Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion

Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.


Sympathetic Crashing Acute Pulmonary Edema (SCAPE), or flash pulmonary edema, is the extreme end of the acute pulmonary edema spectrum. A sympathetic surge occurs as a result of decreased systemic perfusion resulting in further increases in afterload, causing the patient to decompensate. Patients can decompensate quickly, therefore patients require rapid interventions. The use of high-dose nitroglycerin (HDN) has been a topic of interest as it is believed to achieve preload and afterload reduction. However, its use continues to be controversial due to concerns of drug induced hypotension, syncope or paresthesia. Although there are Free Open Access Medical Education (FOAM) based podcasts as well as few studies to suggest the use of HDN, the evidence is limited by statistical flaws, incomplete dosing parameters and inconsistent methods of administration. In order to address these limitations, a protocol at our ED was created to ensure the safe and effective use of HDN. Here, we present a case of HDN use for the management of SCAPE based on this protocol.

Publication types

  • Case Reports

MeSH terms

  • Aged, 80 and over
  • Atrial Fibrillation / complications
  • Clinical Protocols
  • Dyspnea / etiology
  • Humans
  • Hypertension / complications
  • Infusion Pumps
  • Male
  • Nitroglycerin / administration & dosage*
  • Pulmonary Edema / drug therapy*
  • Pulmonary Edema / etiology*
  • Vital Signs / drug effects


  • Nitroglycerin