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Pulmonary Edema, Cardiac Ischemia and Nitro

Question #: 360


When it is determined the patient is experiencing cardiac ischemia and also presenting with acute pulmonary edema (IV established, BP over 140) should the treatment plan only include 0.4mg doses of nitro x6 and try CPAP? Or can nitro be administered to the 0.8mg as stated in the edema directive? My opinion would be to only treat with 0.4mg nitro.


[The answer to your question has multiple folds and will depend on your patient care context, working diagnosis, treatment plan as well as information gathered while monitoring your patient after you started your initial treatment plan.

In a situation where your patient is presenting with Cardiac Ischemia and Acute Cardiogenic Pulmonary Edema (ACPE), we recommend that your care goals be tailored to the patient’s needs. Your management plan can be adapted as the call evolves. We recommend that your management plan includes 12-lead/V4r acquisition/interpretation, maintaining oxygenation as well as coronary perfusion. Coronary perfusion is highly dependent on preload and can be monitored by assessing the blood pressure values.

Your main patient care goal in this situation: finding the right balance in resolving the dyspnea/hypoxia while avoiding the risk of hypotension and cardiogenic shock.

Questions you can ask yourself to tailor nitro administration throughout the call:

  • Is my patient STEMI positive?
  • Is my patient showing signs of Right Ventricular Infarct?
  • Are there co-morbidities that will affect preload?
  • How is my patient responding to nitro 0.8mg/0.4mg and/or CPAP?

For example, in situations where your patient is in ACPE but also presenting with STEMI, it would be preferable to limit the administration of nitro to 3 doses. It will also be important to assess the impact of 0.8mg/0.4mg on hemodynamic versus hypoxic status. ]

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