You are on a busy shift when EMS brings in a tachycardic patient in respiratory distress on a nonrebreather. How do you prepare to evaluate and treat this patient? In this episode, Drew and John are joined by our amazing guests, Molly Estes and George Willis to discuss the case of a patient who presented to the ED with Sympathetic Crashing Acute Pulmonary Edema (SCAPE). For those who have been practicing for a while, SCAPE was formerly known as Flash Pulmonary Edema. While the name has changed, the disease process and the concept of management remain the same. Management of SCAPE can be particularly challenging given the severity of symptoms, however, with the right approach and tools we can vastly improve patient outcomes. 

Positive Pressure Ventilation, Nitroglycerin, Ultrasound…Oh My!

First things first…call respiratory therapy early and often if they are available at your shop. When it comes to SCAPE, positive pressure ventilation (PPV) can be life-saving. PPV in the form of BiPAP and CPAP, are non-invasive ventilation used to help distribute air to the lungs and facilitate gas exchange. In some cases, it may be difficult for patients to tolerate NIPPV as the mask can be uncomfortable and can make people anxious. Some adjustments can be made to help patients tolerate it including changing the mask, breathing exercises, and even anxiolytics. 

We typically think of using nitroglycerin in patients with chest pain, however, there is a huge role for nitroglycerin in SCAPE. At the right doses, it can help with both preload and afterload. Fortunately, in SCAPE patients’ blood pressure can typically tolerate the amount of nitroglycerin needed to help with their respiratory distress.

Bringing the ultrasound to the bedside can help you to clinch the diagnosis of SCAPE and allow you to reach for the PPV and the nitroglycerin more confidently. Findings of a hyperdynamic heart and diffuse B-lines are very suggestive of the pulmonary edema seen in SCAPE.

Broaden the Differential

When someone comes in as sick as a patient with SCAPE, we can get tunnel vision into the diagnosis of SCAPE. Challenge yourself to broaden the differential and consider other things that this could be like asthma exacerbation, ACS, PE, etc.

Lasix or not?

As many know, Lasix is a diuretic medication used to help eliminate excess fluid from the body. You would think that Lasix would be effective in decreasing pulmonary edema of SCAPE, but unfortunately due to time of onset, it often will not act fast enough to be very helpful in the acute period. 

Take Home:
  1. PPV and nitroglycerin early and often.
  2. Ultrasound at the bedside can be a game changer.
  3. Keep your differential broad.

Post by Rick Dasilva


About Our Guest:

George Willis, MD
Associate Program Director at UT Health San Antonio Emergency Medicine Residency

Molly Estes, MD
Clerkship Director, Medical Education Fellowship Director, and Assistant Professor of Emergency Medicine, Loma Linda University

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Clinical Grind: SCAPE

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