Microsoft word - 1-09-12 best practice pah and revatio.docx
Eric Rudnick, MD, FACEP EMS Medical Director
Best Practices for Pulmonary Hypertension and the Interaction
Pulmonary hypertension is a disease process where there is increased resistance to blood flow in the pulmonary arterial circulation. This is occurs as the small pulmonary arteries and capillaries become blocked, narrowed, and/or destroyed. As you recall, the right side of the heart pumps blood (returned from the body) through the lungs to get it oxygenated. This increased resistance to blood flow causes the right side of the patient’s heart to work harder and hypertrophy. Long term this results in right sided heart failure (inability to pump well) with multiple clinical issues.
There are idiopathic (unknown cause) and secondary pulmonary hypertension. Secondary pulmonary hypertension is caused by other diseases as a complication. There are multiple causes of secondary pulmonary hypertension such as pulmonary emboli, sleep apnea, emphysema, left-sided heart failure, and even cocaine abuse.
Some of the more life threatening complications of pulmonary hypertension is blood clots in the lungs (pulmonary emboli), various arrhythmias, and bleeding from lungs/coughing up blood (hemoptysis).
These patients will experience dyspnea (shortness of breath), chest pain, weakness, exercise intolerance, and syncope.
The physical examination findings can be explained by the right sided heart failure. Blood cannot be easily pumped into the lungs and can cause congestion or blood “backing up” in other parts of the body. Patients may have jugular venous distention (enlarged neck veins), hepatomegaly (enlarged liver), pitting edema of the extremities (if the patients are bed ridden then presacral edema), pleural effusions, tachycardia, and signs of hypoxia.
Although there is no cure, there are multiple treatment options available to patients. Treatment with the medication Revatio (Sildenafil) is of the most concern currently to EMS. Sildenafil is the same medication previously used for erectile dysfunction in men. The other trade name for Sildenafil is Viagra. Revatio will cause the same drug – drug interaction as Viagra with nitrates. When patients are given nitrates (for chest pain or congestive heart failure) while taking Revatio (Sildenafil) there can be a sudden, severe, and life threatening drop in blood pressure. The decrease in blood pressure may not respond to either fluid boluses or vasopressors. The most common dosing schedule for Revatio is three times per day. In addition, patients taking Revatio (Sildenafil) may experience a sudden vision loss that needs to be emergently evaluated (decreased blood flow to optic nerve). The bottom line for EMS providers is always ask patients prior to giving nitrates about whether they are taking Revatio (Sildenafil), Viagra (Sildenafil), Cialis (Tadalafil), or Levitra (Vardenafil). It is contraindicated to give patients nitrates with any of the above listed medications.
F:\F-Desk\Protocols\2012\1-09-12 BEST PRACTICE PAH and Revatio.docx
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Example SBA Questions for Primary FRCA 1. A patient in hospital develops a tachycardia with a regular rate of 145 bpm and a blood pressure of 95/42 mm Hg. He denies chest pain, although he is acutely aware of his rapid heart rate. An ECG shows the duration of the QRS complex to be 0.10 s. The single most appropriate immediate treatment is: A. Adenosine 6mg B. Amiodarone 300mg