#1 - SCAPE aka severe acute pulmonary edemaThe Game: You've got 2 minutes before you intubate them, what do you do before they "buy some plastic"??!!
PE: SBP>180, rales bilaterally
For gods sakes throw the lasix in the trash (most patient's are volume depleted, not overloaded)
Step 1: Place BIPAP mask, start PEEP at 6-8, quickly titrate to PEEP 10-12
Step 2: Get IV, need loading dose of Nitro BEFORE drip. So run 400mcg/min for 2 min, then knock down to 100 and titrate up. Can give 2mg bolus if necessary.
Step 3: Once they are out of the woods, to get rid of drip give enalapril or SL captopril. To make medicine happy I'll toss 40 or 80 of lasix at the end to make them happy, but trust me, its not for me.Caveats:
- Nurse won't give drip because rate is too high? "Please step aside, I'll take over"
- "Doc, this mask is FREAKING ME OUT", given them 25-50 fentanylIf you intubate, you have FAILED!Extra nugs:
- 1-2mg of nitro has been shown to be safe
- In a prospective cohort study at Mt. Sinai, they gave on average 1.5mg nitro with ZERO patients needing intubation, 2 had SBP dip under 100 but that resolved spontaneously.
- SL Nitro (this is just my opinion) is useless. Its 400 mcg, but dissolves in 5 minutes, so its really 80 mcg/min, if its EVEN dissolving in that dry mouth. No real thoughts on nitro paste as I never use it. (edited)