Viagra and nitro hypotension

[twist27896]

So we responded to a patient that was almost unconsciousness and it was determined that he had taken 2 doses of prescribed nitro after he had been experiencing chest pain after taking a Viagra earlier during the night. We attempted to VERY AGGRESSIVELY maintain a BP with fluid bolus and epi, placed in tredelenberg, and rushed him to the hospital. I don't know what happened to the patient, but what is there to do in a situation like this? We are taught to not administer nitro to patients on erectile dysfunction meds but not how to treat if the patient has taken the mix themselves. Is there anything that can be done at the prehospital level?

[DwayneEMTP]

Excellent question!

If you started two big IVs running 'open' and had someone squeezing the bag, gave epi, then I'm not sure. Maybe Dopamine would have been a better alternative to the epi, but man, I don't know. But, if I go with what's in my brain at the moment without doing the wuss Google move...I don't know what I would have done differently...

Wait till the smart people show up, they'll have some ideas for the next call like this.

Edit: Having said that, the definition of 'very aggressive' varies quite a bit in the paramedic world in my experience. Most medics I know shit bricks over delivering 1L of NS. I've just never really seen fluid drown people in an instant like so many claim that it does.

I often run 1L open (without obvious contraindications) and it's not uncommon in a patient like that to run three or more. How much did you all push before arrival at the ER?

[paramatt_]

Unless you carry vasopressors there's probably not a whole lot you're going to be able to do. AV in Australia carries metarminol, an alpha 1specific agonist, specifically for this...can't tell you how effective it is, but as Dwayne said, epi would be a second best due to the unwanted beta effects. If that's all you have, then it sounds like you did you best.

Just out of curiosity, what doses of epi were you using and what was the inital BP and any improvement at all?

Edited July 17, 2012 by jstalmm

[JPINFV]

One thing to note is that Viagra (technically under the generic "Revatio," but I have seen it in charts as Viagra) is also used to treat pulmonary hypertension.

[DFIB]

I was reading but have never experienced that a patient in this condition could require 2-3 lts of fluids STAT ans still not maintain BP.

[paramedicmike]

What I'm reading is suggesting aggressive fluid resuscitation along with alpha-adronergic agents like phenylephrine or norepinephrine for sildenafil/nitrate induced hypotension. Ongoing ischemic chest pain issues should be treated with beta blockers.

Although, how many ambulances stateside carry neo or norepi? Not many.

How much epi did you attempt? Like Dwayne, I'm curious how you define aggressive as there are wide variations of the definition in EMS.

JP is correct, too, in saying sildenafil is also used for pulmonary hypertension. In fact, one of its original purposes was to treat neonatal pulmonary hypertension. The ED treatment component was a bit of a secondary discovery.

Excellent question.

[chbare]

http://circ.ahajournals.org/content/99/1/168.full

[jonas salk]

what was his pressure? And what exactly is 'almost unconscious'?

[DFIB]

I consulted with a friend who has ample experience in the field and she told me that fluid resusitation and raising their legs usually resolves this condition but if not vasopressors will usually pull them on up.

[Kiwiology]

I hear aramine is popular