ACUTE PULMONARY EDEMA,

HYPOTENSION,
SHOCK
JetSed

Clinical presentation
History :
Short of breathness
Weakness
Palpitation
Chest pain
Faintness
Light headedness

Clinical presentation
Clinical sign and symptoms :
Anxiety or agitation
Confusion
Hypotension
Tachycardia
Bradycardia
Tachypnoe
Cyanosis
Cool, clammy skin
Decreased or no urine output
Pallor
Profuse sweating, moist skin

Diagnosis
Acute Pulmonary Edema
Hypovolemic shock
Pump problem
Rate problem

Further Assesment to Establish

Diagnosis and Start Treatment
1. Hypovolemic shock?

Find the underlying causes :

- Diminished blood volume resulting from excessive loss
of other body fluids (such as can occur with diarrhea,
vomiting, burns,and so on)
- external bleeding (from cuts or injury), bleeding
from
the gastrointestinal tract, or other
- Internal bleeding
Administer
- Fluid
- Blood transfusion
- or specific interventions

Further Assesment to Establish

Diagnosis
2. Rate problem?
Diagnosis established from ECG

Tachycardia (Atrial fibrillation/flutter,Narrow

complex
tachycardia, Stable wide complex
tachycardia,Stable
monomorphic VT and/or
polymorphic VT)

Bradycardia

Follow the tachycardia or bradycardia algorithm

Further Assesment to Establish

Diagnosis
3. Pump problem?
History of cardiac disease
(such as prior myocardial infarction, hypertension,
familial
heart disease, etc)
Clinical sign and symtoms :
Find more specific sign cardiac disease
(such as apical impulse is displaced laterally
Cardiac auscultation may reveal aortic or mitral valvular
abnormalities, S3 or S4 )

Possible pump problem?

Further test :
Chest x-ray, ECG
Is the patient hypotension?
Treat hypotension and the underlying
causes of pump problem

Further Assesment to Establish Diagnosis and Start

Treatment

4. Acute Pulmonary edema?

Find these clinical sign and symptoms :
Dyspnea at rest and on exertion
Orthopnea and paroxysmal nocturnal dyspnea
(PND)
Cough productive of pink, frothy sputum is
highly suggestive of CHF.
Extremity edema

Acute pulmonary edema

Physical examination:
Peripheral edema, jugular venous
distention, and tachycardia
Tachypnea, using accessory muscles of
respiration
Wheezing or rales may be heard.
Pulsus alternans (indicative of depressed
LV function)

Acute Pulmonary Edema

Chest x-ray might reveal :

Kerley B lines : the early signs

(interstitial edema)
"butterfly" pattern : marked the
alveolar edema
cardiac enlargement may be seen

ACUTE PULMONARY EDEMA

TREATMENT
Begin treatment with the ABCs.

Administer oxygen, 100%

nonrebreather facemask.
Cardiac monitoring and continuous
pulse oximetry.
Intravenous access
Medication and non medication
treatment

Treatment of Acute Pulmonary

Edema
Medication :
Administer :
Furosemide IV 0,5 to 1,0 mg/kg
Morphine IV 2 to 4 mg
Nitroglycerine SL, continued
with nitroglycerine IV drip as
long as systolic BP > 100 mmHg

TREATMENT OF ACUTE
PULMONARY EDEMA
Non Medication
Elevate the head of the bed.
- Patients may be most comfortable in a
sitting position with their legs dangling
over the side of the bed, which allows for
reduced venous
return and decreased
preload.

Morphine
Cautious !!
It should not be given to patients with
decreased sensorium or respiratory
drive, as it may bring about respiratory
arrest.
Prepare!!
Rescucitation aid, and
Antidotum: naloxone (0.8 to 2.0 mg IV
bolus) .

Treatment of hypotension
Systolic BP < 70 mmHg
Administer : Norepinephrine 0,5 to 30 g
Systolic BP 70 to 100 mmHg
Administer : Dopamin 5 15g/kg per minute
Systolic BP 70 100 mmHg
Administer : Dobutamine 2 20g/kg/minute
IV

Rationale of the Drugs

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

Prompt assesment and

treatment will
lead to favorable
outcome

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Makassar, Bandung and Medan..

Tanda
Tandaklinis
klinisShock,
Shock,hipoperfusi,
hipoperfusi,
Gagal
Jantung
Kongestif,
Edema
Gagal Jantung Kongestif, EdemaParu
ParuAkut
Akut
Permasalahan
yang
menyerupai
?
Permasalahan yang menyerupai ?

Edema
EdemaParu
ParuAkut
Akut

Gangguan
GangguanVolum
Volum

Gangguan
GangguanPompa
Pompa Gangguan
GangguanLaju
Laju

Bradikardi
Bradikardi
lihat
lihatalgorithm
algorithm
11Edema
EdemaParu
ParuAkut
Akut
Furosemide
iv
0.5
Furosemide iv 0.51.0
1.0mg/kg
mg/kg
Morphine
iv
2

4
mg
Morphine iv 2 4 mg
Nitroglycerin
NitroglycerinSL
SL
Oxygen/intubasi
Oxygen/intubasisesuai
sesuaikebutuhan
kebutuhan

Berikan
Berikan: :
Cairan
Cairan
Transfusi
Transfusidarah
darah
Intervensi
penyebab
Intervensi penyebabspesifik
spesifik
Pertimbangkan
vasopressin
Pertimbangkan vasopressin

Tekanan
Tekanan
darah?
darah?

Takikardi
Takikardi
lihat
lihatalgorithm
algorithm

TD
TDSystolic
Systolicnd
BP
defines
BP defines22nd
Line
Lineofofaction
action
(see
below)
(see below)

TD
TD
TDSystolic
Systolic
TDSystolic
Systolic
<<7070mmHg
70
s.d
mmHg
70 s.d100
100mmHg
mmHg
Tanda/
gejala
shock
(+)
Tanda/
gejala
Tanda/ gejala shock (+) Tanda/ gejalashock
shock(+)
(+)

Norepinephrine
Norepinephrine iviv
0.5
0.53030mcg/min
mcg/min

Dopamine
Dopamine iviv
551515mcg/kg/min
mcg/kg/min

TD
TDSystolic
Systolic
7070s.d
s.d100
100mmHg
mmHg
Tanda/
gejala
Tanda/ gejalashock
shock(-)(-)

Dobutamine
Dobutamine iviv
222020mcg/kg/min
mcg/kg/min

22ndnd- -Acute
Acutepulmonary
pulmonaryedema
edema
Nitroglycerin
/
nitroprusside
jika
Nitroglycerin / nitroprusside jikaTD
TD>>100mmHg
100mmHg
Dopamine
jika
TD
70

100
mmHg,
Tanda/
Dopamine jika TD 70 100 mmHg, Tanda/gejala
gejalashock
shock(+)
(+)
Dobutamine
jika
TD
>
100
mmHg,
Tanda/
gejala
shock
(-)
Dobutamine jika TD > 100 mmHg, Tanda/ gejala shock (-)
Untuk
Untukdiagnostik/terapi
diagnostik/terapilebih
lebihlanjut
lanjutpertimbangkan
pertimbangkan: :
Kateter
KateterArteri
ArteriPulmoner
Pulmoner
Pompa
Balon
Intra-aorta
Pompa Balon Intra-aorta
Angiography
Angiographyuntuk
untukIMA/
IMA/iskemi
iskemi
Additional
diagnostic
studies
Additional diagnostic studies

TD
TDSystolic
Systolic
>>100
100mmHg
mmHg

Nitroglycerin
Nitroglyceriniviv
10102020mcg/min
mcg/min
Pertimbangkan
Pertimbangkan
Nitroprusside
Nitroprussideiviv
0.1-5
0.1-5mcg/kg/min
mcg/kg/min