Podcast 851: High-Dose Nitroglycerin in SCAPE

<p dir="ltr"><strong>Contributor:</strong> Aaron Lessen MD</p> <p dir="ltr"><strong>Educational Pearls:</strong></p> <ul> <li dir="ltr">SCAPE (Sympathetic Crashing Acute Pulmonary Edema), formerly known as flash pulmonary edema, is a life-threatening condition due to a sudden sympathetic surge that leads to hypertensive heart failure, pulmonary edema, hypoxia, and respiratory distress. </li> <li dir="ltr"><span style= "font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen, Ubuntu, Cantarell, 'Open Sans', 'Helvetica Neue', sans-serif;"> The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation.</span></li> <li dir="ltr"><span style= "font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen, Ubuntu, Cantarell, 'Open Sans', 'Helvetica Neue', sans-serif;"> Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema.</span></li> <li dir="ltr"><span style= "font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen, Ubuntu, Cantarell, 'Open Sans', 'Helvetica Neue', sans-serif;"> Dosing should be high; boluses of HDN are given at doses of 1-2 mg every 3-5 minutes vs. infusions at 200-400 mcg/min then titrating down.</span></li> <li dir="ltr">HDN leads to reduced intubations, less need for ICU admission, and shortened length of hospital stay in patients with SCAPE.</li> </ul> <p dir="ltr"><strong>References</strong></p> <ol> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5-1526.e7. doi:https://doi.org/10.1016/j.ajem.2018.05.013