we can play the credentials game.

You saved that patient's life. And any ER doc who willy-nilly stops a vasoactive drip on a patient with a BP in the 140's is a buffoon.

 

[BigBad]

Drip Ntg was removed from our CHF protocols years ago. I've always gotten the same results with cpap since it also lowers bp. As always we don't treat high bp. Not saying you were but some food for thought, his bp dropped 100 systolic. What if his bp was 150 to start? Might have been a different story in the back of the bus with a drip. you have ntg drip in your protocol sounds like you did a good job.

 

[18G]

Drip Ntg was removed from our CHF protocols years ago. I've always gotten the same results with cpap since it also lowers bp. As always we don't treat high bp. Not saying you were but some food for thought, his bp dropped 100 systolic. What if his bp was 150 to start? Might have been a different story in the back of the bus with a drip. you have ntg drip in your protocol sounds like you did a good job.

In a CHF patient, it is VERY important to treat their hypertension. Pressure reduction in these patients is key to maximizing the hearts efficiency (think decreased afterload and preload) and to reduce the pressure in the pulmonary vasculature which is what allows the fluid to retreat back across the alveolar-capillary membrane and into its proper space.

I agree that IV nitroglycerine is the preferred route for a sick CHF patient where pressure reduction is crucial. Its highly titratable and the effects wear off within minutes of stopping the infusion. It sounds like the OP fixed this patient and the ED totally screwed them up again.