Episode 218: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) скачать в хорошем качестве

Episode 218: Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

(https://coreem.net/podcast/episode-21...) We discuss the diagnosis and management of SCAPE in the ED. Hosts: Naz Sarpoulaki, MD, MPH Brian Gilberti, MD https://media.blubrry.com/coreem/cont... Download (https://media.blubrry.com/coreem/cont...) Leave a Comment (https://coreem.net/podcast/episode-21...) Tags: Acute Pulmonary Edema (https://coreem.net/tag/acute-pulmonar...) , Critical Care (https://coreem.net/tag/critical-care/) Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.  Course Highlights: • Credit: 12.5 AMA PRA Category 1 Credits™ • Curriculum: Comprehensive coverage of Core Emergency Medicine,  with 12 modules spanning from Critical Care to Pediatrics. • Cost: • Free for NYU Learners • $250 for Non-NYU Learners Click Here to Register and Begin Module 1 (https://www.highmarksce.com/nyumc/Pla...) The Clinical Case • Presentation: 60-year-old male with a history of HTN and asthma. • EMS Findings: Severe respiratory distress, SpO₂ in the 60s on NRB, HR 120, BP 230/180. • Exam: Diaphoretic, diffuse crackles, warm extremities, pitting edema, and significant fatigue/work of breathing. • Pre-hospital meds: NRB, Duonebs, Dexamethasone, and IM Epinephrine (under the assumption of severe asthma/anaphylaxis). Differential Diagnosis for the Hypoxic/Tachypneic Patient • Pulmonary: Asthma/COPD, Pneumonia, ARDS, PE, Pneumothorax, Pulmonary Edema, ILD, Anaphylaxis. • Cardiac: CHF, ACS, Tamponade. • Systemic: Anemia, Acidosis. • Neuro: Neuromuscular weakness. What is SCAPE? Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is characterized by a sudden, massive sympathetic surge leading to intense vasoconstriction and a precipitous rise in afterload. • Pathophysiology: Unlike HFrEF, these patients are often euvolemic or even hypovolemic. The primary issue is fluid maldistribution (fluid shifting from the vasculature into the lungs) due to extreme afterload. Bedside Diagnosis: POCUS vs. CXR POCUS is the gold standard for rapid bedside diagnosis. • Lung Ultrasound: Look for diffuse B-lines (≥3 in ≥2 bilateral zones). • Cardiac: Assess LV function and check for pericardial effusion. • Why not CXR? A meta-analysis shows LUS has a sensitivity of ~88% and specificity of ~90%, whereas CXR sensitivity is only ~73%. Importantly, up to 20% of patients with decompensated HF will have a normal CXR. Management Strategy 1. NIPPV (CPAP or BiPAP) Start NIPPV immediately to reduce preload/afterload and recruit alveoli. • Settings: CPAP 5–8 cm H₂O or BiPAP 10/5 cm H₂O. Escalate EPAP quickly but keep pressures to avoid gastric insufflation. • Evidence: NIPPV reduces mortality (NNT 17) and intubation rates (NNT 13). 2. High-Dose Nitroglycerin The goal is to drop SBP to ＜ 140–160 mmHg within minutes. • No IV Access: 3–5 SL tabs (0.4 mg each) simultaneously. • IV Bolus: 500–1000 mcg over 2 minutes. • IV Infusion: Start at 100–200 mcg/min; titrate up rapidly (doses ＞ 800 mcg/min may be required). • Safety: ACEP policy supports high-dose NTG as both safe and effective for hypertensive HF. Use a dedicated line/short tubing to prevent adsorption issues. 3. Refractory Hypertension If SBP remains ＞ 160 mmHg despite NIPPV and aggressive NTG, add a second vasodilator: • Clevidipine: Ultra-short-acting calcium channel blocker (titratable and rapid). • Nicardipine: Effective alternative for rapid BP control. • Enalaprilat: Consider if the above are unavailable. Troubleshooting & Pitfalls The “Mask Intolerant” Patient Hypoxia is the primary driver of agitation. NIPPV is the best sedative. * Pharmacology: If needed, use small doses of benzodiazepines (Midazolam 0.5–1 mg IV). • AVOID Morphine: Data suggests higher rates of adverse events, invasive ventilation, and mortality. A ...