May 15, 2023
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
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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
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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
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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
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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