The panicking, frothing pulmonary edema patient with hypertension and tachycardia on the verge of terminal collapse represents a challenge in the ED or ICU. Most of the time we end up intubating the patient, which comes with a whole host of dangers.
We risk end up intubating a patient with marginal respiratory reserves who is severely hemodynamically unstable. This kind of patient is likely to crash in one way or another once we push the drugs. We want to avoid intubating these patients at this stage. We can, with proper emergency treatment.
In a podcast Scott Weingardt over at EMcrit coined the term S.C.A.P.E (Sympathetic Crashing Pulmonary Edema) to emphasise the sympathetic surge as a central part of the pathophysiology. He presented a simple protocol for dealing with these patients.
Here’s whats you do:
1. Put them on NIV. Start with a PEEP go 6-8 then titrate your way up, often 12-14.
2. Vasodilate them to counter the sympathetic surge that is only making things worse. Start a high dose nitro drip. Start with a loading dose of 400 micrograms a minute for two minutes then reduce to 100 micrograms a minute and titrate up from there.
3. There is no place for furosemide. After you ride out the storm you will find that these patients are volume depleted not overloaded.
Within 5 to 10 minutes you should see vast improvement. Dr Weingardts take on the subject is an absolute must-listen and can be found here.
So can we avoid intubation?
Yes, it seems we can. A Kuwaiti team is about to publish a study on a protocol similar to the above, with Weingardt as co-author. To my knowledge it hasn’t been published yet. I found the abstract on emcrit.com. Of about 40 hypertonic PE patients enrolled they managed to avoid intubation in all of them.