- Email: [email protected]
Nitroglycerin use in esophageal disorders
lowed and encouraged to p e r s i s t with s p o n t a n e o u s coughing and breathing efforts. 1 They further advised that a victim with poor air exchange evidenced by a weak, ineffective cough, stridor, a n d possibly cyanosis should be treated as having complete airway obstruction. Normal coughs are always more effective t h a n artificial coughs or m a n e u v e r s a n d produce at least twice as much pressure in the airway (AS Gordon, written communication, 1976). One m u s t conclude that we should do very little for victims of incomplete airway obstruction if they can effectively cough, breathe, or speak. One should calm and reassure them a n d encourage deep b r e a t h i n g i n order to stimulate a more effective cough. Small foreign bodies in the airway are not necessarily life threatening. The point is t h a t the potential benefits of the Heimlich m a n e u v e r do not outweigh the risks when there is not complete or nearly complete a i r w a y obstruction c a u s i n g weak, ineffective coughing, breathing, and speaking.
Gary H. Rich, MD Emergency Department Mills Memorial Hospital San Mateo, California 1. The American National Red Cross and The American Heart Association: Report to the Conferees and Interim Recommendations. American National Red Cross Conference, October 1975.
studies, to relieve the p a i n of dysphagia t h a t is often a s u b s t e r n a l pain correlated with a n almost complete abolition of r e p e t i t i v e high pressure waves characteristic of esophageal spasm. 1 T h a t study further reported a demonstrated radiographic evidence of elimin a t i o n of curling of the esophagus with s i m u l t a n e o u s relief of chest pain in two cases of diffuse esophageal spasm. The difference in clinical and m a n o m e t r i c results with the use of nitroglycerin has also been addressed by Swamy, 2 who demonstrated abolition of high pressure wave contractions with the use of nitroglycerin i n p a t i e n t s w i t h o u t gastroesopbageal reflux. He docum e n t s a n d a t t r i b u t e s nonresponse to nitroglycerin in p a t i e n t s who have gastroesophageal reflux. Although no studies in l i t e r a t u r e seem to address the use of n i t r o g l y c e r i n specifically i n the face of esophageal food obstruction, a definite smooth muscle r e l a x a n t effect has been well documented, as has abolition of pressure waves. It would seem reasonable to advocate nitroglycerin in this setting and to undertake controlled studies, especially since the effects of the glucagon are said to work by i n h i b i t i n g aliment a r y t r a c t m o t i l i t y , to decrease lower e s o p h a g e a l sphincter pressure, and to act as a general esophageal smooth muscle relaxant. I have certainly s e e n this modality work, and I hope t h a t a clinical trial will be forthcoming to answer the question of the degree of effectiveness of nitroglycerin in this setting.
Mark S. Gibson, MD Chairman, Emergency Services Marshfield Clinic Marshfield, Wisconsin
Authors' Reply Although we are basically in a g r e e m e n t with the comments of Dr. Rich, the purpose of our report was not to debate the issue of whether the Heimlich man e u v e r should have been performed. A t r a i n e d indiv i d u a l decided t h a t the situation described w a r r a n t e d performance of the m a n e u v e r . The H e i m l i c h m a n e u v e r m a y be performed by some people when the indications are not clear, which m a y relate to widespread public education a n d the t r a i n i n g of nonmedical personnel to perform this technique. The purpose of the report is to alert the emergency physician to a potentially serious complication of the Heimlich m a n e u v e r .
Gary A. Agia, DO Senior Postdoctoral Fellow Daniel J. Hurst, MD Director, Division of Pulmonary and Environmental Medicine University of Missouri-Columbia School of Medicine Columbia, Missouri
Nitroglycerin Use in Esophageal Disorders To the Editor: I'd like to c o n g r a t u l a t e J o n a t h a n Glauser, MD, et al on their article entitled ~Intravenous Glucagon in the M a n a g e m e n t of Esophageal Food O b s t r u c t i o n " (8:228-231, 1979). I would like to draw a t t e n t i o n to the often overlooked fact t h a t another medical modality exists concerning the approach to esophageal disorders, and t h a t is the use of nitroglycerin. Nitroglycerin has been shown, in well-documented m a n o m e t r i c
66/280
1. Orlando RC, Bozymsky EM: Clinical and manometric effects of nitroglycerin in diffuse esophageal spasm. N Engl J Med 289:23-25, 1973. 2. Swamy N: Esophageal spasm: clinical and manometric response to nitroglycerin and long-acting nitrates. Gastroenterology 72:23-27, 1977.
Emergency Department Treatment of Esophageal Obstruction To the Editor: I n the J u n e 1979 issue, G l a u s e r et al (8:228-231, 1979) discussed the use of i n t r a v e n o u s glucagon i n the m a n a g e m e n t of esophageal food obstruction, as well as the uses o f p a p a i n and endoscopy as other t r e a t m e n t modalities. I would like to point out t h a t either long or short acting n i t r a t e s are also useful in the t r e a t m e n t of esophageal obstruction, and would like to share with you a case study which should emphasize this often overlooked alternative. I n April i979, we had the pleasure of t r e a t i n g a 53-year-old white w o m a n who h a d been diagnosed p r e v i o u s l y as h a v i n g r e c u r r e n t p a r t i a l esophageal obstruction secondary to stricture from chronic reflex esophagitis. As an outpatient, she had been treated with narcotic analgesics and b a r b i t u r a t e s when she felt symptoms of esophageal Obstruction coming on and for the most part did well on this medication. On this day, however, she was u n a b l e to achieve relief from her medication and came to our emergency department. On arrival she was noted to have profuse salivation, dysphagia, and upper chest pain. After appreciating t h a t her vital signs were stable and t h a t there was
Ann Emerg Med
9:5 (May) 1980
Gary H. Rich, MD Emergency Department Mills Memorial Hospital San Mateo, California 1. The American National Red Cross and The American Heart Association: Report to the Conferees and Interim Recommendations. American National Red Cross Conference, October 1975.
studies, to relieve the p a i n of dysphagia t h a t is often a s u b s t e r n a l pain correlated with a n almost complete abolition of r e p e t i t i v e high pressure waves characteristic of esophageal spasm. 1 T h a t study further reported a demonstrated radiographic evidence of elimin a t i o n of curling of the esophagus with s i m u l t a n e o u s relief of chest pain in two cases of diffuse esophageal spasm. The difference in clinical and m a n o m e t r i c results with the use of nitroglycerin has also been addressed by Swamy, 2 who demonstrated abolition of high pressure wave contractions with the use of nitroglycerin i n p a t i e n t s w i t h o u t gastroesopbageal reflux. He docum e n t s a n d a t t r i b u t e s nonresponse to nitroglycerin in p a t i e n t s who have gastroesophageal reflux. Although no studies in l i t e r a t u r e seem to address the use of n i t r o g l y c e r i n specifically i n the face of esophageal food obstruction, a definite smooth muscle r e l a x a n t effect has been well documented, as has abolition of pressure waves. It would seem reasonable to advocate nitroglycerin in this setting and to undertake controlled studies, especially since the effects of the glucagon are said to work by i n h i b i t i n g aliment a r y t r a c t m o t i l i t y , to decrease lower e s o p h a g e a l sphincter pressure, and to act as a general esophageal smooth muscle relaxant. I have certainly s e e n this modality work, and I hope t h a t a clinical trial will be forthcoming to answer the question of the degree of effectiveness of nitroglycerin in this setting.
Mark S. Gibson, MD Chairman, Emergency Services Marshfield Clinic Marshfield, Wisconsin
Authors' Reply Although we are basically in a g r e e m e n t with the comments of Dr. Rich, the purpose of our report was not to debate the issue of whether the Heimlich man e u v e r should have been performed. A t r a i n e d indiv i d u a l decided t h a t the situation described w a r r a n t e d performance of the m a n e u v e r . The H e i m l i c h m a n e u v e r m a y be performed by some people when the indications are not clear, which m a y relate to widespread public education a n d the t r a i n i n g of nonmedical personnel to perform this technique. The purpose of the report is to alert the emergency physician to a potentially serious complication of the Heimlich m a n e u v e r .
Gary A. Agia, DO Senior Postdoctoral Fellow Daniel J. Hurst, MD Director, Division of Pulmonary and Environmental Medicine University of Missouri-Columbia School of Medicine Columbia, Missouri
Nitroglycerin Use in Esophageal Disorders To the Editor: I'd like to c o n g r a t u l a t e J o n a t h a n Glauser, MD, et al on their article entitled ~Intravenous Glucagon in the M a n a g e m e n t of Esophageal Food O b s t r u c t i o n " (8:228-231, 1979). I would like to draw a t t e n t i o n to the often overlooked fact t h a t another medical modality exists concerning the approach to esophageal disorders, and t h a t is the use of nitroglycerin. Nitroglycerin has been shown, in well-documented m a n o m e t r i c
66/280
1. Orlando RC, Bozymsky EM: Clinical and manometric effects of nitroglycerin in diffuse esophageal spasm. N Engl J Med 289:23-25, 1973. 2. Swamy N: Esophageal spasm: clinical and manometric response to nitroglycerin and long-acting nitrates. Gastroenterology 72:23-27, 1977.
Emergency Department Treatment of Esophageal Obstruction To the Editor: I n the J u n e 1979 issue, G l a u s e r et al (8:228-231, 1979) discussed the use of i n t r a v e n o u s glucagon i n the m a n a g e m e n t of esophageal food obstruction, as well as the uses o f p a p a i n and endoscopy as other t r e a t m e n t modalities. I would like to point out t h a t either long or short acting n i t r a t e s are also useful in the t r e a t m e n t of esophageal obstruction, and would like to share with you a case study which should emphasize this often overlooked alternative. I n April i979, we had the pleasure of t r e a t i n g a 53-year-old white w o m a n who h a d been diagnosed p r e v i o u s l y as h a v i n g r e c u r r e n t p a r t i a l esophageal obstruction secondary to stricture from chronic reflex esophagitis. As an outpatient, she had been treated with narcotic analgesics and b a r b i t u r a t e s when she felt symptoms of esophageal Obstruction coming on and for the most part did well on this medication. On this day, however, she was u n a b l e to achieve relief from her medication and came to our emergency department. On arrival she was noted to have profuse salivation, dysphagia, and upper chest pain. After appreciating t h a t her vital signs were stable and t h a t there was
Ann Emerg Med
9:5 (May) 1980