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Podcast 97 - Taming The Afterload:Push Dose Nitro w/ Michael Perlmutter

In this episode we talk with Michael Perlmutter (@DitchDoc14) who recently released a poster board for an upcoming paper evaluating the safety and efficacy of push-dose nitroglycerin in EMS for patients experiencing sympathetic induced pulmonary edema. In this episode you will hear us refer to this subset as "SCAPE" patients. This term was coined by Scott Weingart in his very first EMCrit podcast and stands for sympathetic crashing acute pulmonary edema (SCAPE). The safety of this method is extremely beneficial for services that do not have access to an IV pump.

Heres is the assessment and treatment algorithm that was used in the study:

Mike and I discuss how the degree of afterload that inhibits forward ejection from the left ventricle (LV) is relative to health of the LV. It is important to stress that blood pressure does not need to be extremely high in order for CO to be inhibited.

Systolic pressure = diastolic pressure + pressure exerted by LV during systole

The afterload or diastolic pressure is a product of cardiac output and peripheral vascular resistance. If we decrease cardiac output (cardiogenic shock) peripheral vascular resistance will likely increase to maintain perfusing MAP. 

This study utilized a systolic metric (120 mmHg after two sprays of subligual nitro) to continue down the path of bolus dose nitro. In my opinion it may be benefical to consider MAP or diastolic inclusion in future studies. In addition to the majority of NIBP utilizing MAP to extrapolate sys/dias, if afterload is inhibiting forward LV flow, pulse pressure will be low.

Here is the entire poster. 

 

 

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