SCAPE

Increased afterload –> to pulm edema –> stress response with epi/NE/etc –> vasoconstriction –> afterload increase and the cycle continues

Workup: basic labs (including BNP), ekg, cxr, can do US/echo (can be normal or reduced EF)
-Concern if BNP >500
Treatment: BIPAP/CPAP for PPV, nitro drip (start at 100mcg/min and titrate from there, can give sublingual in the meantime while setting up drip)
-most are fluid down so don’t diurese (i.e. no Lasix right away, confirm fluid status first)
-Can wean BIPAP/CPAP once pt’s BP is at their normal and nitro <50mcg/min. Wean PEEP by 2 q10min, if patient doesn’t tolerate then turn back up. Once below PEEP 5 then can attempt switch to NC
-Can start ACE-I (enalapril/captopril) as patient improves
-Morphine can make some more comfortable but poor support for it overall

WPW and SVT

SVT: AVNRT and AVRT
AVNRT: abnormal circuit going round and round in the AV node, goes down septum so narrow
AVRT: doesn’t use AV node but rather accessory pathway (WPW), so often wide

WPW: 2 conduction pathways (AV node and accessory pathway), accessory pathway doesn’t have the pause that AV node provides thus PR is shortened and QRS broadens (can be wide, usuall 110s) and sloping upstroke (delta wave).
-Orthodromic and Antidromic
-Orthodromic has the impulse come back up the accessory pathway and going back into AV node. Antidromic is the opposite.
-Orthodromic is narrow because conducting through the AV node and bundle of His (looks like normal AVNRT)
-Antidromic is wide because it conducts through the ventricle, looks like VTach
-WPW+AFib: accessory pathway allows a lot of the atrial impulses to go down that are normally blocked by AV node. Looks like AFib with aberrancy but rate between some beats can be up to 300bpm. Also get some variation beat to beat in QRS structure, some will be narrow and some will be wide, overall different QRS morphologies of the different beats.

Adenosine blocks AV node, CCB and amiodarone slow AV node conduction. So Adenosine will return orthodromic WPW tachycardia to normal WPW ekg/rhythm. If antidromic then shock if unstable or procainamide because procainamide blocks the accessory pathway. Also, use procainamide or shock if WPW and AFib.

Pharmacy Pressor Lecture (A=alpha, B=Beta, doses in mcg/kg/min unless specified)

Vasopressors: vasopressin and phenylephrine (increase SVR)
Ionotropines: dobutamin, milrinone, isoproterenol (increase CO)
Inopressors: NE, epi, dopa (SVR and CO increase)
Beta-1 increases myocardial contractility and chronicity
Alpha-1 is arterial smooth muscle contracture

Vasopressin acts on V1 (vasoconstrict) and V2 (fluid resorption in kidney, slower) receptors
Dose is 0.3U/min, no more, no less. NE sparing effect. Can cause tissue ischemia and other ischemia at higher doses.

Dopamine: 0.5-5mcg/kg/min primarily hits dopamine receptors, but as you increase it hits B-1 (5-10mcg), and at 10-20 you hit A receptors. More arrhythmia than NE. Usually start around 5mcg/kg/min, max 20mcg/kg/min.

NE: strong A with some B. Start at 0.02mcg/kg/min (can start 0.1 or 0.2 if really needing it) and max 0.8mcg/kg/min. Too high can cause peripheral and GI ischemia.
-Safe to give up to 24hrs peripherally

Epi: mainly B activity below 0.05, then above you get more A activity. Starting dose 0.02, max 0.8

Phenylephrine: strong A only, start 0.5mcg/kg/min, max at 3. Reflex bradycardia and tachyphlaxis are possible adverse reaction.

Dobutamine (Do-beta-mine): Almost all Beta (1>2), start 2.5, max 20, used for HF and symptomatic brady, does increase myocardial demand

Milrinone: PDE-3 inhibitor, Start 0.125, max 0.75. Increases contractility and improves relaxation. Vasodilation leading to hypotension is adverse effect

Weight-based dosing: ideal BW for the morbid obesity. Can always titrate.
If extravasation: Stop infusion, aspirate as much fluid as possible, warm compresses for 30mn q4hrs for 24hrs, give phentolamin (5-10mg diluated in 10ml NS) injected in affected site

Cardiogenic shock: first line is NE, if low output can consider adding Epi
Hypovolemic shock: Stop the bleed and replace volume, pressors not recommended, adequately resuscitate before any pressor
Neurogenic shock: MAP goal >85, NE phenylephrine or dopa (>10mcg) but NE #1
Septic shock: NE then add vaso if needed. If refractory to pressors -> hydrocortisone 50 q6hrs

Push-dose pressors: Phenylephrine and epi
-Phenylephrine: concentration 100mcg/ml, giving 0.5-2ml q2-5min, onset 1min, lasts 10-20min. Good for patients who are hypotensive and tachy
Our code phenylephrine sticks are 1mg/10ml which are the correct concentration
-Epi: 10mcg/ml, dose 0.5-2ml every 2-5min.
Our code epi sticks are 1mg/ml, to make the push dose concentration mix 1ml from code epi into 9ml of NS and you get appropriate concentration.