EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

Get in on those first two words. Sympathetic induced, meaning these patients endogenous epinephrine and norepinephrine is what's screwing up their heart function right now. And they're crashing. If you don't do anything in the next two minutes Your patient's going to be intubated. That's the patient we're talking about. We're not talking about, oh, mild shortness of breath. We're not talking about a patient who you could just

Dither around waiting for the x-ray. This is the patient where you have maybe five minutes to intervene or they're gonna buy some plastic. Now how do you know you have escape? Well first of all they're gonna have brawls up to their nipple line. And their blood pressure is going to be greater than one hundred eighty systolic. When you see those patients, diagnosis is really not the problem.

You don't need BNP to know you're in big trouble here. These patients have obvious lung sound findings, and their blood pressure tells you the reason this is going on is due to afterload. So the first thing you do is you get your LASIKs and you throw it in the trash. It's not gonna help you. It's very potentially going to hurt you. No LASIKs in these patients. Now I'm sure your EMS providers have already given it.

Well that's just fine. But you don't have to exacerbate the problem. Most of these patients will wind up volume depleted, not volume overloaded, when you look at their intravascular space. You're probably gonna wind up giving some fluid to these patients, not trying to diurese them. The problem is not fluid overload. The problem is

that they have too much afterload. Why does it happen? Well for whatever reason they get a little fluid in their lungs and then their body starts feeling like it's drowning. Stress response causes release of epinephrine, norepinephrine. Angiotensin too, aldosterone, all these cause vasoconstriction. The failing heart cannot pump against a vasoconstricted afterload. It starts failing even more.

More fluid backs up to the lungs, more drowning, more fight-and-flight response, more afterload. And it's a vicious cycle, and the only way to break it is to vasodilate their arterial side.

So these patients roll through the door, they look horrible, they might have altered mental status. The first thing you should do is put them on non-invasive ventilation. You grab a mask, you pop it on, and you put them on the ventilator. Now, I don't even care about the huge debate between BIPAP and CPAP. It really is mostly A misunderstanding of these technologies. There's no separation. It's all non-invasive. And just like on the ventilator, you have different settings for different patients.

Same thing for non-invasive. Some patients are gonna get just peep. Some patients you might wanna put on some pressure sport. It doesn't matter. What matters is that you optimize the PEE. That's what's going to do the work in these patients. And a lot of these studies that showed problems with BIPAP compared good amounts of PEEP to crappy PEEP plus pressure support. And those patients are going to do worse.

So you put them on the mask and you just dial your PEEP up to six or eight to start with, and very quickly you're gonna titrate up to ten, twelve, or fourteen on your PEEP or EPAP. Then if you feel it's important to add on some inspiratory pressure, knock yourself out. I don't tend to do it, but if you wanted to, it shouldn't cause much problem. I don't think you really gain very much in these patients as opposed to the COPD or.

So now they're on the non-invasive, this is gonna buy you some time. At this point you get your IV line and then you start up a nitro drip. Now most of the time I see the residents using nitroglycerin wrong in these patients. You can't start them up at 10 micrograms and wow, titrate up to 30 and think you're doing something. You're not doing jack. The real effects of nitroglycerin for these patients don't start until about a hundred micrograms.

and you gotta knock them up much, much higher sometimes. So how do I do it? Right now with nitroglycerin most folks are dripping it and expecting a rapid effect. It's not gonna happen. So what you wanna do is you want to give them a loading dose. So what you run is 400 micrograms a minute for two minutes.

And then I knock them back to 100 micrograms and titrate up from there. And you'll see dramatic effects. You'll see two minutes after starting that nitroglycerin drip, the patient is incredibly improved. Now, even this is considered a wimpy dose. You could even give two milligrams. That's two thousand micrograms at a time. There's literature for that. I don't do it that way. I've been very happy with the four hundred microgram a minute.

loading dose for a couple minutes and then go from there. If you go to the show notes, all these doses will be there for you. But if you've got this patient on CPAP and you've given them that loading dose of nitroglycerin, I challenge you to find the patient that's not going to improve. If you're intubating these patients, you've failed. I can't remember the last time I've intubated a patient for pure acute pulmonary edema when their blood pressure's been high.

In fact, I had a patient a couple weeks ago, came in looking like death. No mental status, the guy is flailing about. We put him on CPAP simply to preoxyne him for our intubation. We started him up on the nitro drip and three minutes later this guy looked like a rose. We wound up not intobathing. So that's the way it works. Non-invasive the second they hit the door. Loading dose of nitroglycerin and then high doses somewhere between one hundred and four hundred micrograms a minute.

And these patients will improve. Now the questions come up, our nurses will not allow us to use these doses? I can't believe this stuff when I hear it. I love emergency nurses. I think without them our departments obviously would not function. But they should never be a barrier. to the care you want to provide. If the nurses won't do it You should do it. Stop thinking you're a surgeon and start thinking like an anesthesiologist.

You should be able to do every single task in your emergency department yourself. And if someone's willing to do it for you, consider that bonus. So you should know how to work the drip pumps, you should know how to administer medication, you shouldn't be reliant on another practitioner for the care you want to provide. So learn to use the drip pumps. It's not fair to ask a nurse to titrate nitroglycerin up to 400 micrograms. You have to do that.

You don't have to stand at the bedside for an hour doing this. You should have the entire treatment done within ten minutes. That's how long it takes to reverse these patients. And you should be at the bedside for every minute. Been asked a question about ACE inhibitors. I used to think they were the greatest thing in the world, I'd slip captopril underneath the patient's tongue. At this point I don't do it anymore. I just titrate up the nitroglycerin. Then when the patient starts improving

and I want to start weaning them off the nitroglycerin, that's when I give my ACE inhibitor, IV anallopril if you have it. Otherwise just have them swallow a captopril. And that will take the place of the nitroglycerin. So I no longer give it up front. because I have plenty of nitro dosing I could use instead. And I use it as my surrogate when I want to get them weaned off that nitroglycerin drip. Last question is opioids? Morphenes become anathema without much data to support it either way.

I'll tell you this, once you have the patient on non invasive, some of them will require To give them comfort on that mask because it does not feel good. Now as to what you use, I don't think there's a good evidence basis for any of these agents. But I'll tell ya, a little fentanyl goes a long way to making these patients comfortable. It will not decrease your preload.

These patients should not have any respiratory distress from the doses I'm using, which is somewhere in the neighborhood of 25 to 50 micrograms, and it becomes much more palatable for them to have that mask strapped onto their face. Great agent for this, which we don't have available yet, would be dexmedatomidine. It would be perfect for this circumstance.

So that's the first mCrit podcast. Please, please, please go to the comments section and tell me what you think. Tell me what you'd like done differently. Tell me if this format works for you. If you go to the show notes, we'll have references for all the things we spoke about. And hopefully you'll subscribe so you can keep getting these podcasts. Well, this is Scott Weingart saying goodbye and thank you.