EM Quick Hits 56 – Nitroglycerin in SCAPE, REBOA, Diverticulitis Imaging, CRAO, Penicillin Allergy, Physician Personality Emergency Medicine Cases

Topics in this EM Quick Hits podcast

Justin Morgenstern on the use of high dose nitroglycerin in SCAPE (1:08)

Andrew Neill and Leah Flanagan on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) indications and evidence (8:33)

Brit Long on indications for CT in suspected diverticulitis (26:41)

Tahara Bhate on Central Retinal Artery Occlusion (CRAO) and diagnostic error (34:47)

Matthew McArthur on penicillin allergy and penicillin challenges (42:58)

Susan Lu on how ED physician personality influences patient outcomes (52:16)





Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn, Brit Long, Matthew McArthur, edited by Anton Helman

Cite this podcast as: Helman, A. Morgenstern, J. Neill, A. Long, B. Bhate, T. McArthur, M. Lu, S.  EM Quick Hits 56 - Nitroglycerin in SCAPE, REBOA, Diverticulitis, Diagnostic Error, Penicillin Allergy, Physician Personality. Emergency Medicine Cases. April, 2024. https://emergencymedicinecases.com/em-quick-hits-april-2024/. Accessed June 19, 2024.

High dose nitroglycerin for SCAPE - the first RCT



High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial by Siddiqua et al. 2024, the first RCT on this topic, suggests higher doses of nitroglycerin that are typically used are safe and effective.



P: 52 SCAPE patients with hypoxia, hypertension, respiratory distress; all were also receiving BiPAP

I: High dose nitroglycerin group; IV bolus nitroglycerin 600-1000 mcg followed by an infusion starting at 100 mcg/min

C: Usual dose nitroglycerin; no bolus; nitroglycerin infusion starting at 20-40 mcg/min, max 250 mcg/minute

O: Resolution of symptoms in 6 hours was 65% for the high dose group vs 12% in the usual dose group (NNT = 2); endotracheal intubation was 4% in the high dose group vs 19% in the usual dose group; the high dose group also had lower admission rate, shorter length of stay, fewer MACE; there was no hypotension in either group; the usual dose group reported more headaches compared to high dose group



Is this all too good to be true?



* Limitations: This was a small, single center, unblinded trial; even though these outcomes are largely objective, this does not mean they are not biased (i.e. only recording expected results); the results may also not be generalizable as the patients in this study were very sick



However, other literature would agree.



* Wilson et al. 2016: 2 mg (2000mcg) push doses were associated with decreased ICU admissions and only 2% having hypotension

* Matthew et al. 2021: high dose IV bolus of nitroglycerin 600-1000 mcg had no complications

* Houseman et al. 2023: Nitroglycerin infusions starting at >100 mcg/hr had a only a 4% rate of hypotension



Practical bottom line => Consider a nitroglycerin bolus dose 2-3 sprays SL (800-1200 mcg) OR IV bolus 500-1000 mcg if an IV is in place. Then start a nitroglycerin infusion at 100 mcg/min and titrate. Remember than BiPAP is another critical intervention for all of these patients.

More on Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

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