Mohamed, a listener from Sudan, emailed asking about the treatment of acute pulmonary edema in patients with low blood pressure. This is in distinction to SCAPE patients (see podcast 1).
If the patients have pulmonary edema and low BP from a cardiac cause, then they are in cardiogenic shock.
First, consider the etiology:
- Rate-related
- Valve Disorder
- Ischemic (Right sided infarct, STEMI, NSTEMI)
- Cardiomyopathy
- Toxicologic
At the same time, you are treating the patient with:
- Inotropes (dobutamine, milrinone, calcium)
- Pressors to achieve a MAP > 65 (allows coronary perfusion)
- Oxygenation support, most likely with intubation
- Optimize O2 carrying capacity (Hb>10)
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Hey Scott,
Great lecture. I had a question on how to manage severe AS patients with heart failure in your ED. Conventional wisdom has taught that we should not vasodilate this patient because it can produce a precipitous drop in BP, since the heart can’t increase cardiac output against the fixed stenosis. But I am aware of one study in NEJM where they gave nitroprusside and it improved cardiac output. What do you recommend? Also what are your thoughts on nicardipine for SCAPE?
Raghu