Flash pulmonary edema: Difference between revisions
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==Background== | ==Background== | ||
* | *Presentation: | ||
**Rales, crackles | |||
** | **SBP > 180 mmHg | ||
** | **Tachycardic | ||
** | |||
*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''' | ||
| Line 12: | Line 11: | ||
**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 | ||
==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 | |||
##*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) | #*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% | |||
##*Wean PEEP down 2 cmH2O q10 min | |||
##*At 5 cmH2O, trial of NC | |||
==References== | ==References== | ||
*Weingart, S. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema. April 2009. http://emcrit.org/podcasts/scape/. | |||
<references/> | <references/> | ||
Revision as of 19:54, 17 August 2015
Background
- Presentation:
- Rales, crackles
- SBP > 180 mmHg
- Tachycardic
- 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
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[1])
- 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[2]
- Wean CPAP after sustained BP at pt's norm[3]
- Decrease FiO2 to 40%
- Wean PEEP down 2 cmH2O q10 min
- At 5 cmH2O, trial of NC
References
- Weingart, S. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema. April 2009. http://emcrit.org/podcasts/scape/.
- ↑ 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/