Those that listen to Scott Weingart on EmCrit will recognise that this is basically taken from his podcast on SCAPE.
I’ve used the management plan on a number of patients’ now and find it really effective.
Saved me a couple of intubations.
If you want some more information or a more entertaining presentation I would recommend checking out podcast 1.
Should emphasise that this algorithm is geared towards the typical 6am patient presenting with marked sympathetic overload (diaphoretic/hypertensive) and signs of acute pulmonary oedema as compared to the patient with a bit of fluid in their lungs secondary to CCF
- Pathophysiology: Afterload mediated heart failure.
- Aim of treatment is to decrease SBP rapidly and remove the oedema from the lungs with PPV
- PEEP: Start at 6-8 and titrate up to 10-12 as tolerated
- GTN Infusion: Loading dose of 400mcg/min for 1-2 minutes (or until lose radial pulse) and then decrease to 60mcg/min.
- Dosing using our infusion concentrations: 50mg in 500mls = 100mcg/mL
- Would start the infusion at 240mls/hr and decrease to 60mls/hr after any of the endpoints below:
- SBP normalising
- Infusion lasting 2 minutes
- Losing radial pulse (it comes back quickly!)
Titrate to blood pressure: Goal roughly SBP of 120mmHg
- Can use low dose captopril once patients stabilised to facilitate weaning of GTN drip (3.125mg-6.25mg)
- Don’t waste your time with frusemide: GTN more effective and patients with SCAPE can often be volume deplete.
If you have any thoughts/criticisms about this protocol feel free to post in the comments.