How I Educate Series: Jessie Werner, MD

This week’s How I Educate post features Dr. Jessie Werner, the Clerkship Director and Medical Education Fellowship Director at UCSF Fresno. Dr. Werner spends all of her shifts with learners which include emergency medicine residents, off-service residents, medical students, physician assistants, nurse practitioners, and fellows. She describes her practice environment as a busy (120,000 patients/year) ED in the central valley healthcare desert. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Educational, hands-on, and accessible.

What delivery methods do use when teaching on shift?

I’m a visual learner so like to draw on paper or make lists, outlines, learning points, etc; I also love looking up helpful images on the computer.

What learning theory best describes your approach to teaching?

Maybe a combination of humanism and constructivism? I try to meet learners at their level and help them achieve their own goals, but I also believe that a lot of learning happens from seeing something/doing something/experiencing it, and problem-solving.

What is one thing (if nothing else) that you hope to instill in those you teach?

You can never know it all (and that’s ok!). We all need to keep up-to-date, look up answers, and ask for help. I like it when learners ask questions because it helps me learn too!

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I try to teach when a patient is being presented, when we’re running the list, or if new information becomes available. That grounds the teaching in a patient and *hopefully* makes it more memorable.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I mostly pay attention to the physical exam and the MDM. There’s so much that we do during the shift for patient care that we don’t always document. I try to encourage learners to use dot phrases, time stamps, and the ED Course whenever they do anything.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

They definitely can. It can sometimes feel like there isn’t enough time for quality teaching when the department is really busy. Sometimes I go to the bedside with my learner or have them round with me in order to be more efficient. It’s also nice to hear them interview the patient or watch them do a procedure in real-time.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I try to remember how I felt when I was a fourth-year resident. :)

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

It depends. If a learner expresses certain goals, then we try to achieve those during the shift. Otherwise, it usually unfolds more organically.

Do you typically see patients before or after they are presented to you?

Again, it depends. I like to try to see patients ahead of time so I can more easily give thoughts/feedback about the patient as they’re presented to me. Sometimes that just isn’t possible and I see them after the presentation. I *try* not to say much about management until I’ve seen the patient for myself.

How do you boost morale amongst learners on shift?

The doc box vibe is real. If a member of the team is grumpy and negative it’s transmitted to everyone. I think it’s important to come in with positivity and energy so the whole team benefits. Encouraging breaks or snack time can be helpful too.

How do you provide learners feedback?

I usually give verbal feedback in real time.

What tips would you give a resident or student to excel on their shift?

Be positive, work hard, and go the extra mile.

Are there any resources you use regularly with learners to educate during a shift?

I love online resources and FOAM. I use EMRAP procedure videos a lot.

What are your three favorite topics to teach during a shift?

Procedures, post-intubation care, and running a room.

What techniques do you employ when teaching on shift?

I love the one-minute preceptor. I also like bedside teaching whenever possible.

What is your favorite book or article on teaching?

I use various mentors the most — Amal Mattu and Jessica Mason for example.

Who are three other educators you’d like to answer these questions?

Jessica Mason, Whitney Johnson, Stuart Swadron

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Jessie Werner, MD|2022-11-22T09:33:23-08:00Nov 23, 2022|How I Educate, Medical Education, Uncategorized|

SAEM Clinical Images Series: An Enlarging Scalp Mass

A 27-day-old female infant born at 34 weeks 4 days with a prenatal history of maternal syphilis treated with penicillin presented with an enlarging scalp mass since birth. Since birth, the patient has had a 1 cm erythematous and flat lesion on her scalp. Since that time, the lesion has continued to grow and develop scales. On the day of presentation, the lesion was noted to be 7-8cm in diameter with multiple surrounding smaller lesions. There is some clear to bloody drainage coming from the main lesion. The patient has otherwise been growing and developing normally. No fevers or other sick symptoms. Feeding well. Mom has no concerns with bowel movements or voiding habits.

Additional Images

Physical Exam

General: She is active. She is not in acute distress. She is well-developed.

HEENT: No congestion or rhinorrhea. Mucous membranes are moist. No posterior oropharyngeal erythema.

Cardiovascular: Normal rate and regular rhythm. Normal pulses. No murmur heard.

Pulmonary: Respiratory effort is normal. No retractions. Normal breath sounds. No wheezing.

Skin: Skin is warm. Capillary refill takes less than 2 seconds. On the left side of the scalp, there is a large raised keratinized plaque with a stuck-on appearance. Some red blood is noted when tapped with a white sheet. The plaque is firm and non-tender. On the rest of the scalp, there are several peeling flat lesions with hair attached, and intermittent alopecia.

Neurological: No focal deficit present. She is alert. Suck is normal.

Laboratory Data

Scalp ultrasound: Posteriorly exophytic left parietal lesion is peripherally echogenic, possibly representing a calcified lesion or cephalohematoma. CT or MRI may be useful for further evaluation, as clinically indicated.

Case Question: What is the differential for scaly lesions on the scalp in this age group?

a. Seborrheic Dermatitis: A common, self-limiting eruption consisting of erythematous plaques with greasy, yellow-colored scales that distribute to the areas of the body with sebaceous glands.

b. Atopic Dermatitis: Erythematous, scaly, crusted lesions that are poorly demarcated. It is pruritic and commonly involves the cheeks, scalp, and extensor surfaces.

c. Psoriasis: Uncommon in infants, but can mimic seborrheic dermatitis with sharply demarcated, shiny, erythematous plaques with fine silvery scales in non-intertriginous regions.

d. Tinea Capitis: While rare, tinea can present with a scaly scalp rash in infants. There may be a mild to moderate inflammatory reaction associated as well as hair loss.

e. Langerhans Cell Histiocytosis (LCH): LCH can present as refractory seborrheic dermatitis. There may also be papules or reddish-brown nodules that appear with the rash.

Case Question: What is the diagnosis and management?

Pityriasis Amiantacea secondary to Seborrheic Dermatitis with a significant build-up of crust and scale. Pityriasis amiantacea is an exaggerated inflammatory response to regional dermatitis, most often seborrheic dermatitis. Treatment consists of a keratinolytic and antibacterial ointment. In this patient, 1:4 part vinegar and water soaks were recommended twice daily, followed by mupirocin ointment until the resolution of the lesions.

Case Discussion

Take-Home Points

Seborrheic dermatitis is a commonly presenting rash in infancy.
When rashes are refractory to conservative management, additional diagnoses and sequelae need to be considered.

References

Amorim GM, Fernandes NC. Pityriasis amiantacea: a study of seven cases. An Bras Dermatol. 2016 Sep-Oct;91(5):694-696. doi: 10.1590/abd1806-4841.20164951. PMID: 27828657; PMCID: PMC5087242.
Olanrewaju O. Falusi; Seborrhea. Pediatr Rev February 2019; 40 (2): 93–95. https://doi.org/10.1542/pir.2017-0215. PMID: 30709979.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Jane Rivas, MD|2022-11-06T10:06:06-08:00Nov 7, 2022|Dermatology, Pediatrics, SAEM Clinical Images, Uncategorized|

How I Educate Series: John Casey, DO

This week’s How I Educate post features Dr. John Casey, the Program Director at OhioHealth Doctors Hospital in Columbus, OH. Dr. Casey spends 100% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, nursing students, physician assistants/nurse practitioner students, and EMS students. He describes his practice environment as a busy community teaching hospital located on the city’s edge, with a diverse patient population and many socioeconomic challenges. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Use. The. Force.

What learning theory best describes your approach to teaching?

Deliberate practice. I think it’s so very important to identify an area of weakness and target it. I try and focus my teaching energy on areas where learners have blind spots and get them to engage in very targeted practice in that specific area.

What is one thing (if nothing else) that you hope to instill in those you teach?

Always be curious, and not be afraid to challenge your own beliefs – or to have them challenged!

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I try and teach my more senior residents how to incorporate junior learners and students into their workflow. When a learner locks on to you for a shift you don’t know if you’re getting a parachute or a knapsack…don’t jump out of the plane until you have identified which they are.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Nope. Department flow and metrics are part of the learning process. A lot of our job is more than medicine. To be happy and successful in this career long term you have to have a plan to manage these stressors – so better to learn it in residency while you have support from experienced emergency physicians. There will always be faster shifts, slower docs, efficient nurses, and lab slow downs – learn to work through them.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Be confident in your own abilities to manage situations, and remember you learned to be better through practice. As long as you are available to support them, and recognize the boundaries of what is safe for the patient and the learning environment, then most learners appreciate this on the other side. Earlier in my career, I probably let learners struggle a little more than I should have, and this is a place where I have learned – and grown – through feedback.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I think it’s better to let them develop as the shift unfolds. I will often ask if the learner has something in mind, and if they do I am happy to cover it – but no guarantees!

Do you typically see patients before or after they are presented to you?

I deliberately shake this up. When I see them before, I will often engage the patient in helping me get feedback on the learner. I will ask that they not specifically mention I have seen them, and give them an area to focus on (like did the resident ask similar questions to what I asked, or did they make them feel comfortable, etc.). I will then circle back and get feedback – you can learn a lot about how residents interact with patients using this method. Also – I love to go into the room while they are doing the exam and interview. Hawthorne effect aside, you can learn a ton about how the learner is doing overall!

How do you boost morale amongst learners on shift?

I work hard to pay attention to the overall mood of the shift and try and throttle accordingly. I am by nature a storyteller and like to share experiences. It’s more than just lip service when we talk about cases where we didn’t do as well as we wanted at something. Human nature is to feel like we are totally responsible for mistakes when almost always there is a substantial mix of exogenous events that lead to failure. Also – I remind learners that whatever they feel in the moment is OK – those feelings about an event change with time and perspective. Windshields in a car are big for you to look forward, and rear-view mirrors are tiny so you can remember past lesions – but focus on what’s next. Additionally….dad jokes.

What tips would you give a resident or student to excel on their shift?

Be nice. Work hard. Stay humble. If you only have enough energy for one on a given day, be nice.

What are your three favorite topics to teach during a shift?

ECG interpretation, anaphylaxis, and reading a room

What is your favorite book or article on teaching?

Thanks for the Feedback: The Science and Art of Receiving Feedback Well by Stone and Heen. I guess it’s not really a book on teaching per se, but if you can help people learn this skill (and master it yourself) it can make for a great learning environment!

Who are three other educators you’d like to answer these questions?

Dr. Katie Holmes, Dr. Deena Bengiamin, and Dr. Kristy Schwartz

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By John Casey, DO, MA, FACEP|2022-09-03T11:12:21-07:00Sep 28, 2022|How I Educate, Medical Education, Uncategorized|

How I Educate Series: Alex Koyfman, MD

This week’s How I Educate post features Dr. Alex Koyfman, who serves as core faculty at UT Southwestern in Dallas, TX. Dr. Koyfman spends approximately 90% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, and physician assistants. He works clinically at Parkland Memorial Hospital which is the busiest urban ED in the country. He also spends time in their independent urgent care and ED observation unit, both of which also have a mix of different learners. Below he shares with us his approach to teaching learners on shift.

Name 4 words that describe a teaching shift with you.

Autonomy, growth, curiosity, pt advocacy

What delivery methods do use when teaching on shift?

A focused discussion based on the needs of the learner and what is high-yield in our environment.

What learning theory best describes your approach to teaching?

A mixture of multiple which is actually documented in my book The Emergency Medicine Mindset.

What is one thing (if nothing else) that you hope to instill in those you teach?

Excellence in clinical care is the ultimate form of patient advocacy and deliberate practice gets you to mastery.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Volume definitely impacts teaching as 1a) patient care, and 1b) education; they feed off of each other. The focus is on impactful clinical documentation for the transition of care, not medicolegal paranoia; it is impractical to achieve excellence in all spheres of practice. We must be thoughtful communicators at the bedside on working diagnoses and degrees of uncertainty. Each piece of information you request, you must account for in the context of the patient.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

The focus is on decision-making (practical risk stratification). Does the MDM jive with the remainder of the documentation? Have risk factors/red flags been thoughtfully explained? It helps to highlight what to focus teaching on.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Mixed bag; I can’t disagree with the more you see the more comfortable you become. Often metrics don’t jive with evidenced-based medicine, however, many of our grads will be responsible for this and judged based on it in their future careers. Thankfully, it doesn’t dominate our practice environment in an onerous manner.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Experience teaches you to get comfortable with this. It is very important to get it right for resident development. There are many more greys in EM decision-making than black or white, thus if reasonable then no need to intervene pre-emptively.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

The learner sets the tone for clinical education. At the same time, I’m not shy to bring up topics based on what we’re seeing.

Do you typically see patients before or after they are presented to you?

Depends on the stage of the learner + the volume/practical need to move things along.

How do you boost morale amongst learners on shift?

Invest meaningfully in the development of each individual I work with.

How do you provide learners feedback?

Best handled in real-time if flow allows. The next best is right after the shift. Written feedback is a formality, I am not convinced that many learners review these and items can be misconstrued. This is an area that’s easy to avoid, yet crucial to do, and takes a departmental culture.

What tips would you give a resident or student to excel on their shift?

One foot outside of your comfort zone each shift; marginal gains add up. Reflect/be proactive about anything that didn’t go smoothly or caused consternation.

Are there any resources you use regularly with learners to educate during a shift?

Heavy on foamed (emDocs, IBCC, EM Cases, etc.) with PubMed/Google Scholar literature mixed in.

What are your three favorite topics to teach during a shift?

EM mindset; decision making; high-risk, low-prevalence diseases; anything critical care; advocacy for our field in the academic arena

What techniques do you employ when teaching on shift?

Adapted from best practices here as well as paying attention to my colleagues.

What is your favorite book or article on teaching?

Thinking, Fast and Slow by Daniel Kahneman; Radical Candor by Kim Scott

Who are three other educators you’d like to answer these questions?

Brit Long, MD; Manny Singh, MD; Alex Sheng, MD; Marina Boushra, MD

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Alex Koyfman, MD|2022-09-20T21:32:20-07:00Sep 21, 2022|How I Educate, Medical Education, Uncategorized|

This week’s How I Educate post features Dr. Graham Snyder, the Associate Program Director at the University of North Carolina and Director of Education for WakeMed Health and Hospitals. Dr. Snyder spends approximately 90% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a Level 1 trauma center that sees 125,000 patients annually. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Practically Academic, Comradery, Rejuvenating

What delivery methods do use when teaching on shift?

YouTube, just-in-time sim task-training, observation and feedback of the resident teaching the student.

What learning theory best describes your approach to teaching?

Cognitive learning

What is one thing (if nothing else) that you hope to instill in those you teach?

Love and an appreciation of the honor of caring for patients in their time of need.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Yes. I hire a scribe to offset time for patient discussions.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

On-shift. By asking them socratically how different parties, consultants, PMD’s, lawyers, and the patients themselves would interpret their documentation in the event that their diagnosis is correct…or if it was completely wrong.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

It’s a fine balance. Much like showing compassion and patient counseling, teaching is a corner that could be cut but I choose not to. I also preferentially pick up patients myself that are low yield so I do not need to spend time listening to presentations where I anticipate little teaching opportunity.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

As a life-long learner and a simulation lab director, I am continually developing my airway and procedural skills in general. I focus particularly on managing learners who are having challenges in completing procedures and this allows me to continue teaching, even when they are struggling while avoiding putting patients at risk.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

If the residency leadership team has identified a weakness during our monthly reviews, I make that weakness the goal of the shift. Otherwise, I try to huddle with the resident at the start of the shift to see what they have self-identified as a learning goal.

Do you typically see patients before or after they are presented to you?

After unless I “discover” an interesting patient of my own that I intended to see alone but is just so fascinating that I send the resident in redundantly.

How do you boost morale amongst learners on shift?

I like to both say the words and physically, “take a moment” and point out the countless great wins we have every day: recognition of subtle EKG changes, transforming a terrified patient into a calm one, early recognition and resuscitation of a deadly disease, and force them to not overlook the victories, that can so easily get overshadowed by the frustrations.

How do you provide learners feedback?

On shift, after shift, written and verbal.

Are there any resources you use regularly with learners to educate during a shift?

Up to Date, EM-RAP, and YouTube.

What are your three favorite topics to teach during a shift?

Difficult airways, excited delirium, and ultrasound of the hypotensive patient.

Who are three other educators you’d like to answer these questions?

Jerry Hoffman and Gary Greenwald

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Graham E. Snyder, MD, FACEP|2022-09-03T10:59:27-07:00Aug 31, 2022|How I Educate, Medical Education, Uncategorized|

Background

Direct-acting oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are widely used for various indications and considered first-line therapy for prevention of acute ischemic stroke in patients with nonvalvular atrial fibrillation [1]. The management of acute ischemic stroke in patients on DOACs presents a difficult clinical scenario in the emergency department due to concern for increased risk of hemorrhage. IV thrombolytics (e.g., alteplase, tenecteplase), a mainstay in acute ischemic stroke management, are not recommended in current guidelines for patients whose last DOAC dose was within the last 48 hours [2, 3]. Therefore, patients with an acute ischemic stroke who are compliant with their DOACs are often excluded from guideline recommended therapy. Additionally, as covered in a previous ALiEM post, it is not recommended to reverse anticoagulation status in order to administer a thrombolytic.

Evidence

The use of IV thrombolytics in patients on DOACs was evaluated by Kam et al in a 2022 study published in JAMA [4]. This retrospective analysis included 163,038 patients from the AHA/ASA Get With The Guidelines-Stroke registry with acute ischemic stroke who received IV alteplase within 4.5 hours of symptom onset. Of the total number of patients, only 2207 had documented use of a DOAC within the last 7 days, with 25 of these patients reporting DOAC use within 48 hours. Patients on warfarin or other anticoagulants were excluded. The primary outcome was symptomatic intracranial hemorrhage (ICH) within 36 hours of IV alteplase administration. After adjusting for clinical factors, the rate of symptomatic ICH was not significantly different between patients taking DOACs and those not on anticoagulation (3.7% vs. 3.2%, adjusted OR 0.88, 95% CI 0.70 to 1.10). However, when stratified based on time from last DOAC dose, patients who took their DOAC 0-48 hours prior had an 8% rate of symptomatic ICH compared to 3.2% among those not on DOACs. Furthermore, the rate of any alteplase complication was 12% vs. 6% in those taking DOACs within 48 hours vs. no DOAC.

Limitations

The population at highest risk for bleeding is patients who took a DOAC within the last 48 hours, and this study only included 25 such patients.
- A similar study tried to answer the same question for warfarin patients with an INR between 1.5-1.7. They also failed to include enough patients to make any definitive conclusions. [5]
Timing from the last DOAC dose was given as a range, with the majority of patients reporting use sometime within the last 7 days. It has been established in current AHA/ASA guidelines that receipt of DOACs past 48 hours prior is considered safe for thrombolytic administration, and if the included institutions were following current recommendations, thrombolytics were likely administered mostly to patients outside the 48-hour window.
Large potential for selection bias, since it was reported that almost 23,000 patients on DOACs from the original registry (who were otherwise eligible) did not receive thrombolytics.
Not clear how patients were determined to be on DOACs or if the authors were able to confirm this in unresponsive/intubated/deceased patients retrospectively. This could have resulted in DOAC patients being included in the non-DOAC group, which could have falsely evened-out the bleeding rates.

Bottom Line

The management of acute ischemic stroke in patients receiving prior anticoagulation presents a challenging clinical scenario.
Studies to date fail to include enough patients to evaluate the true risk of bleeding.
This study supports the current guideline recommendation to avoid alteplase in patients receiving a DOAC within 0-48 hours due to the increased risk of intracranial hemorrhage.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Published correction appears in Circulation. 2019;140(6):e285. Circulation. 2019;140(2):e125-e151. doi: 10.1161/CIR.0000000000000665. PMID: 30686041.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. PMID: 31662037.
Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021;6(1):I-LXII. doi: 10.1177/2396987321989865. PMID: 33817340.
Kam W, Holmes DN, Hernandez AF, et al. Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA. 2022;327(8):760-771. doi:10.1001/jama.2022.0948. doi: 10.1001/jama.2022.0948. PMID: 35143601.
Xian Y, Liang L, Smith EE, et al. Risks of intracranial hemorrhage among patients with acute ischemic stroke receiving warfarin and treated with intravenous tissue plasminogen activator. JAMA. 2012;307(24):2600-2608. doi:10.1001/jama.2012.6756. doi: 10.1001/jama.2012.6756. PMID: 22735429.

Primary author:

Jessica Mason, PharmD

PGY-2 Emergency Medicine Pharmacy Resident

Massachusetts General Hospital

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2022-03-18T08:03:52-07:00Apr 2, 2022|EM Pharmacy Pearls, Heme-Oncology, Neurology, Tox & Medications, Uncategorized|

Background

Nitroglycerin (NTG) is an important intervention to consider for patients with Sympathetic Crashing Acute Pulmonary Edema (SCAPE) as it significantly reduces preload, and even modestly reduces afterload with high doses. For acute pulmonary edema in the ED, NTG is often administered as an IV infusion and/or sublingual tablet. Starting the infusion at ≥ 100 mcg/min produces rapid effects in many patients and can be titrated higher as tolerated, with doses reaching 400 mcg/min or greater. Combined with noninvasive positive pressure ventilation (NIPPV) and in some cases IV enalaprilat, patients often turn around quickly, from the precipice of intubation to comfortably lying in bed [1, 2]. But what does the literature say about starting with a high-dose NTG IV bolus followed by an infusion?

Evidence

A 2021 prospective, pilot study of 25 SCAPE patients proposed a clear and systematic protocol (below) for treating these critically ill patients with a combination of high-dose NTG bolus (600 – 1000 mcg over 2 mins) followed by an infusion (100 mcg/min) and NIPPV [3].There were no cases of hypotension after the bolus and 24 of the 25 patients were able to avoid intubation. Additionally, an earlier PharmERToxGuy post summarizes some of the previous studies evaluating the use of a high-dose NTG IV bolus for acute pulmonary edema.

It is important to note that some institutions may not allow IV push NTG or may limit the use of NTG boluses. Providers may then opt to implement dosing strategies such as bolusing from an IV infusion pump or initiating the infusion at a high rate for a short period (e.g., NTG 300 mcg/min for 2-3 minutes) before reducing the rate to a more traditional infusion rate (e.g., 100 mcg/min).

Bottom Line

A few small ED studies support the use of an initial IV NTG bolus followed by an infusion compared to the infusion alone [1, 2]
There is a low risk of hypotension following a single IV NTG bolus
Consider using the following protocol to identify which doses may be best for specific patients based on initial systolic blood pressure

Click for full-sized version [3]

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med. 2020;38(1):132-137. doi: 10.1016/j.ajem.2019.06.046. PMID: 31327485.
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. PMID: 27825693.
Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-dose nitroglycerin bolus for sympathetic crashing acute pulmonary edema: a prospective observational pilot study. The Journal of Emergency Medicine. Published online June 2021:S0736467921004674. doi: 10.1016/j.jemermed.2021.05.011.

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2021-07-06T07:20:14-07:00Jul 10, 2021|EM Pharmacy Pearls, Pulmonary, Tox & Medications, Uncategorized|

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