Here it is, the 1st EMCrit podcast.
It’s on the topic of Sympathetic Crashing Acute Pulmonary Edema (SCAPE).
To boil it down to 10 seconds:
- Start patient on Non-invasive ventilation with a PEEP of 6-8; quickly titrate to a PEEP of 10-12.
- Start the patient on a nitroglycerin drip. Administer a loading dose of 4oo mcg/min for 2 minutes (120 ml/hour on the pump for 2 minutes with the standard nitro concentration of 200 mcg/ml.) Then drop the dose to 100 mcg/min and titrate it up from there as needed.
By 10 minutes, your patient should be out of the water.
See EMCrit.org for the references.
Please leave comments and tell me what you think.
-Scott
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{ 23 comments… read them below or add one }
can you continue to keep the files under 10mb? that way you don’t need wifi to download directly to an iphone.
thanks-
seth
no problem for the audio, when we post videos, won’t be possible.
Had an iatrogenic case of pulmonary edema the other day, pt with ESRD on HD; had a CTA, on the way back developed severe dyspnea, had very wet lungs and high BPs. Apparently happens commonly due to the high osmolarity of the contrast.
Slapped the bipap on while we were getting the NTG drip set up, clinically improved and bought us time to set up the drip. Within about 2-5 minutes he felt much better. Worked great!
Dan, that’s excellent!
Have you seen any cases where the BP has fallen precipitously with the use of the 400 mcg/min x 2 minutes of nitroglyerine? What is the half-life of iv nitroglycerine?
Thanks,
Jim Squires
Canada
1/2 life of nitro is between 1-4 minutes so even if they drop it won’t be for long
I have never seen a precipitous drop of of their pressure at the beginning of treatment when you are giving the bolus.
They often drop as they are resolving, which is a function of underlying dehydration.
If they did drop at the beginning, it should respond to a small fluid bolus.
Correct me if I’m wrong, but 400 mcg is the dose of a slntg. We regularly give three of those in a row, with the same BP precautions.
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You’re correct but what is the bioavailability of sl nitro compared to IV??
Bioavailability is pretty near IV b/v sublingual route avoids liver metabolism on first pass. 400 mcg of SL nitro is designed to be absorbed over 5 minutes so the dose is acutally ~80 mcg/min. THis is however predicated on having spit in your mouth. Most of these bad scape patients have bone dry mouths and don’t absorb the pills well.
Scott – the early management of SCAPE patients is BIPAP and NITRO – at what point do you start diuresing these patients?
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When they are comfortable and the blood pressure is where you want, observe intravascular status. Then consider fixing it, usually the answer is they need fluid, not diuresis
What about natrecor? I know it got bad press from its mortality statistics and it was overmarketed but I felt clinically that I have had good success in the past in particular in a crashing patient
Brian,
Thanks for writing.
The data that have emerged in the past few years seems to indicate an increased risk of mortality when compared to standard care. In the reported trials, this seemed to be just a trend, but then two additional deaths seem not to have been reported in the natrecor group, which if you recalculate the p-values is actually a stat. sig. increased mortality.
Even the original trial published in JAMA 2002 did not seem to have any clinically important effects when compared to minimal dose nitrites.
I have found aggressive doses of nitrites to be the quickest and most effective way to go, but there are many ways to skin this cat.
–Scott
I wonder if I only use bipap and high dose nitro, will the cxr change remarkably? I know the patients I take care get better, usually gets hits with iv nitro, not as high as you have recommended , instead at 50-100mcg/min and bipap, and lasix, double the patient’s daily use in iv form. I did once forget to give iv lasix, and more than 1.5 liter came out of the patient and he wanted to know if he could go home after 3 hrs of treatment. I know we usually diurese too much and leave them dehydrated/volume depleted.
Jose,
Thanks for writing. In SCAPE patients, ALL of the chest x-ray findings are from too much afterload. X-ray will improve entirely if you vasodilate and give NIV. And, the patients will diurese as soon as you perfuse the kidneys.
scott
Found it very interesting that you recommended Dexdomitor for sedation as ideal in these patients – if you’re fighting afterload, won’t the peripheral vasoconstriction caused by dexdomitor be detrimental? I’m an ER veterinarian and a recent follower of the program and podcasts. Thanks!
Medora,
Great to have a vet. listener! I think you are talking about the possible initial elevation of pulse and blood pressure at the very start of a dexmedetomidine infusion, yes? If so, I have not witnessed this in clinical practice in these patients, probably b/c they are already experiencing great sympathetic stimulation and I have potent vasodilators infusing. What has been you experience in 4-legged patients?
scott
Scott,
We see relatively profound bradycardia. Maybe due to the nature of how we use this drug (sometimes for chemical restraint, at doses of 10-15 mcg/kg IV) and also for sedation of instrumented patients (at CRI of 1-2 mcg/kg/hr) we see heart rates in the 40′s. With the higher doses the peripheral vasoconstriction is very significant (mucous membranes turn white initially) and I imagine the reflex bradycardia can only support the increased afterload and initial hypertension. I do like this drug a lot and we can perform minimal surgical procedures (i.e. laceration repairs) with this alone. My preferred recipe is Dexdomitor + a pure mu agonist + a local block. I have not measured initial blood pressure after administration – I suspect a direct arterial line would be the most accurate way to monitor hemodynamic effects. Interesting exchange of info, thanks!
Medora
I can’t tell you how many cases of SCAPE we see at my program in the Bronx. Gonna pitch the afterload reduction dose of NTG to my attendings, see how they react.
Enjoyed the lecture this past week at Mt. Sinai. EMCrit all the way.
Thanks so much for your kind comments. I’m going to have to get permission from one of patients to video the change from arrival to 15 minutes later, because in this case seeing is believing.
Scott
We typically slap on the bipap, get the drip going (albiet at lower dosages) and see the improvement, although I wonder how many intubations/ICU admissions we’d mitigate. BTW, where’s the data? Any upcoming studies?
any place for ACE inhibitors in acute management?
Salman,
Thanks for commenting. I used to give them up front, but now I get them stabilized and see where their blood pressure winds up. Sometimes, surprisingly they are low after the acute catecholamines fade. If they are still hypertensive, I then give the ACEI.
scott