Mohamed, a listener from Sudan, emailed asking about the treatment of acute pulmonary edema in patients with low blood pressure. This is in distinction to SCAPE patients (see podcast 1).
If the patients have pulmonary edema and low BP from a cardiac cause, then they are in cardiogenic shock.
First, consider the etiology:
- Rate-related
- Valve Disorder
- Ischemic (Right sided infarct, STEMI, NSTEMI)
- Cardiomyopathy
- Toxicologic
At the same time, you are treating the patient with:
- Inotropes (dobutamine, milrinone, calcium)
- Pressors to achieve a MAP > 65 (allows coronary perfusion)
- Oxygenation support, most likely with intubation
- Optimize O2 carrying capacity (Hb>10)
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Hi, my name is Scott Weingart. 
{ 2 comments… read them below or add one }
Hey Scott,
Great lecture. I had a question on how to manage severe AS patients with heart failure in your ED. Conventional wisdom has taught that we should not vasodilate this patient because it can produce a precipitous drop in BP, since the heart can’t increase cardiac output against the fixed stenosis. But I am aware of one study in NEJM where they gave nitroprusside and it improved cardiac output. What do you recommend? Also what are your thoughts on nicardipine for SCAPE?
Raghu
Hey Scott, and to the other readers out there!
I am in my first year of practice, and since my 2nd year residency I’ve been listening to these podcasts, I think they are awesome, and love every bit of it. I just wanted to share my first case of cardiogenic shock that I managed just 2 days ago according to your teachings. Wonderful. It was the end of my shift 5 minutes before midnight, and this 65 yo male is wheeled in by EMS, had been complaining of Chest pain for 1 hour, was pale, diaphoretic, had a pulse of 35 and a BP that had dropped in the ambulance to 85/55 from a previous 130 systolic. He was alert and oriented and initially had warm feet and clear lungs. He had a history of heart disease but was a poor historian. EKG showed new flipped T waves in the anterolateral leads and a new 3rd degree AV Block with afib. Bedside EDE showed a grossly preserved EF. I started him on ASA, Plavix and Heparin from the get go and tried 2 atropine and a 500 cc Bolus. No improvement. Since he was on Beta-blokers I tried to reverse them with CaCl and Glucagon, no changes. Started him on Dobutamine first, then added Levophed. His BP improved minimally despite titration but HR did not. Transcutaneous pacing was unsuccessful and painful. I intubated him with RSI etomidate and succs, and tried pacing again, no changes ( I was pacing his pectorals ). His HR by this point fell down further to 28, 22 and he went into PEA. 2 min of cardiac massage and some more atropine and epi got him back to baseline. I had no on call cardiology and the closest centre was 1 hour away by ambulance. Finally managed to get ahold of a local cardio that was not on call and he placed a transcutaneous pace that finally stabilized the patient.
Thank you Scott for your teachings, I remembered your podcast as I was managing this case and listened to it the next day for further validation. A phone FU 2 days later showed that the patient was extubated and off pressers, awaiting his definitive pacemaker.