All of the following are used in the initial management of acute life threatening cardiogenic pulmonary edema, except:
Correct Answer: Digoxin
Description: Answer is A (Digoxin) Digoxin has no definitive role in the management of Acute Pulmonary Edema `Digitalis is not the initial drug of choice for management of patients with acute severe pulmonary edema (severe hea failure) because of its mild inotropic effect and because of the delay in time to peak action. It should not be used in the management of acute cases, in the absence of atrial arrhythmias as its use may complicate an already difficult management problem. Digoxin is only recommended if the patient is in atrial fibrillation and this is contributing to the cardiac failure - 'Circulation' Journal of American Hea Association Digoxin is not recommended in acute pulmonary edema unless there is associated rapid atrial fibrillation. Rapid atrial fibrillation in this situation is better treated with urgent cardioversion' - 'Coronary care manual by Thompson (Elsevier) 2"a/508 `Digoxin has no definitive role in the management of acute congestive hea failure (acute pulmonary edema) ' - Clinical Emergency Medicine (Cambridge University Press) 2005/499 `Once a mainstay of treatment because of their positive inotropic action digitalis glycosides are rarely used at present. However they may be useful for control of ventricular rate in patient with rapid atrial fibrillation or flutter with LV dysliinction' Initial Management of Acute Pulmonary Edema (Acute Hea Failure) Oxygentation with face mask or Positive Pressure Ventilation (Non invasive) Vasodilatation by Nitrates (or Nitroprusside) Diuretic therapy by Furosemide (or other loop diuretics) Morphine for relief of physical psychological stress and to improve haemodynamics. Ino ropes should be used based on clinical and haemodynamic parameters of the at ent who does not respond to initial treatment. Pulmonary Edema Oxygen and Ventilatory Suppo Morphine Vasodilators Diuretics Inotropic Agents * Supplemental oxygen Morphine diminishes Vasodilators are Diuretics are Inotropic agents are The maintenance of anxiety and decreases indicated in most recommended for indicated in the Sa02 within normal limits (95-98%) is sympathetic outflow, thereby reducing both patients with acute pulmonary edema initial management of acute severe management of Acute pulmonary edema in the impoant to maximize venous and aerial (AHF) as first line pulmonary edema presence of peripheral oxygen delivery to vasoconstriction therapy if especially in the hypoperfusion tissues resulting in decreases associated with presence of (hypotension/reduced renal * Non invasive in ventricular preload adequate blood symptoms function) with or without ventilatio n (without ( w and after load. pressure and signs secondary to fluid congestion or pulmonary endotrachial * Morphine is of congestion with retension (Reduce edema refractory to intubation) recommended for the low diuresis to Alveolar Edema) di iuretcs and vasodilators at CPAP or Non invasive treatment of Acute open the peripheral * Intravenous optimal doses. positive Pressure severe pulmonary circulation and to administration of * Dobutamine/Dopamine Ventilation (NIPPV) edema especially if lower preload. Loop Diuretics * Phosphodiesterase The use of CPAP and associated with * Nitrates (Furosemide, Inhibitors (Milrinone / NIPPV in Acute restlessness and (sublingual/Intrave Bumetonide or Enoximone) Cardiogenic dyspnea (effectively nous) (Agent of Torasemide) is the * Levosimenden Pulmonary Edema is ameliorates choice) preferred choice * Norepinephrine/ associated with a symptoms) * Nitroprusside due to their strong Epinephrine significant reduction (Associated and brisk diuretics in the need of tracheal intubation and mechanical ventilation. Hypeensive Crisis) * Nesiritide effect. Digoxin is not recommended as on inotrope for the management of Acute pulmonary Edema because of its mild inotropic effect and delay in time to peak action (slow action). Digoxin may be selectively considered for patients with Atrial Fibrillation where AF is contributing to cardiac failure / pulmonary edema.
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