Flash pulmonary edema: Difference between revisions

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==Background==
==Background==
*Presentation:
*Term coined by Scott Weingart on EMCrit.
**Rales, crackles
*No specific name for this:
**SBP > 180 mmHg
**Hypertensive emergency with CHF
**Tachycardic
**Acute cardiogenic pulmonary edema
**SCAPE
*Differentiate this from acute CHF exacerbation or hypotensive cardiogenic shock, which does not display sympathetic overdrive
*Differentiate this from acute CHF exacerbation or hypotensive cardiogenic shock, which does not display sympathetic overdrive
*Must act quick, as '''pt can decompensate within 5-10 minutes'''
*Must act quick, as '''pt can decompensate within 5-10 minutes'''
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**Sympathetic surge occurs as a result of decreased systemic perfusion
**Sympathetic surge occurs as a result of decreased systemic perfusion
**Afterload further increases and pt rapidly decompensates
**Afterload further increases and pt rapidly decompensates
==Clinical Presentation==
*Rales, crackles
*SBP > 180 mmHg
*Tachycardic
==Differential Diagnosis==
{{Pulmonary edema types}}
==Diagnosis==
*Clinical presentation and physical exam alone should prompt intervention


==Management==
==Management==
*Key is to vasodilate arterial side, while maintaining oxygenation
*Key is to vasodilate arterial side, while maintaining oxygenation
#*BiPAP with PEEP of 8 mmHg
*BiPAP with PEEP of 8 mmHg
#*Titrate PEEP quickly to 12
*Titrate PEEP quickly to 12
#*High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation<ref>Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.</ref>)
*High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation<ref>Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.</ref>)
##*Goal BP at the pt's norm
**Goal BP at the pt's norm
##*Load 800 mcg over 2 min (may start at 100 mcg/min, then titrate rapidly to 400 mcg/min for 2 min)
**Load 800 mcg over 2 min (may start at 100 mcg/min, then titrate rapidly to 400 mcg/min for 2 min)
##*Then start maintenance at 100 mcg/min, titrate up as needed
**Then start maintenance at 100 mcg/min, titrate up as needed
#*Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
*Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
#*However, after critical parts under control, assess for volume overload
*However, after critical parts under control, assess for volume overload
#*Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction<ref>Hamilton RJ, Carter WA, Gallagher JE.  Rapid Improvement of acute pulmonary edema with sublingual captopril.  Acad Emerg Med 1996; 3: 205-12.</ref>
*Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction<ref>Hamilton RJ, Carter WA, Gallagher JE.  Rapid Improvement of acute pulmonary edema with sublingual captopril.  Acad Emerg Med 1996; 3: 205-12.</ref>
#*Wean CPAP after sustained BP at pt's norm<ref>Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/</ref>
*Wean CPAP after sustained BP at pt's norm<ref>Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/</ref>
##*Decrease FiO2 to 40%
**Decrease FiO2 to 40%
##*Wean PEEP down 2 cmH2O q10 min
**Wean PEEP down 2 cmH2O q10 min
##*At 5 cmH2O, trial of NC
**At 5 cmH2O, trial of NC
 
==Disposition==
 
 
==See Also==
 


==References==
==References==
<references/>
*Weingart, S. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema. April 2009. http://emcrit.org/podcasts/scape/.
*Weingart, S. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema. April 2009. http://emcrit.org/podcasts/scape/.
<references/>
 
 
[[Category:Cards]]
[[Category:Critical_Care]]

Revision as of 01:42, 18 August 2015

Background

  • Term coined by Scott Weingart on EMCrit.
  • No specific name for this:
    • Hypertensive emergency with CHF
    • Acute cardiogenic pulmonary edema
    • SCAPE
  • Differentiate this from acute CHF exacerbation or hypotensive cardiogenic shock, which does not display sympathetic overdrive
  • Must act quick, as pt can decompensate within 5-10 minutes
  • Pts are generally more fluid depleted despite "wet" lungs, so don't give furosemide
  • Usually hx of poorly controlled HTN
    • Acute afterload increase causes pulmonary edema and poor peripheral perfusion
    • Sympathetic surge occurs as a result of decreased systemic perfusion
    • Afterload further increases and pt rapidly decompensates

Clinical Presentation

  • Rales, crackles
  • SBP > 180 mmHg
  • Tachycardic

Differential Diagnosis

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]

Diagnosis

  • Clinical presentation and physical exam alone should prompt intervention

Management

  • Key is to vasodilate arterial side, while maintaining oxygenation
  • BiPAP with PEEP of 8 mmHg
  • Titrate PEEP quickly to 12
  • High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation[2])
    • Goal BP at the pt's norm
    • Load 800 mcg over 2 min (may start at 100 mcg/min, then titrate rapidly to 400 mcg/min for 2 min)
    • Then start maintenance at 100 mcg/min, titrate up as needed
  • Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
  • However, after critical parts under control, assess for volume overload
  • Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction[3]
  • Wean CPAP after sustained BP at pt's norm[4]
    • Decrease FiO2 to 40%
    • Wean PEEP down 2 cmH2O q10 min
    • At 5 cmH2O, trial of NC

Disposition

See Also

References

  1. ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
  2. ↑ Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.
  3. ↑ Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
  4. ↑ Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/
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