How to SCAPE the vicious cycle

57 year old male was brought in to resus bay with acute dyspnea, hypoxemia, diaphoretic. Hx significant for HTN, DM, HFpEF. HR of 156, SBP 189 mmHg, Sa02 85% on high flow 02. ECG revealed atrial fibrillation with RVR, nonspecific ST changes.

Sympathetic Crashing Acute Pulmonary Edema

SCAPE: distinguishing features is vasoconstriction secondary to sympathetic activation, exaggerated RAAS. Triggers: Sympathetic overdrive (stress, anxiety, inflammation, uncontrolled HTN), Acute MI, Volume overload.

Sympathetic surge

Arterial vasoconstriction ^ afterload, ^ myocardial 02 demand, decreased 02 content from alveolar edema causing end organ ischemia, decrease CO, RAAS activation, brain ^ SNS activity, Sympathetic surge leading to more vasoconstriction…

Signs and Symptoms

Acute dyspnea, hypoxemia, tachypnea, HTN ( SBP >160), clinical features of sympathetic activation, bilateral rales, or diffused B-lines shown with POCUS.

Treatment

Patient respond rapidly to Bipap and high dose NTG.

IV NTG bolus 600 cmg – 1000 mcg, followed by infusion of 100 mcg/min for the next 10 min. Continue infusion if SBP improving, or increase NTG infusion by 20 mcg/min q 10 min until SBP start decreasing (refractory can go up to 800 mcg/min, adjust bipap to maximize pressure BP titratable med like nicardipine).

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