Podcast 851: High-Dose Nitroglycerin in SCAPE

Contributor: Aaron Lessen MD

Educational Pearls:

• 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. 
• The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation.
• Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema.
• 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.
• HDN leads to reduced intubations, less need for ICU admission, and shortened length of hospital stay in patients with SCAPE.

References

1. 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

2. 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

3. Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:https://doi.org/10.1016/j.ajem.2020.03.062

4. Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:https://doi.org/10.1016/j.ajem.2016.10.038

Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce & Jorge Chalit, OMS1