Acute Pulmonary Edema/Hypotension/Shock Clinical signs of hypoperfusion, congestive heart f acute pulmonary edema Attach monitor, pulse oximeter, ‘and automatic blood pressure What is the nature of the problem? Volume problem Includes vascular resistance problems Pump problem ‘Administer Fiuids Blood transfusions Cause-specific interventions Consider vasopressors, if indicated + Assess ABCs + Assess vital signs + Secure airway + Review history + Administer oxygen ‘+ Perform physical examination * Start IV + Order 12-lead ECG Order portable chest xray Algorithm Figure lure, Systolic BP <70 mm Hg? ‘Signs ana symptoms of shook systolic BP 70-100 mm Hg? Signs ang symptoms of shock systolic BP 70-100 mm Hg? No signs and sympt Systolic BP >100 mm Hg toms of shock Consider + Dopamine: + Norepinephrine 25-20 pgikg per min IV + Dobutaminess 015-30 g/min IV or (Add norepinephrine it bape) 2-20 ugikg per + Dopamine dopamine is >20 min lV 5-20 pavkg per min igikg per min) “= Nitroglyeerin start 10-20 pgimin IV (use if ischemia persists and BP remains elevated. Titrate to effect) andlor + Nitroprusside 0.1-5.0 yakkg per min IV Consider further acti in acute pulmonary edema tions, especially i the patient is irst-line actions Furosemide \V 0.5-1.0 mgkg Morphine \V 1-3 mg Nitroglycerin SL Oxygeniintubate PRN Second-line actions + Nitroglycerin IV it BP >100 mm Hg * Nitroprusside WV i BP >100 mm Hg + Dopamine it BP <100 mm Hg Dobutamine't BP >100 mm Hg Positive end-expiratory pressure (PEEP) Continuous positive airway pressure (CPAP) Tr hird-line actions ‘Amrinone 0.75 mg/kg then 5-15 ya/kg per min (it other drugs fil) Aminophylline 5 maxg (if wheezing) Thrombolytic therapy (if not in shock) Digoxin (if arial fibrilation, ‘supraventricular tachycardias) Angioplasty (if drugs fail) {ntra-aortic balloon pump (bridge to surgery) ‘Surgical interventions (valves, coronary artery bypass grafts, heart transplant) Move to dopamine and stop norepinephrine when BP improves. Avoid dopamine (cons [Ads dopamine (and avosd dobutamine) systole BP drops below 90 mm Hg, Star wth nitragiycern I nital blood pressures ae in ths range > Base managerent lier is pont on invasive hemodynamic manionng posable Guideines presume cnicl signs of hypopertusion. Fi bolus of 250-500 mL normal saline shoul! be tid. II 0 response, consider sympathomimotis. ier dobutamine) no signs of hypoperfusion __/