Flash Pulmonary Edema

  • Acute Decompensated Heart Failure

  • it is acute decompensated heart failure with sudden onset of severe pulmonary edema occurring within minutes

  • cause → CHAMP (ACS, HTN-emergency, Arrhythmia, Mechanical/valve, PE/PNA)

Plan

  • pt upright to reduce venous return

  • start BIPAP early (PEEP 5–10), increase intrathoracic pressure, decrease preload, and helps push fluids out of alveoli → O2 > 90%

  • ABG, Trop, BNP, Lytes, EKG

  • POCUS → B lines and ventricular function

  • if Hypertensive →
    SBP <160 High-dose NTG bolus: 800 mcg IV over 2–3 min then repeat q3–5 min (total 2–3 mg)
    or if SBP >160 → 1–2 mg (1000–2000 mcg) in 3–5 mins, can repeat q3–5 min ×2–3 doses
    then can start drip 100–400 mcg/min targeting SBP ↓20–30%
    → ↓ afterload and preload → ↑ cardiac output → renal perfusion

  • Lasix as adjunct but after NTG if clear evidence of systemic volume overload (cardiomegaly, peripheral edema, weight gain) (avoid if euvolemic)

  • if ACS go to cath lab

  • Afib with RVR → cardiovert

  • valvular → consult cardiothoracic consult

  • PE → AC

  • intubate if pH <7.2, exhaustion, AMS

  • in Hypotension/Shock → ICU, need inotropes, IABP (afterload reduction) or Impella/ECMO for LV failure

  • suspect renal artery stenosis can cause flash, do US