acute lung edema

ACUTE PULMONARY ACUTE PULMONARY EDEMA, HYPOTENSION,EDEMA, HYPOTENSION,

SHOCK SHOCK

JetSedJetSed

Clinical presentationClinical presentation

History :History :

Short of breathnessShort of breathness

WeaknessWeakness

PalpitationPalpitation

Chest painChest pain

FaintnessFaintness

Light headednessLight headedness

Clinical sign and symptoms :Clinical sign and symptoms :Anxiety or agitation Anxiety or agitation ConfusionConfusionHypotension Hypotension TachycardiaTachycardiaBradycardia Bradycardia Tachypnoe Tachypnoe Cyanosis Cyanosis Cool, clammy skin Cool, clammy skin Decreased or no urine output Decreased or no urine output PallorPallorProfuse sweating, moist skinProfuse sweating, moist skin

Clinical presentationClinical presentation

DiagnosisDiagnosis

Acute Pulmonary EdemaAcute Pulmonary EdemaHypovolemic shockHypovolemic shockPump problemPump problemRate problemRate problem

Further Assesment to Establish Further Assesment to Establish Diagnosis and Start TreatmentDiagnosis and Start Treatment

1. Hypovolemic shock?1. Hypovolemic shock?Find the underlying causes :Find the underlying causes :

- Diminished blood volume resulting from - Diminished blood volume resulting from excessive excessive loss loss of other body fluids (such as can of other body fluids (such as can occur occur with diarrhea, vomiting, burns,and so with diarrhea, vomiting, burns,and so on)on)

- external bleeding (from cuts or injury), - external bleeding (from cuts or injury), bleeding bleeding from from the gastrointestinal tract, or the gastrointestinal tract, or otherother

- Internal bleeding - Internal bleeding AdministerAdminister

- Fluid- Fluid- Blood transfusion- Blood transfusion- or specific interventions- or specific interventions

Further Assesment to Establish Further Assesment to Establish DiagnosisDiagnosis

2. Rate problem?2. Rate problem? Diagnosis established from ECGDiagnosis established from ECG

Tachycardia Tachycardia (Atrial fibrillation/flutter,Narrow (Atrial fibrillation/flutter,Narrow complex complex tachycardia, Stable wide complex tachycardia, Stable wide complex tachycardia,Stable tachycardia,Stable monomorphic VT and/or monomorphic VT and/or polymorphic VT)polymorphic VT)

BradycardiaBradycardia

Follow the tachycardia or bradycardia algorithmFollow the tachycardia or bradycardia algorithm

Further Assesment to Establish Further Assesment to Establish DiagnosisDiagnosis

3. Pump problem? 3. Pump problem?

History of cardiac diseaseHistory of cardiac disease (such as prior myocardial infarction, hypertension, (such as prior myocardial infarction, hypertension, familial familial heart disease, etc)heart disease, etc)

Clinical sign and symtoms :Clinical sign and symtoms :Find more specific sign cardiac disease Find more specific sign cardiac disease

(such as a(such as apical impulse is displaced laterallypical impulse is displaced laterallyCardiac auscultation may reveal aortic or mitral Cardiac auscultation may reveal aortic or mitral valvular valvular abnormalities, Sabnormalities, S33 or S or S44 ))

Possible pump problem?Possible pump problem?

Further test :Further test :

Chest x-ray, ECGChest x-ray, ECG

Is the patient hypotension?Is the patient hypotension?

Treat hypotension and the underlying Treat hypotension and the underlying causes of pump problemcauses of pump problem

Further Assesment to Establish Diagnosis and Start Further Assesment to Establish Diagnosis and Start TreatmentTreatment

4. Acute Pulmonary edema?4. Acute Pulmonary edema?

Find these clinical sign and symptoms :Find these clinical sign and symptoms :– Dyspnea at rest and on exertionDyspnea at rest and on exertion– Orthopnea and paroxysmal nocturnal Orthopnea and paroxysmal nocturnal

dyspnea (PND) dyspnea (PND) – Cough productive of pink, frothy sputum is Cough productive of pink, frothy sputum is

highly suggestive of CHF. highly suggestive of CHF. – Extremity edemaExtremity edema

Physical examination: Physical examination: • Peripheral edema, jugular venous Peripheral edema, jugular venous

distention, and tachycardia distention, and tachycardia • Tachypnea, using accessory muscles of Tachypnea, using accessory muscles of

respirationrespiration• Wheezing or rales may be heard.Wheezing or rales may be heard.• Pulsus alternans (indicative of depressed Pulsus alternans (indicative of depressed

LV function)LV function)

Acute pulmonary edema…Acute pulmonary edema…

Acute Pulmonary Edema…Acute Pulmonary Edema…

Chest x-ray might reveal : Chest x-ray might reveal : – Kerley B lines : the early signs Kerley B lines : the early signs

(interstitial edema)(interstitial edema)– "butterfly" pattern : marked the "butterfly" pattern : marked the

alveolar edema alveolar edema – cardiac enlargement may be seen cardiac enlargement may be seen

ACUTE PULMONARY EDEMA ACUTE PULMONARY EDEMA TREATMENT TREATMENT • Begin treatment with the ABCs. Begin treatment with the ABCs.

Administer oxygen, 100% Administer oxygen, 100% nonrebreather facemask.nonrebreather facemask.

• Cardiac monitoring and continuous Cardiac monitoring and continuous pulse oximetry.pulse oximetry.

• Intravenous accessIntravenous access• Medication and non medication Medication and non medication

treatmenttreatment

Treatment of Acute Pulmonary Treatment of Acute Pulmonary EdemaEdema

Medication : Medication :

Administer : Administer : – FurosemideFurosemide IV 0,5 to 1,0 mg/kg IV 0,5 to 1,0 mg/kg– Morphine Morphine IV 2 to 4 mg IV 2 to 4 mg – NitroglycerineNitroglycerine SL, continued SL, continued

with nitroglycerine IV drip as with nitroglycerine IV drip as long as systolic BP > 100 mmHglong as systolic BP > 100 mmHg

TREATMENT OF ACUTE TREATMENT OF ACUTE PULMONARY EDEMAPULMONARY EDEMA

Non MedicationNon Medication– Elevate the head of the bed. Elevate the head of the bed.

- Patients may be most comfortable in a - Patients may be most comfortable in a sitting sitting position with their legs dangling position with their legs dangling over the side over the side of the bed, which allows for of the bed, which allows for reduced venous reduced venous return and decreased return and decreased preload.preload.

Morphine……Morphine……

Cautious !!Cautious !!

It should not be given to patients with It should not be given to patients with decreased sensorium or respiratory decreased sensorium or respiratory drive, as it may bring about drive, as it may bring about respiratory arrest.respiratory arrest.

Prepare!!Prepare!!

Rescucitation aid, and Rescucitation aid, and

Antidotum: naloxone (0.8 to 2.0 mg IV Antidotum: naloxone (0.8 to 2.0 mg IV bolus) .bolus) .

Treatment of hypotensionTreatment of hypotension

• Systolic BP < 70 mmHg Systolic BP < 70 mmHg

Administer : Norepinephrine 0,5 to 30 Administer : Norepinephrine 0,5 to 30 gg

• Systolic BP 70 to 100 mmHgSystolic BP 70 to 100 mmHg

Administer : Dopamin 5 – 15Administer : Dopamin 5 – 15g/kg per g/kg per minute minute

• Systolic BP 70 – 100 mmHgSystolic BP 70 – 100 mmHg

Administer : Dobutamine 2 – 20Administer : Dobutamine 2 – 20g/kg/minute g/kg/minute IVIV

Rationale of the DrugsRationale of the Drugs

DopamineDopamine

Stimulates both adrenergic and dopaminergic Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effects depend on the receptors. Hemodynamic effects depend on the dose. Lower doses stimulate mainly dopaminergic dose. Lower doses stimulate mainly dopaminergic receptors that produce renal and mesenteric receptors that produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation. Cardiac stimulation and renal vasodilation is produced by higher doses.vasodilation is produced by higher doses.Positive inotropic agent at 2-10 mcg that can lead Positive inotropic agent at 2-10 mcg that can lead to tachycardia, ischemia, and dysrhythmias. Doses to tachycardia, ischemia, and dysrhythmias. Doses >10 mcg cause vasoconstriction, which increases >10 mcg cause vasoconstriction, which increases afterload.afterload.

Prompt assesment and treatment will lead to favorable outcome

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Tanda klinis Shock, hipoperfusi,Gagal Jantung Kongestif, Edema Paru Akut

Permasalahan yang menyerupai ?

Tanda klinis Shock, hipoperfusi,Gagal Jantung Kongestif, Edema Paru Akut

Permasalahan yang menyerupai ?

Edema Paru AkutEdema Paru Akut Gangguan VolumGangguan Volum Gangguan PompaGangguan Pompa Gangguan LajuGangguan Laju

Takikardilihat algorithm

Takikardilihat algorithm

Bradikardilihat algorithm

Bradikardilihat algorithm

Tekanan darah?

Tekanan darah?

1– Edema Paru Akut• Furosemide iv 0.5 – 1.0 mg/kg• Morphine iv 2 – 4 mg• Nitroglycerin SL•Oxygen/intubasi sesuai kebutuhan

1– Edema Paru Akut• Furosemide iv 0.5 – 1.0 mg/kg• Morphine iv 2 – 4 mg• Nitroglycerin SL•Oxygen/intubasi sesuai kebutuhan

Berikan :• Cairan• Transfusi darah• Intervensi penyebab spesifikPertimbangkan vasopressin

Berikan :• Cairan• Transfusi darah• Intervensi penyebab spesifikPertimbangkan vasopressin

TD Systolic > 100 mmHg

TD Systolic > 100 mmHg

TD Systolic 70 s.d 100 mmHgTanda/ gejala shock (-)

TD Systolic 70 s.d 100 mmHgTanda/ gejala shock (-)

TD Systolic 70 s.d 100 mmHgTanda/ gejala shock (+)

TD Systolic 70 s.d 100 mmHgTanda/ gejala shock (+)

TD Systolic < 70 mmHgTanda/ gejala shock (+)

TD Systolic < 70 mmHgTanda/ gejala shock (+)

TD SystolicBP defines 2nd

Line of action(see below)

TD SystolicBP defines 2nd

Line of action(see below)

• Norepinephrine iv 0.5 – 30 mcg/min

• Norepinephrine iv 0.5 – 30 mcg/min

• Dopamine iv 5 – 15 mcg/kg/min

• Dopamine iv 5 – 15 mcg/kg/min

• Dobutamine iv 2 – 20 mcg/kg/min

• Dobutamine iv 2 – 20 mcg/kg/min

•Nitroglycerin iv10 – 20 mcg/min Pertimbangkan•Nitroprusside iv0.1-5 mcg/kg/min

•Nitroglycerin iv10 – 20 mcg/min Pertimbangkan•Nitroprusside iv0.1-5 mcg/kg/min

2nd - Acute pulmonary edema• Nitroglycerin / nitroprusside jika TD > 100mmHg• Dopamine jika TD 70 – 100 mmHg, Tanda/ gejala shock (+)•Dobutamine jika TD > 100 mmHg, Tanda/ gejala shock (-)

2nd - Acute pulmonary edema• Nitroglycerin / nitroprusside jika TD > 100mmHg• Dopamine jika TD 70 – 100 mmHg, Tanda/ gejala shock (+)•Dobutamine jika TD > 100 mmHg, Tanda/ gejala shock (-)

Untuk diagnostik/terapi lebih lanjut pertimbangkan :• Kateter Arteri Pulmoner• Pompa Balon Intra-aorta• Angiography untuk IMA/ iskemi• Additional diagnostic studies

Untuk diagnostik/terapi lebih lanjut pertimbangkan :• Kateter Arteri Pulmoner• Pompa Balon Intra-aorta• Angiography untuk IMA/ iskemi• Additional diagnostic studies