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Severe Acute Pulmonary Edema

Morning report 5/10/13

Andrew Sweeny

on 13 August 2013

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Transcript of Severe Acute Pulmonary Edema

Severe Acute Pulmonary Edema Clinical scenario: A 62yo F with known CHF is brought in by ambulance for shortness of breath starting . On exam, she is tachycardic, tachypnic, BP 208/112, and O2 saturation of 89% on non-rebreather. What's going on? Sympathetic Crashing Acute Pulmonary Edema CPAP/BiPAP First thing that should be done
Pressure (IPAP) support doesn't matter too much
PEEP (EPAP) of 6-8 initially and titrate up to 10-12 to push fluid out of lungs. Patient appears in moderate respiratory distress, stating that she can't breath, and is repeatedly pulling off her non-rebreather. Lung exam reveals coarse breath sounds throughout and up to lung apices. How do we know? Hypertensive
(greater than 180 systolic) Tachycardic Wet lungs In Distress What is the optimal way to treat? CPAP Nitro bolus Fentanyl SEVERE acute pulmonary edema Nitro bolus Rapid effect will most likely not be seen until after 100mcg/min
400mcg/min x2 minutes for loading
100mcg/min thereafter
Sublingual does not have same onset or bioavailability
Can titrate up to 400mcg/min if patient's pressure can tolerate Fentanyl Blunt the stress response, help relieve the afterload
Makes non-invasive ventilation more tolerable to panicking patient
25 - 50 is probably enough
NOT evidence based Lasix will not help in this patient - acute decompensation driven primarily by sympathetic tone. These are scary doses, what if I tank the BP? Don't fear, the half life of nitro is 1-4 minutes. Can't I just use sublingual over IV?
Both bypass first past liver metabolism. Sure, you can. But make sure you put at least 6 pills under the patient's tongue because they're designed to dissolve at a rate of 80mcg/min. And let's hope all that air blowing in his/her face doesn't dry up the saliva needed to dissolve the pills. Sources:
Am J EM 17:6 - sympathetic tone in acute cardiogenic pulmonary edema
Annals EM 1997, 30:382 - bolus nitro/nitro drip vs. drip alone
Lancet 1998 351:389-393 - nitrates vs. lasix
Ann Emerg Ned 2006;48:260 - systematic review of BiPAP

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