Sympathetic Crashing Acute Pulmonary Edema
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- Опубликовано: 27 июл 2024
- In this video I discuss how I manage patients with SCAPE including how I titrate and use non-invasive ventilation and nitroglycerin.
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Thanks for the video Salim! Always a good day when I see a new one in my feed. Just a nitpick if you'll have it. SL nitro 0.4mg tab is not 100% bioavailable. Effective dose is ~160 mCg, different Cmax from IVP so comparing them is apple and oranges.
TY so much and realize SL nitroglycerin is not 100% bioavailable (i.e. it is apples to oranges)...I use it more to help people cognitively wrap their brains around 400mcg of nitroglycerin isn't crazy :)
Thank you again! Learned a lot.
Glad it was helpful!
By far my favorite disease process to manage. Worst parts about it is convincing everyone I’m not insane for giving that much nitro, and then catching hell from the admitting doc for not giving diuretics. Even after I explain the reason for not giving diuretics, they never seem to understand, and inevitably slam them with diuretics as soon as they get admitted. I’m glad SCAPE is getting some more attention lately too, because too often I see colleagues intubate these pts as soon as they roll in, which is a shame in my opinion. Sometimes there’s simply no time and your hand is forced because they come in completely unresponsive, but this is rarely the case.
100% agree...the aha moment for people is that SL NTG = 400mcg
@@SalimRezaie You’re exactly right, I explain it the exact same way and it helps a lot! I usually start a drip at 200 mcg/min and often quickly titrate up to 400 mcg/min (max I can do on our pumps). I’m usually able to shut it off before I ever leave the room and then it never goes back up. There’s some stubborn ones though where 400 just isn’t cutting it, and I’ve had to add on nicardipine a handful of times, which does the trick and I can shut it all off. I haven’t done the 1,000 mcg bolus, but I have been wanting to. Only hesitation is bc I know I’m going to get a ton of blowback from my nurses. Over what period of time are you giving that bolus though, just curious?
agreed! love talking to people with similar language. it's super difficult to implement new proven treatment ways to people who don't try to learn 😢
@@nurulnajwa6825 Stay humble, stay curious :)
great take on it! great explanation
i remember seeing on ACEP a lecture were the speaker's take was 1g if SBP 200, confess I didn't read after that
also, what's your take on inotropics?
I have never used greater than 1000mcg as my bolus...not sure I am aware of any evidence that has shown safety/efficacy of doses greater than 1000mcg. Most of these patients will be hypertensive and will not need inotropes.
@@SalimRezaie makes sense. I'll see if I can find the talk and evidence on that
@@SalimRezaie so, i found the talk, it was a 2021 ACEP talk, the lecturer said he'd do 1-2mg depending on SBP, "as per the paper" - the paper is this: 10.1016/j.jemermed.2021.05.011
they used 600-800-1000mcg bolus depending the SBP, found nothing about 2mg.
There's this were they used 2mgs boluses - 10.1016/j.annemergmed.2007.02.022 - not great quality, and used as second line treatment (after oral ntg, lasix, morphine and NIV)
Also this one 10.1016/j.ajem.2016.10.038 - both ain't great, but seems to be an option, and looks like it's being used
take home point: read the papers presented on the talks haha
Exactly my point...not sure where the 2mg came from...
1. The first paper you cite is the one I base my clinical practice on --> rebelem.com/i-love-me-some-high-dose-ntg-and-niv-for-scape/
2. The second paper was 29 patients, non-randomized, and single arm (i.e. no comparator); This study is not powered for adverse events and despite that 3.5% [95% CI 0.4% to 15.0%] with symptomatic hypotension compared to ZERO patients in the non-intervention group
3. The third paper was a retrospective trial of 395 patients over a 5 year period comparing intermittent bolus (n = 124) vs continuous infusion therapy (n = 182) vs combination therapy of bolus and infusion (n = 89); Again study not powered for this however numerical trends showed more hypotension in the combination group (6%) vs bolus group (1.9%) vs continuous infusion group (1.3%)
My point being...2mg is too much...the two studies you present are not powered to say this is a safe practice. My two cents
@@SalimRezaie tbh, that's not a great paper either, with 25 pts and no control group, don't you agree? Not saying it doesn't make sense or that it doesn't work, just saying it's not the most robust evidence, but I guess it's the best we have. On the other side, it hits me a bit like the 2g bolus of TXA, that started being adopted after they shown that 6 rangers didn't die, and now is being studied...
But again, thanks for the attention and will to discuss with a stranger on the internet
I agree with most of what you said, but we don’t routinely use morfine in pulmonary edema any more because of the study’s that showed increased mortality and intubation rate. Would you consider a short acting benzodiazepine like midazolam to calm the patient instead of those agents or ketamine and dexmetomedine that are not available in all emergency departments?
Many EMS agencies don't have ketamine or dexmetomidine...They will be the primary point of contact in these patients...They have BZDs and opioids as their options. The problem with current evidence base is we don't know all the confounders nor what doses/frequency in which morphine was given (also we wrote about this on REBEL EM --> rebelem.com/why-we-should-consider-not-using-morphine-in-acute-heart-failure/ AND rebelem.com/morphine-kills-in-acute-decompensated-heart-failure/) . The doses of opioids I advocated for are super small doses and to be used sparingly. That being said...I would much rather use ketamine or dexemetomidine (when available).
If there is small leak in seal ,I have heard that's ok
Pt in distress,feel claustrophobic so it's ok
What do you think
I ll nt press fir a very tight seal
I find coaching the patients before and during initial application of the mask works best...if they are still not tolerating it then some form anxiolytics will be needed...Also pretty sure most masks that get applied already have some form of a small leak.