Each drug has advantages and disadvantages. Frusemide has been around for most of our entire careers and we have all whizzed into the ward/A&E
at 5am knowing that we had a sure-fire treatment. However, it's effect is not the well-known diuresis, but relaxation of the pulmonary artery. In
fact, bumetanide is better at this but has not achieved the same popularity. The diuresis is actually a nuisance; firstly the patient needs to relieve it
rapidly and secondly they pee out all their potassium, which may precipitate arrhythmias in the already potassium depleted such as those on a
long-term diuretic or those also on salbutamol. There is also the issue of secondary hyperaldonsteronism in chronic loop diuretic users (although
this does not explain the occasional treatment failure) and the problems of hearing loss with rapid injection.
Buccal nitrates have the disadvantage of not being so well known. Their effectiveness is spectacular and the onset is more rapid than with
frusemide, as they act directly at the nitric oxide level. There is no massive diuresis either. Most people are very wary of giving nitrates to the
decompensating left ventricle sort of patient with systolics below 90. In fact these do well (unless the bp is as a result of cardiogenic shock, which
can be difficult to spot; is that LBBB new or not?) with the blood pressure coming up quite quickly which always feels counter-intuitive. They are a
doddle to administer (providing the dentures are taken out first) compared to i.v. nitrates and, as Andy says, can always be spat out. I would love to
see our local crews get it as it is safe and extremely effective. With some runs to hospital exceeding 30 miles we still get patients dying inbound
simply because they have become too hypoxic.
As it seems to be topic of the month, don't forget CPAP for these patients.
Best wishes,
Rowley Cottingham
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