Causes of cardiogenic pulmonary edema
- Excessive venous return (i.e increased preload) i.e. Tap is left open
- Excessive systemic vascular resistance (i.e. increased afterload) i.e. Hose is narrow
- LV dysfunction: a disorder of contractility or a disorder of rate and rhythm i.e. Pump failure
GOALS OF TREATMENT
2. Using a bigger/ wider hose: Decreasing afterload
Nitroglycerin, nitroprusside, hydralazine and ACE-I
3. Improving pump function: using ionotropic support
Patients with STEMI, where pump function is affected, there arises a need for ionotropic support.
- Treatment of pulmonary edema should be focused on ‘fluid redistribution’ and not ‘fluid removal’.
- First line: Nitroglycerin and NIV (start ASAP)
- Second line: ACE-I (in addition or instead of NTG)
- Third line: Diuretic like furosemide
- Morphine has NO ROLE in modern management of cardiogenic pulmonary edema
Listen to Dr. Mattu's talk on Pulmonary Edema
- Beltrame JF, Zeitz CJ, Unger SA, et al. Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema. J Card Fail (1998) 4:271-9.
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- Cotter G, Metzkor E, Kaluski E, et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 1998;351:389-93.
- Figueras J, Weil MH. Blood volume prior to and following treatment of acute cardiogenic pulmonary edema. Circulation 1978;57:349-55.
- Gammage M. Treatment of acute pulmonary oedema: diuresis or vasodilatation? Lancet 1998;351:382-3.
- Kraus PA, Lipman J, Becker PJ. Acute preload effects of furosemide. Chest 1990;98:124-8.
- Mattu A, Sharma S, Perkins AM, Zevitz ME: Pulmonary edema, cardiogenic. eMedicine Journal 2002;3(2)
- Mattu A. Pulmonary edema. Emergency Physicians Monthly 2002;9(9):1,4-8,12,16,22.
- Tei C, Horikiri Y, Park JC, et al. Acute hemodynamic improvement by thermal vasodilation in congestive heart failure. Circulation 1995;91:2582-90.
- Barnett JC, Zink KM, Touchon RC. Sublingual captopril in the treatment of acute heart failure. Curr Ther Res 1991;49:274-81.
- Avoiding Common Errors in the Emergency Department: Mattu, Shanmugam, Swadron, Tibbleg, Woolridge
- Cardiovascular Emergencies : Amal Mattu
- Heart Failure, Clinical Pathways in Emergency Medicine: Prof. Suresh S David
M.B.B.S., ECFMG (USA)
Lifesupporters Institute of Health Sciences, Mumbai
I am an Emergency Medicine enthusiast, a lifelong learner, a proponent of Evidence Based Medicine, love ECGs, resuscitation and emergency cardiology. After my graduation I worked as a Research Assistant in the USA. I have always been actively involved in teaching basic and advanced lifesaving skills to medics, paramedics and lay public since 2012. Currently I am pursuing EM Residency at Kokilaben Dhirubhai Ambani Hospital under George Washington University - Masters in Emergency Medicine Program. My vision is to create awareness about EBM and develop EM as a stand alone speciality in India.