So this week, something a little out of the ordinary–you'll just have to listen to get the full context. So let's jump into the SCAPE Debate
Other SCAPE Stuff on EMCrit
The Instagram Clip
PulmToilet very kindly removed the clip from instagram, so listen to the podcast to hear the clip
Debate Prep
Intro
“ My issue is that you have people running around. And you can tell me if I'm wrong, but you get to Mr. Jones' home in Upper Darby, he ate like four hotdog and his blood pressure's two 40 over one 20. He's diaphoretic and going nuts. You're gonna say, oh this escape, we better give him 500 a nitro. That's fucking a hundred percent. That's fucking crazy If he dies, like they like just imagine if he dies, right?
And they get an actual cardiologist on the stand. Not that you should like practice medicine, like thinking about if you get sued, but like, just think of just. Just think about the optics. Like what physician is like, what, none that I can tell, like what cardiologist's gonna say. Oh, yeah. Like we give a milligram a nitro all the time for like, like never, never, ever, never let.”
SCAPE as a Diagnosis
“SCAPE is not Real, It is a fake diagnosis, It is not a Real Diagnosis”
Flash Pulmonary Edema-What about when hypotensive
This is where we were 20 years ago
Is it separate from Acute Heart Failure, Systolic Heart Failure with Hypertension
It’s Just Hypertensive Emergency
“it is a hypertensive emergency”
When residents say SCAPE, I say, “ no, he has hypertensive emergency and its clinical manifestation is pulmonary edema”
“It just reads as Acute, hypertensive heart failure. “
So patient with bp 168, sitting comfortably in bed, with rales ⅓ way up is the same as SCAPE?
“Did I miss SCAPE, this just looks like a hypertensive emergency to me”
“And he’s got +9 pitting edema–this is not scape”
It's just Flash Pulmonary Edema
What does SCAPE mean?
Sympathetic
Sweaty, peripherally clamped down, ice cold
Crashing
Looks like they need to be intubated in the next 5 minutes
Recapitulating Arguments we Dealt with 20 Years Ago
Just give them some sublinguals, low dose nitro drip, and lasix and they’ll be fine
They don’t see these patients
Based on what he said
Doesn’t Understand these Patients
Doesn’t Understand how Nitro works
They are at 50 in ICU, 10 times less than what they tell you???
Doesn’t Understand the Pathophys
Thinks they have to do cocaine or something
“like why? Like where did this. This nitro, like, where did this subset and what, what the bros will say is like, oh, it's a sympathetic outflow. Um, it's hypers sympathetic tone from something. I'm like, how do you know that they've had, they have some sympathetic outflow that then leads to escape, right?”
“If I put you underwater, you wouldn't be able to breathe either, and you'd be fucking like trying to fight everyone. So like. It's impossible to differentiate. Is there this sympathetic surge before scape, or did Mr. Did you know Mr. Jones from Upper Darby just not take his amlodipine that day? His blood pressure went to two 40.”
“He flashed, and now he's dying from being underwater. Like how, how do you tell the difference? That's why he's having this sympathetic surge. Yeah, it's, yeah, because he's fucking dying. I, I'll tell you what, if I suffocate you, you're gonna have a sympathetic surge. Trust me. But the way that it's, yes, the way that you, these, the way that, um, it's usually parsed out is like there's a sym, there's some sympathetic like hypers sympathetic activity or something.”
“Some, I think if you just throw sympathetic surge emergency in like in some way, shape or form into a syndrome, everyone's like, wow, that's pretty fucking bad. Like, yeah, dude, you should definitely give him a ton of nitro for that. And without like thinking like, what are we talking about here? So. I, you know, unfortunately I don't have like a, some, like, I don't have a, an answer, like there's no answer that I can provide you with.”
“I, what I would say is think twice before you hit someone with one or two milligrams of nitro bolus. Because I'll tell you what, if you kill that patient and that patient sus your ass, you're not gonna have a leg to stand on because this evidence, this quote unquote evidence that you have is all garbage.”
Nitroglycerin
Doesn’t Understand What Nitro Actually Does in SCAPE
400 mcg bolus reduces afterload predominantly in CHF patients [Haber et al. Journal of the American College of Cardiology Volume 22, Issue 1, July 1993, Pages 251–257]
“It was a, yeah, it was, uh, I believe it was a 37 minute patient contact time for EMS. Yes, yes, yes. With the half-life of nitro. Yeah, that's, what are you doing? I'm not doing shit. It i's almost like, like you're just dropping their blood pressure twice and then it's coming back and Well, that was the other thing is that, um, so even if, like, even if this bolus dropped the pressure, um, like you're just gonna be back as you mentioned, like you're just gonna be back to where you started.”
“I'm looking at the notes that you sent me and you wrote Nitro Short Half-Life. So even if intermittent bolus gets your blood pressure lower, it's short-lived, which brings you right back to where you started with whatever, what the, so then you were at, what the, so then what did you do besides expose the patient to harm?”
Asking for Nitro Tabs if Nick was in the Hospital
What is the delivered med for a nitro tab
And then I’d get some cardine and then it’s done
After 300 mcg of nitro, which is less than a sublingual tablet
Incoherent point about citing a cath lab study where they gave 300 mcg
And it had effect on aortic afterload
Second study, need 120/min to get any effect on PCWP (Am J Cardio 2004;93:237)
“Why do we give a loading dose of Medications–We don’t understand the pharmacodynamics” (i think you mean pharmacokinetics, but whatever)
½ life 1-2 minutes
Loading nitro makes zero pharmacologic sense
Like it’s cool to break protocol sometimes, but it’s unnecessary
Make Nitro 500/minute, are you insane?
This is Standard of Care, Guideline Recommended
Side Effects/Harm
Headache
Multiple times you mentioned that if a cardiologist got on the stand and you gave 500 or 1 mg of nitro
“It’s Poorly Done Literature, It’s Garbage, It’s Bullshit, It’s Shit Literature”
Everything we do in critical care
Doesn’t Know How Studies Work
Yes, you choose SBP of 90 on a cuff every 5 minutes because that is the industry standard for the outcome of hypotension
“If they are 160 systolic on a cuff, then their aortic root pressure may be significantly less”
This doesn’t matter, we use peripheral blood pressures so when the MAP is 65 peripherally, the aortic root pressure is less
Seem to misunderstand that in every patient with SBP of 90, the lower aortic pressure is there and isn’t an issue, that is the desired aortic pressure
“Nitroglycerin is a fine drug for hypertensive emergency, especially if there is acute heart failure”
Alternatives-Just Tube Mr. Jones
Clip
Nicardipine
How would you dose the cardine that you would get and then it would be done?
FDA Package insert
CARDENE I.V. 20 mg in 200 mL (0.1 mg/mL): Initiate therapy at 50 mL/hr (5 mg/hr). If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 25 mL/hr (2.5 mg/hr) every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 150 mL/hr (15 mg/hr), until desired blood pressure reduction is achieved.
Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 30 mL/hr (3 mg/hr).
Why don’t these idiots just use Nicardipine?
15 minutes to make a meaningful dent in bloodpressure
Offset of Nicardipine
50% in the first 30 minutes FDA package
Misdiagnosis
These patients are easily discerned in the first few minutes
Giving Mr. Jones 3 mg of nitro for a COPD exacerbation, or a PE or a PE, or Pneumonia, or Pneumonia
Aortic Stenosis
Nicardipine contraindicated in advanced AS (AHA Evaluation and Management of High Blood Pressure in Adults)
Did he mean aortic stenosis with hocm or either one
Why are You Doing this?
Is this shitposting?
You’ve made a comment that this is a cult of personality and you are here to debunk it?
Clip: Stir the Shit
Do you think the physicians in EM are stupid?
Why Every Time you Represent Emergency Medicine do you use a Particular Voice?
“It is unnecessary flexing, bunch of nonsense”
A general rule I have is not to tell another specialty how to do their job within the auspices of their specialty’s specialty
Appeal to Authority
10 docs-then proceeds to name all inpatient physicians
Willard he’s really smart, and he says so too
Do you have a problem with me?
“My point is like. That protocol that was, that was circulated right In someone that has this like massive platform. Like if you look at the study that it's based on, which I did look at like it's a garbage study.”
“Like this study is garbage. Like this thing right here, I'm putting in the, I'm putting it in the camera so you can see it. That is for the, that is for the listeners. So this, let me, for the people listening, it's, this is garbage. 2023. Safety of pre-hospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema.”
Is what you are doing making things better or worse?
Prehospital
Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4-year review
This is a garbage study
Debunking Other Stuff from Okayest Medic Podcast
Keep quoting ohms law to explain decreased afterload from cpap
If anything Laplace would apply, Ohms law certainly not
No effect on inotropy (is that what you mean by contractility?)
Of course you can have COPD without smoking, though far more rare
- Alpha-1 antitrypsin
- Pollutants
- Second hand smoke
- Childhood resp disease
Bibliography
- “Bolus Intravenous Nitroglycerin Predominantly Reduces Afterload in Patients with Excessive Arterial Elastance.” Accessed October 5, 2025. https://www.jacc.org/doi/epdf/10.1016/0735-1097%2893%2990841-N.
- Breidthardt, T., M. Noveanu, M. Potocki, et al. “Impact of a High-Dose Nitrate Strategy on Cardiac Stress in Acute Heart Failure: A Pilot Study.” Journal of Internal Medicine 267, no. 3 (2010): 322–30. https://doi.org/10.1111/j.1365-2796.2009.02146.x.
- Cotter, G., E. Metzkor, E. Kaluski, et al. “Randomised Trial of High-Dose Isosorbide Dinitrate plus Low-Dose Furosemide versus High-Dose Furosemide plus Low-Dose Isosorbide Dinitrate in Severe Pulmonary Oedema.” Lancet (London, England) 351, no. 9100 (1998): 389–93. https://doi.org/10.1016/S0140-6736(97)08417-1.
- Frank Peacock IV, W., Joseph Varon, Ramin Ebrahimi, Lala Dunbar, and Charles V. Pollack Jr. “Clevidipine for Severe Hypertension in Acute Heart Failure: A VELOCITY Trial Analysis.” Congestive Heart Failure 16, no. 2 (2010): 55–59. https://doi.org/10.1111/j.1751-7133.2009.00133.x.
- Henry, Kyle, Brittany Pelsue, Heather Hartman, and Brian Gulbis. “Low versus High Dosing Strategies of Intravenous Nitroglycerin for the Management of Sympathetic Crashing Acute Pulmonary Edema.” The American Journal of Emergency Medicine 98 (August 2025): 41–45. https://doi.org/10.1016/j.ajem.2025.08.017.
- Houseman, Brandon S., Ashley N. Martinelli, Wesley D. Oliver, Sandeep Devabhakthuni, and Amal Mattu. “High-Dose Nitroglycerin Infusion Description of Safety and Efficacy in Sympathetic Crashing Acute Pulmonary Edema: The HI-DOSE SCAPE Study.” The American Journal of Emergency Medicine 63 (January 2023): 74–78. https://doi.org/10.1016/j.ajem.2022.10.018.
- Kelly, Geoffrey S., Lindsey A. Branstetter, Tim P. Moran, Nathan Hanzelka, and Claudia D. Cooper. “Low- versus High-Dose Nitroglycerin Infusion in the Management of Acute Pulmonary Edema.” The American Journal of Emergency Medicine 65 (March 2023): 71–75. https://doi.org/10.1016/j.ajem.2022.12.022.
- Levy, Phillip, Scott Compton, Robert Welch, et al. “Treatment of Severe Decompensated Heart Failure with High-Dose Intravenous Nitroglycerin: A Feasibility and Outcome Analysis.” Annals of Emergency Medicine 50, no. 2 (2007): 144–52. https://doi.org/10.1016/j.annemergmed.2007.02.022.
- Long, Brit, William J. Brady, and Michael Gottlieb. “Emergency Medicine Updates: Sympathetic Crashing Acute Pulmonary Edema.” The American Journal of Emergency Medicine 90 (April 2025): 35–40. https://doi.org/10.1016/j.ajem.2024.12.061.
- Mathew, Roshan, Akshay Kumar, Ankit Sahu, Sachin Wali, and Praveen Aggarwal. “High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study.” The Journal of Emergency Medicine 61, no. 3 (2021): 271–77. https://doi.org/10.1016/j.jemermed.2021.05.011.
- Patrick, Casey, Louis Fornage, Brad Ward, et al. “Safety of Prehospital Intravenous Bolus Dose Nitroglycerin in Patients with Acute Pulmonary Edema: A 4-Year Review.” Journal of the American College of Emergency Physicians Open 4, no. 6 (2023): e13079. https://doi.org/10.1002/emp2.13079.
- Pramudyo, Miftah, William Kamarullah, Raymond Pranata, et al. “Low-Dose versus High-Dose Intravenous Nitroglycerin in the Treatment of Sympathetic Crashing Acute Pulmonary Oedema: A Systematic Review and Meta-Analysis Focusing on Efficacy, Safety and Outcomes.” BMJ Open 15, no. 6 (2025): e099142. https://doi.org/10.1136/bmjopen-2025-099142.
- Raggi, Jason R., Thomas W. O’Connell, and Daniel J. Singer. “Nicardipine: When High Dose Nitrates Fail in Treating Heart Failure.” The American Journal of Emergency Medicine 45 (July 2021): 681.e3-681.e5. https://doi.org/10.1016/j.ajem.2020.12.016.
- Sharon, Ahuva, Isaac Shpirer, Edo Kaluski, et al. “High-Dose Intravenous Isosorbide-Dinitrate Is Safer and Better than Bi-PAP Ventilation Combined with Conventional Treatment for Severe Pulmonary Edema.” JACC 36, no. 3 (2000): 832–37. https://doi.org/10.1016/S0735-1097(00)00785-3.
- Siddiqua, Naazia, Roshan Mathew, Ankit Kumar Sahu, et al. “High-Dose versus Low-Dose Intravenous Nitroglycerine for Sympathetic Crashing Acute Pulmonary Edema: A Randomised Controlled Trial.” Emergency Medicine Journal: EMJ 41, no. 2 (2024): 96–102. https://doi.org/10.1136/emermed-2023-213285.
- Silvers, Scott M., Seth R. Gemme, Sean Hickey, et al. “Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022.” Annals of Emergency Medicine 80, no. 4 (2022): e31–59. https://doi.org/10.1016/j.annemergmed.2022.05.027.
- Stemple, Krisi, Kyle M. DeWitt, Blake A. Porter, Michael Sheeser, Eike Blohm, and Mark Bisanzo. “High-Dose Nitroglycerin Infusion for the Management of Sympathetic Crashing Acute Pulmonary Edema (SCAPE): A Case Series.” The American Journal of Emergency Medicine 44 (June 2021): 262–66. https://doi.org/10.1016/j.ajem.2020.03.062.
- Wilson, Suprat Saely, Gregory M. Kwiatkowski, Scott R. Millis, John D. Purakal, Arushi P. Mahajan, and Phillip D. Levy. “Use of Nitroglycerin by Bolus Prevents Intensive Care Unit Admission in Patients with Acute Hypertensive Heart Failure.” The American Journal of Emergency Medicine 35, no. 1 (2017): 126–31. https://doi.org/10.1016/j.ajem.2016.10.038.
PulmToilet's Research Packet
Additional New Information
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit Wee – ANDROMEDA-SHOCK-2 Explosion – A Discussion with the Lead Investigators - November 4, 2025
- EMCrit 411 – You Need to Understand the Andromeda-Shock-2 RCT for Septic Shock - October 30, 2025
- EMCrit 1:1 Nursing 006 – Post-Cardiac Arrest (Post-Arrest) Care - October 23, 2025
This is an interesting conversation I have seen patients who fit the SCAPE description and think that high dose nitro has been a helpful treatment modality. That being said I think it’s a pretty specific and in my part of the world not terribly common(my east coast buddies talk about seeing these patients like weekly ). I’ve personally and have seen several paramedic students/EM residents pretty badly mix things up because they thought someone with rales and a bp of 170/90 and moderate respiratory distress that’s actually due to something else. If nitro is harmful in this circumstance is pretty… Read more »
Hi Scott, I recently listened to the episode of the Pulm Toilet Podcast and felt compelled to share my impression regarding the host’s demeanor. I found the tone and delivery to be unnecessarily disrespectful, bordering on inflammatory. It genuinely seemed as though the host was intentionally acting this way to provoke reactions or attract attention—perhaps in an effort to grow their listener base. While I’m not personally offended by strong language or edgy commentary, I do think there’s a line between authenticity and performative vulgarity. Resorting to crassness or antagonism for views or likes detracts from meaningful clinical discussion and… Read more »
Gabriel,
can you specify are you speaking about
this podcast or the podcast recorded on World’s Okayest Medic Podcast?
If my podcast, are you talking about me or PulmToilet in terms of host demeanor?
As to your questions:
In an ideal world, ultrasound would be available looking for B-Lines, certainly not valve interrogation. Most ED docs can’t screen valves at this point.
Not sure I mentioned in the podcast or not, but if you shoot for a BP like 160 systolic, nitro is fine in aortic stenosis, usually even markedly beneficial.
Hi scott, I was referring to pulm toilet ( snippets from your podcast and the world okayest medic). After listening to your podcast i went to listen to his podcast to make sure those snippets weren’t taken out of context. Now i am familiar with the world okayest medic because of my friend melody bishop was a guess on this podcast and even then i didn’t really enjoy the demeanor and attitute adopted by the host. I don’t know if this podcast encourages guesses to speak and act that way (vulgar), but i am not a fan of this approach.… Read more »
Can you share your nitro protocol in the crashing phase?
Scott- Great response to haters!!
Loved this dialogue. I have had this type of negative interaction in real life. And as ED doctor it’s.easier to say:
“Flash Pulmonary edema with respiratory failure due to hypertensive emergency or what we call SCAPE”
My question:: what is your level of concern with high dose IV calcium channel blockers worsening cardiac contractility?
I guess hopefully future trials will see..
until you get to overdose levels, Nicardpine and Clevidipine retain their selectivity and will not negatively affect inotropy
I’m a paramedic who has worked in both the field and in the ED and I’ve taken issue with some of the commentary on “The World’s Okayest Paramedic” podcast in the past. Not to sound dramatic, but I was kind of shocked when I heard the episode in question that dismissed SCAPE. I was hoping you were going to respond to what was said and you did not disappoint. I appreciate how in-depth you go with material and how you back up what you say with evidence and good clinical/practical commentary, and that’s something that not everyone in the EM/EMS… Read more »
As a hospitalist who does rural ICU, I have seen SCAPE in inpatients. Is usually in the morning when the night doc put off doing anything for the AM crew. And sometimes in a nervous cardiac cripple right before they’re supposed to go home. I like the term SCAPE far better than “flash pulmonary edema” which really tells nothing. Along w the slug of NTG and BIPAP and Lasix, i give 2 of midaz or loraz if on the ward, and STAY WITH THEM. The RN and pharmacist are always nervous the first time, i tell them to just chill,… Read more »
Hi Scott, I really liked the way you respectfully debunked the criticism of the concept of SCAPE. As someone with 20 years prehospital experience, I have long thought that there are some prehospital and early emergency presentations that benefit from a ‘hyperacute’ management arm, that is distinct from standard internist care. For example, I believe the principles you apply in SCAPE management also apply in the crashing anaphylaxis pt. Aggressive early therapy (in this case Adrenaline/Epinephrine infusion), which is then quickly titrated down once the pathology has been entrained (eg. 25mcg/min, up to 50 after 2/60, up to 75 next,… Read more »
Just listened to the podcast and the last 5 minutes during which Scott talks about professionalism and how to treat a colleague or any human being are so spot on. We need more people calling out others for being hateful, for being ignorant, and for spreading negativity. Makes me wish Scott would run for office!
I’m a little confused why you didn’t address pulmtoilet’s stance on scape when you were on the world’s okayest medic podcast. Was that something that was agreed upon before the record button was punched? That podcast (and this one) misses the mark without an opposing voice.
I was flabbergasted by PulmToilet’s comments in a way I can’t describe. Episode 1 of EmCrit was published in April 2009, a few months before I started residency. This means that I essentially “grew up” with this approach and I am hard pressed to think of even a single patient in 16 years of practice who I had to intubate due to their pulmonary edema. There was one patient who arrested on arrival due to EMS care that was not aggressive enough in a patient who “couldn’t tolerate CPAP”. That patient came back after a round or two of CPR… Read more »
yep!