EMDutch

While being sick at home and still working on diuretics in Acute Pulmonary Edema I thought to myself, why not post something I have already finished but never put on the internet. (Better lazy then tired as we say in Holland ) Sadly I found that most of it has to be translated into English, except for the following “poster”.

One of my great residents (Annemarie v/d/ Velden) was interested in morphine and benzodiazepines for the relief of acute dyspnea. Opiates have traditionally been used as one of the main treatments of acute dyspnea and are still recognized as such. Most current textbooks and official guidelines advise the use of morphine as one of the first-line treatments for patients in acute dyspnea and a majority of physicians accept it to be the case. Benzodiazepines are widely used for the relief of breathlessness in advanced diseases and are regularly recommended in the literature. For me this was something you never think about and it just works….but does it really???

Here is what we did and the results we found:

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Welcome back on the EMDutch website….the website talking about emergency medicine below sealevel. And because we, the people living below sealevel (It sound more scary than it is), use nitroglycerin (NTG) for acute decompensated heart failure, that is what we will be mainly talking about. I know there are other vasodilators out there, like nitroprusside and nesiritide, but for us NTG is the vasodilator/nitrate of choice!

Nitroglycerin is a nitrate that causes venodilation at low doses and arterial dilation at higher doses. (1) There is little doubt about its effectiveness in AHF and it lacks significant side effects (2), but its use is limited by marked underdosing in clinical practice. (3) And this is so true in my own hospital! Nurses and fellow doctors are used to giving 150ug/h in stable chest pain patients, which they can titrate up to 500 ug/h. In acute heart failure (with a normal-high blood pressure) this is just not enough.

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