Flash pulmonary edema
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]
- Cardiogenic pulmonary edema
- Noncardiogenic pulmonary edema
- Negative pressure pulmonary edema
- Upper airway obstruction
- Reexpansion pulmonary edema
- Strangulation
- Neurogenic causes
- Iatrogenic fluid overload
- Multiple blood transfusions
- IV fluid
- Inhalation injury
- Pulmonary contusion
- Aspiration pneumonia and pneumonitis
- Other
- High altitude pulmonary edema
- Hypertensive emergency
- ARDS
- Flash pulmonary edema
- Immersion pulmonary edema
- Hantavirus pulmonary syndrome
- Missed dialysis in kidney failure
- Naloxone reversal
- Negative pressure pulmonary edema
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
- ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
- ↑ Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.
- ↑ Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
- ↑ Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/
- Weingart, S. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema. April 2009. http://emcrit.org/podcasts/scape/.