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
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 2022 RCT was halted early due to harm in the morphine arm (43% adverse events vs. 18% with midazolam).
The Role of Diuretics
In SCAPE, diuretics are not first-line.
- The problem is redistribution, not volume excess. Diuretics will not help in the first 15–30 minutes and may worsen kidney function in a (relatively) hypovolemic patient.
- Delay Diuretics until the patient is stabilized and clear systemic volume overload (edema, weight gain) is confirmed.
Disposition
- Admission: Typically requires CCU/ICU for ongoing NIPPV and titration of vasoactive infusions.
- Weaning: As BP normalizes and work of breathing improves, infusions and NIPPV can be gradually tapered.
Take-Home Points
- Recognize SCAPE: Hyperacute dyspnea + severe HTN. Trust your POCUS (B-lines) over a “clear” CXR.
- NIPPV Immediately: Don’t wait. It saves lives and prevents tubes.
- High-Dose NTG: Use boluses to “catch up” to the sympathetic surge. Don’t fear the dose.
- Avoid Morphine: Use small doses of benzos if the patient is struggling with the mask.
- Lasix Later: Prioritize afterload reduction over diuresis in the hyperacute phase.
