Emerge in EM

E11: DDX- SCAPE

• Mohamed Hagahmed

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🎙️ Podcast Episode Intro – DDX:SCAPE | Picklesburgh Pulmonary Panic

What happens when a 50-year-old man suddenly can’t breathe—right in the middle of the Picklesburgh festival? 🥒😯

Join Dr. Hagahmed and Dr. Addy as they walk through a high-stakes emergency case of acute dyspnea in a patient with a history of hypertension, hyperlipidemia, and diabetes. From scene safety and rapid assessment to high-flow oxygen, CPAP, and beyond, they break down the critical steps in recognizing and managing SCAPE—Sympathetic Crashing Acute Pulmonary Edema—a diagnosis that goes beyond your typical CHF flare.

You’ll hear key insights into:

  • How to prioritize ABCs under pressure
  • When to think SCAPE vs. CHF
  • The role of nitroglycerin and non-invasive ventilation
  • Why early recognition saves lives

By the end, the patient stabilizes—but not before offering powerful teaching points for every emergency provider.

🎥 Want to see the case play out?
Watch the full video on our YouTube channel: EMERGE in EM
👉 https://youtube.com/@emergeinem?si=27-MFKEHQKRXGVhH

Subscribe, listen, and always be ready to ask:
What would you do?

Mohamed:

What's up everyone? This is Mohamed Hagahmed, and I've always wanted to start a case discussion and I found this to be the best opportunity. To discuss a case and go over differential diagnoses, and I thought about a name, what to call this series. So DDX came in mind and DDX stands for Differential Diagnoses. The goal of this video is to go over a real medical case and put our investigation hat on. And try to figure it out. And this time I am joined by a good friend of mine, the friendliest Canadian citizen you could ever meet in your life is Dr. Addy. Thank you so much for joining me, man. How you've been?

Addy:

Good, I'm happy to hang out with you for a little bit and talk about this so I'll actually start us off with this case. So Mo, you are, let's say that you're one of the EMS physicians and you're being called to the scene. The setting is Picklesburgh, which for those of you not from Pittsburgh, it is a festival for nothing but pickles. And there you have a patient chief complaint is sudden onset dyspnea just cannot breathe. Feels like he just cannot get any air into his chest. He's 50 years old. Past medical history, hypertension, hyperlipidemia, diabetes. Vitals as you see here, heart rates 110. BP is 210/110. Resps are 32. And per his initial SPO2, he is Satting 84% on room Air. Mo, if you come to the scene and you see this kind of patient, what are some of the first things that run through your mind?

Mohamed:

I first gotta make sure the scene is safe and not that many pickles being thrown at me.

Addy:

That's always a concern.

Mohamed:

Addie, come on, we gotta explain to people what Picklesburgh is, so what type of food? And drinks, by the way, guess what you can find in Picklesburgh?

Addy:

I'm gonna guess and say probably pickles.

Mohamed:

pickle juice. I don't know about you. I don't like pickle juice. Pickle sandwiches. I don't know. Dressings, all types of salt fest. Okay, so I show up on the scene, nobody throwing pickles at me. The scene is safe and I find my patient. So my first priority would be like, what do they look like? Are they in obvious distress?

Addy:

Yeah, let's say that when you take a look at them, the first thing you notice is they are breathing hard and they're breathing fast. They appear to be in distress speaking to you in three to four word sentences at a time using accessory muscles to breathe.

Mohamed:

So I am the clinician on site. So my first priorities are ABCs, so I'm gonna put some oxygen on them. Obviously ask them more questions. First trying to get them more comfortable. Put'em on a chair, on a stretcher. Depending on where they are, I might need to think about extricating them and how I'm gonna move them to the truck, to the ambulance depending on the crowd. So I need some help. Okay, so let's say the patient is now lying on a stretcher inside the ambulance. My priorities are now oxygen. Maybe trying to get some IV access and some more history. So my first question is, how are you today, sir? What's going on today?

Addy:

I just, I can't breathe. It started suddenly. I was at Picksburg, I had my pickle shot. I had my pickle sandwich. I even had some pickle ice cream. And then I just started to notice that I was having worsening trouble breathing. I have no other symptoms. I don't have any pain in my chest, nausea, vomiting, anything like that. I just feel like I can't breathe. And let's say he says that with a little bit more urgency than I am sitting here chilling out

Mohamed:

So that would be my second question is how is the worker breathing? Are there like an obvious distress, meaning that they're using accessory muscles, they're restless, agitated.

Addy:

all of the above. They just appear to be working harder and harder to breathe as you speak to them in the truck.

Mohamed:

So this is probably the guy that I might not need to ask that many questions as much as I would like to know and solve this puzzle. But I try to maybe stabilize them first. So high flow oxygen, see how they do with that. And by high flow, maybe 15 liters nonrebreather mask. Are they getting any better with the

Addy:

That their SP O2 has increased from 84% to a whopping 86%, but you do not see any improvement in their work of breathing.

Mohamed:

Okay, so now I'm concerned I don't want'em to get tired. Probably I would move sooner to applying CPAP in that case. And obviously in a pre-hospital setting, they have CPAP, they don't have BPAP. So I would start at maybe 10 initial pressure for inspiratory pressure and see how they're doing with that. And at the same time I decided on a CPAP. Hopefully maybe my partner can help me with getting an IV access and I'll do a kind of a quick physical examination. So I'll look at the head. Obviously there are other diaphoretic or

Addy:

sweaty They appear diaphoretic and you see a little bit of peri oral cyanosis.

Mohamed:

Okay. What about the neck? Am I seeing any JVD or tracheal deviation?

Addy:

a good question. You are seeing a big plump JVD, like the perfect ej, if you wanted deal like that. Much of jugular venous distention. No tracheal deviation.

Mohamed:

Okay, so sir, how many pickles have you eaten today?

Addy:

I, I lost count. I.

Mohamed:

Okay, so JVD are present bilaterally. Now I'm gonna go to the cardiopulmonary examination. What am I hearing? A breath sounds present bilaterally. Equal bilaterally. What about the heart tones?

Addy:

so you hear we'll start off with the heart actually. So heart tones you hear, heart sounds one and two, they appear normal, just tachycardic. When you listen to the breath sounds, you hear wheezing bilaterally.

Mohamed:

Oh, okay. Wheezing. Wheezing, okay. Interesting. Can be a reactive bronchospastic. Multiple pathologies. What about the belly? Any signs of any traumatic injuries or ascites? And as I go down on my examination, I'm looking at them. Anything on the feet, meaning that I'm not expecting pedicure, I'm expecting any type of pedal edema or anything like that.

Addy:

Yes, you actually, do you see some pedal edema on the bilateral lower extremities? Not a whole lot, but just enough to make you go, Ooh, that appears abnormal.

Mohamed:

Okay so far I'm leaning towards the volume overload kind of state. Maybe they're in acute pulmonary edema. So I think that's a good point to bring up is how many of you actually check for pedal edema? And I would tell you, like all my patients, like I like to expose extremities and just to kinda get an idea of what their volume status, I use that as my kind of. Surrogate marker. And then in addition to the JVD and the shortness of breath and the overall clinical setting, I'm thinking this is likely gonna be SCAPE or sympathetic crashing, acute pulmonary edema. In that setting, how are they feeling with the CPAP?

Addy:

So now that you have the CPAP on them, you do see that their spo O2 has gone up to 90% and you notice that their workup breathing has improved slightly. They feel. A little bit better. Can you walk me through how you got to that differential of pulmonary edema?

Mohamed:

Yeah. So I'm thinking now given the story, the location of this and the likely comorbidities they might have other like cardiovascular conditions in addition to the large load of salts in this. Big giant festival. Probably this is a patient that is now going into the SCAPE pulmonary edema route. Given the acute insult either of medication, maybe non-adherance or the high salt intake that probably played a role in this. Now, clinically, I tell you his picture, even though you told me that he was wheezing. I'm more leaning toward a volume overload versus a reactive airway disease. And I know, some of you might think, oh, wheezing is always COPD or asthma. I beg to differ and I'll tell you that wheezing can also happen in pulmonary edema. Is that right, Addie? What's, what's

Addy:

That's absolutely, I think I think understandably we get anchored into thinking, oh, wheezing, it has to be an obstructive lung process, but wheezing can occur because of the actual edema pressing on those bronchials and causing turbulent airflow. That just means that if you're having a patient that you're suspecting of volume overload, that's wheezing on exam, who that means that they are having a lot of pulmonary edema and they need treatment quick.

Mohamed:

And honestly, Addie, I don't wanna anchor either, so that's why I'm asking all these questions because I still wanna make sure that I got my diagnosis or my preempt diagnosis right. Obviously I don't wanna give them, CPAP and they're having, I don't know. Maybe something else. Intra thoracically. Intra abdominally. So I definitely don't wanna rule out other life-threatening conditions. So thinking of things I might be thinking about are. Let's say, acute pulmonary edema obviously is one. PE, pulmonary embolism, occlusive MI. So this is definitely the guy that I really want to get an EKG as soon as possible. I definitely wanna also consider maybe signs of sepsis or cardiac issues, like a mitral valve issue. Is this like an acute tricuspid regurg issue? Is this a global, cardiomyopathy? Pericarditis. Tamponade, of course, dissection. All these things like are coming through my mind, but it sounds like I'm like leaning towards a volume overload status based on the overall story that he was in a high salt inducing festival. And also has all his cardiac comorbidities. And the fact that he was improving also on a CPAP tells me that his oxygenation is improving because of the increased inspiratory pressure. So now I definitely wanna do something about the blood pressure and my go-to in the pre-hospital setting with would be nitroglycerine. In that case, we'll get sublingual.

Addy:

talk me through more about that. Why nitro? Why sublingual? Tell me more about what you're thinking.

Mohamed:

Yeah, so if we're thinking about SCAPE in general, I'm thinking about an increased catecholaminergic surge. And if we think about the exact pathophysiology, obviously you have. This diffuse capillary leak causing the edema in the alveoli, and of course compromising oxygenation and diffusion. So it's causing an increased VQ mismatch. So in that case, that sympathetic surge will cause global systemic vascular resistance or systemic vasoconstriction. So that increase in SVR, so that goes up. With an increase in SVR, you have increased afterload on the heart, and then obviously the LV's output would diminish because of the increased afterload and that backup of. Blood, depending also on their underlying, cardiac conditioning can go back, into the lungs and causing increased pulmonary vascular resistance. And then that can also compromise the right ventricle. LV and RV, I don't know if you know this, they get along very nicely if one fails the one completely like ha.

Addy:

It's a very codependent relationship.

Mohamed:

So probably that's like what's causing all the fluid to back up in the lungs and causing this this person's severe dyspnea and hypoxia.

Addy:

Tell me more about the dosing of nitroglycerin in the pre-hospital setting.'cause that's not my area of expertise.

Mohamed:

Yeah, I know this is like something we discuss in our protocols at least here in the US and in Pennsylvania specifically. But we normally start by giving one sublingual dose of nitroglycerin. So the usual dose is 0.4 milligrams, and if you do the conversion, it's gonna come to 400 micrograms. So that's 0.4 sublingual nitroglycerine. Now I'm gonna ask you this and what is the challenge of giving? Prehospital sublingual, nitro in somebody who looks like him.

Addy:

My biggest challenge is gonna be one, if they're breathing that fast, they are gonna be having insensible losses. Their mouth is gonna be so darn dry, it may be difficult for them to absorb it. It also might be difficult for them to open their mouth to even get the medication in, especially if they've already been slapped onto the CPAP.

Mohamed:

Yeah that's the main challenge is getting the CPAP mask off. And so there is another option, which is. Something you could put as a paste so it can in a patient's skin. But again, you mentioned something in this person's physical examination, which is the diaphoresis or the sweaty skin. This also might compromise,

Addy:

that's a really good point.

Mohamed:

That's like my, I feel like I like paste nitroglycerin. Not on me. The patient. But I feel like it just, it has variable absorption rates and it can, sometimes you really don't know what the patient is getting, so I fear that if I did that maybe too much, I'm not sure what they got. It might compromise the blood pressure. It might make them But the beauty of nitroglycerin is that is only short acting. So even if they become, if they became trans transiently, hypotensive. Hopefully they will bounce back or go back to a normalish blood pressure. But I'll tell you, that's the main challenge. That's why I prefer and I'm sure that's what you do. Also in the hospital. We'll get to the hospital treatment. I prefer intravenous nitroglycerin, and we'll talk about the doses again a bit, but intravenous is more reliable and predictable in the rates of absorption and exactly knowing how much I'm giving that patient.

Addy:

no, absolutely. So let's say that in this patient's case, you give a little bit of sublingual nitroglycerin. And it does help, it does actually help to bring down his blood pressure slightly from 210, let's say the systolic now goes down to 180. When you recheck it, he feels a little bit better. You get that initial EKG like you discussed. And what exactly are you looking for on that? EKG.

Mohamed:

In this clinical setting, obviously I wanna make sure it's not ischemic right? So I don't wanna. I wanna miss an occlusive mi in that case. So I wanna make sure there's no ST segment elevation reciprocal changes, something that would tell me maybe he's having acute occlusive event that would require, cath lab activation in pre, in, in the pre-hospital setting. That's the, that's like the main concern. The other things that I've been looking for, the things like the tachycardia, the maybe signs of LVH or left ventricular hypertrophy. That would tell me maybe this person has just an enlarged ventricle because of just chronic hypertension or maybe a cardiac issue before that he had

Addy:

Love it. So your EKG, you get, and you see no signs of ischemia. You just see sinus tachycardia, but maybe a little bit of left ventricular hypertrophy. This guy's been going to picklesburgh every single year, so I think that's, I think we'll allow him that. What would you do at this point?

Mohamed:

That's who we call in Pittsburgh, a loyal yinzer.

Addy:

So what are you gonna do at this point?

Mohamed:

At this point they're feeling better. I'm gonna continue reassessing them. If I was with the paramedic, I. We'll decide in terms of what hospital to go to, but each hospital in the city has the ability to care for him. But I'm gonna make sure at least, with the nitroglycerine, that the blood pressure is also stable and frequent reassessment. Ooh, I forgot one major point that we need to know in the history before we give a natural, which is.

Addy:

Are they taking it for any other reasons?

Mohamed:

Or Yes. So whether they're taking nitroglycerin or something else or they're taking

Addy:

Sildenafil. Yeah

Mohamed:

Cialis I have to make sure because that would further tank the blood pressure. So I wanna make sure that's not the case before I give the Nitro. So the patient remains stable in the field, Addie, and now I'm bringing that patient to you and they look much more comfortable with the CPAP. So now you have them and I give you this solid handout. And what will be your next step? Discharging them

Addy:

I would probably take a sip of my coffee, start putting in the discharge orders and just quit my shift. Go home, have a nice nap. No. What I would do is at that point I would reassess them myself. I would make sure that the IV access that was obtained in the field is still working for me, is still flushable. Make sure the patient is on our monitor now, ensuring that they are in a rhythm that's compatible with life and recheck their vital signs. So can I have a repeat set of vitals?

Mohamed:

Yeah. It looks like the nurse got multiple vital signs. That's good news. That's a good nurse. So the blood pressure repeatedly so multiple times, anywhere between 140 to 150 systolic. The diastolic between eighties to nineties and heart rate in the low 100. So 105, 108, 110, no higher than 110. He's breathing much better on the CPAP and now obviously being transitioned to your BPAP and oxygenation at around 98%.

Addy:

So at this point, I'd like to go ahead and do another primary survey, making sure that the patient has an intact airway, that there's a good open conduit that's taking place for the airway, making sure that to take a good listen to those bilateral breath sounds. Do I hear crackles? Do I hear wheezing as That'll help to inform my treatment. And as well, just make sure that from a circulatory standpoint, he is supporting his own circulation. So let's say that he is still hypertensive. Let's even jack up that number a little bit higher since probably the nitro wore off by this point. Let's say he is enough to like 160's, 170's. The clinical picture that was given to me by EMS would also make me be concerned for flash pulmonary edema. So like you correctly stated, I would transition this person over to BPAP while he is still undifferentiated, and maybe just prior to initiating any further IV treatments. I would probably ask for a couple things. One is a repeat EKG in the ER.'cause again, thinking of my worst first, my priorities, an EKG would change this patient's management completely as I'd be thinking more about a STEMI or some sort of myocardial infarct. And I would also reach for my ultrasound too.

Mohamed:

So you do a basal ultrasound and it just showed some LV dysfunction. Enlarged left ventricle. No signs of global hypokinesis, no, no effusion, no tamponade, physiology, and no right ventricular abnormalities, like no septal, bowing, or enlarged right ventricle

Addy:

Good. And how about the lung exam on ultrasound?

Mohamed:

yeah. So you see some B lines bilaterally and B lines are indicative of what?

Addy:

They're usually, if they're asymmetric in their bilaterally, they indicate some form of interstitial edema. So in this clinical setting, you have this patient with a history of hypertension, hyperlipidemia, hypoxemic, and respiratory distress with bilateral B lines with an elevated JVD also would feel comfortable calling this SCAPE or sympathetic crashing acute pulmonary edema. In particular on the hospital side of things that I would ask my, my providers to look out for when they, these patients get transported is for evidence of. A quite a dramatic tachycardia, 110 to 120 to 140's, a dramatic hypertension as well. With all those signs of pulmonary overload that would make me immediately concerned and that changes my priorities right away. We have this patient on BPAP and it's making sure that I titrate the BPAP to ensure that the patient gets good oxygenation, focusing particularly on the peep. And this is the point where I start reaching for my nitroglycerin. And this is where things start to get controversial and it depends where you work. My personal belief with IV nitroglycerin in particular if for these kind of patients is you gotta hit'em hard and hit'em fast. The amount that I provide is I actually do a bolus of a thousand to 2000 micrograms of nitroglycerin over two minutes. That's given as a bolus dose. Subsequently, I put the patient on a micro, on a nitro drip, starting at about 400 mics, titrating all the way up to 800 mics. And my goal is to get their systolic blood pressure under 140 as that under 140 number means that I am heavily reducing the afterload and therefore improving forward flow. The biggest caveat of this is that our nursing colleagues that are starting this, especially if they're not comfortable with those dosings, it is important for us to talk through our reasoning as to why we are going with such high dosing.

Mohamed:

Yeah, I think that was the main challenge I feel like in, in those cases.'cause these large doses can freak people out. I.

Addy:

They freak me out.

Mohamed:

You sure you know what you're doing, doctor? I dunno what medical school you have there in Canadian, in the US we have a different type of medical school system. I don't know, if people like, get sometimes uncomfortable with those large doses. I usually give a little bit of education that this is actually, I. The prehospital dose, which is a sublingual 0.4 milligrams, is actually 400 microgram. We do it a milligram, two milligrams intravenously. And these are, the just a single sublingual dose is 400 micrograms. So I think that you know that with that education the staff now is more comfortable in giving it. And obviously you already started the, you started the IV drip. Now my question to you add is like, why this is not just CHF exacerbation. I don't know

Addy:

Yeah.

Mohamed:

what's the difference between that and SCAPE like. Why we call it? Obviously we discussed the pathophysiology of SCAPE, but what is the difference between SCAPE and simple congestive heart failure exacerbation?

Addy:

I actually just came up with a good analogy on the spot, so I hope this works. Let's say that you have a plate and you have a cup on that plate. The cup is full of water and it's always full of water, and that cup full of water represents your central volume status for a patient that is having a CHF exacerbation. So they have this history of heart failure, and let's say they drank a lot of. Coca-Cola and had a lot of pickles and they already have that history. They have this insidious onset of worsening volume overload, which causes severe pitting. Peripheral edema. It causes a gradual worsening dyspnea, and that's almost as if you are pouring more water onto that cup, and it starts overflowing onto the plate. As opposed to in SCAPE something hit this patient hard, something caused this patient to have a severe sympathomimetic release. So instead of adding more water to the cup, what's actually taking place is the water that's already in the cup is being redistributed because of that high sympathetic surge. And where is it being dis redistributed to? The lungs. And so therefore the difference that you will notice is particularly on physical exam, less evidence of chronic overload. You may see a little bit of pedal edema, but this is not that dramatic bloated appearance that you see for a lot of CHF patients. You actually just see maybe some elevated JVD, but for the most part, they appear almost euvolemic on exam other than the lung exam.

Mohamed:

this is, by the way, a great analogy, but also I feel like who have a baseline congestive heart failure. When they have those exacerbations, they don't generally present acutely as SCAPE. The rapid fluid shifting from the splanchnic, blood vascular bed into the systemic bed, and then into the lungs in turn, because of the increased afterload and the systemic vascular resistance going up. So these folks on that have congestive heart failure. Usually we see them present with exacerbation if they miss a medication. If their medication adjustment is not appropriate or for them, or dietary, usually dietary habits gone outta whack, Thanksgiving and whatnot, other events or high salt intake or decrease physical activity. So you see that decline in their functioning over days versus this guy, this patient that we saw acutely in the festival. Having shortness of breath and then boom, that's the trigger that hit him so hard. So yes, this is what I see most commonly. And I, and again, yes you are right. You, in both patients, you'll see some signs of volume overload. The crackles, maybe wheezing, the pitting edema, I would argue sometimes in SCAPE. If it's that rapid and that acute, you might not see pitting edema, and I think you mentioned that briefly. You might not see pitting edema, it'd just be too early.

Addy:

One of my, one of my favorite questions to ask young learners when I have a patient in SCAPE is. Should we give this patient diuretics and young learners will oftentimes say yes because they understandably are confusing these two distinct physiological processes in SCAPE. Actually, if you give the patient diuretics, you may actually cause them to become hypovolemic, and that may actually worsen the issue taking place,

Mohamed:

Yeah. They might end up needing diuretics later, but not in the acute treatment phase.'cause again, some of the patients might have a baseline. Cardiac dysfunction maybe a lower EF. And then they have a kind of a, a combined conditions. Both of them like have heart failure and then the trigger cause SCAPE, so they might need diuretics later. But in the acute phase, we have to focus on turning off the switch that catecholaminergic surge. So the catecholamines, we need to bring it back to baseline. Shifting fluid around controlling the blood pressure and improving oxygenation in order for us to improve that VQ mismatch. And that's what they need. Now, let me ask you this. Do you give these people fluid boluses?

Addy:

That's a really good question. It really depends on what I'm seeing on my exam. The standard answer the non-thinking answer would be no. Of course not. They're fluid overloaded. But as we're harping on right now, these patients, they may actually be euvolemic or even a little hypovolemic. And you may find that when you turn on that nitro, it drops their pressure too fast because actually they are a little hypovolemic. So it is important for us to be very careful and consider the need for cautious fluid administration, especially if we suspect something else taking place such as sepsis or anything else of that sort.

Mohamed:

I agree. And this is like the distinction between. The two. And as we mentioned, there can be a gray area, like some of these people can have a mixed kind of disease picture, but the acute phase is always the same. The acute phase, this hypertensive kind of emergency. And yes, we can use the term hypertensive emergency in this case because it's hypertension with end organ dysfunction and that dysfunction is in the heart. So it is a true hypertensive emergency. Addie, this is not. Hey, I took my blood pressure is 190 over 100. I gotta go to the hospital to make sure that someone bring my blood pressure down despite the lack of any symptoms. That's not what we're talking about. This is an acute hypertensive crisis because it is end organ dysfunction. And I'll be honest with you, sometimes you never know of these people might also present with an acute kidney injury as well, depending on how long they've been sitting on this condition. So it's all about the physical examination. I just wanna mention briefly, this is our state A LS protocol. So this is the pre-hospital protocol that we normally use. And usually for this protocol, if you see a patient that has an elevated blood pressure and concern for volume overload and you suspect SCAPE. Even though it does not say SCAPE on the protocol, you start by giving them at least one to three doses of sublingual nitroglycerine. And then you can add the other stuff, the CPAP, and then calling medical command. So for those of you who are not in the United States, this is in our pre-hospital protocol and this is what we use to train our paramedics and and EMTs. Now, I was gonna say for some EMS agencies who do carry an IV pump the protocol also allows for these agencies to administer nitroglycerin via IV using the pump. And some agencies in the city of Pittsburgh do have that capability. So they give intravenous nitroglycerin using the pump. And you can see here all these starting doses, 200 microgram, which to me is like obviously a lower dose, but people start normally slow and then they call the doctor to get some more approval for additional doses as well.

Addy:

So I think this is a good opportunity for us to yeah, talk about how this case resolved and then go through some big teaching points. After I give this patient the Nitro and the Nitro drip, he's on BiPAP now. Mo what happens to my patient from here?

Mohamed:

Yeah, so it sounds like they were hungry afterwards. They said, get this mask off me. I'm ready to go. I don't want to miss the rest of the festival. They were doing better and they said that they were feeling much better after the oxygen and the medication you gave them. So

Addy:

That's a good that's a good point actually to just emphasize as well is these patients, if you attack them aggressively with interventions. It is like seeing night and day. These patients, you are gonna think that they're on the brink of death and all of a sudden you're admitting them to obs level of care because they look so great that you don't even need to consider the ICU for them.

Mohamed:

Yeah, I remember. The ICU, that was their usual destination way back then. Now we fix them so quickly. Even in our, in the pre-hospital setting, we fix them. By the time they get to the ED, they're feeling a little bit better, and then you make them feel much, much better. And yes, they get admitted to the hospital for observation. Usually not an intensive care unit. We normally admit them for those reasons to make sure they're maintaining their status quo. They're continuing to improve and also look for other possible cardiac conditions that exacerbated this.'cause a lot of these people maybe have not seen a primary care doctor or don't have any health insurance or. Have a lot of, complicated psychosocial situation. So you'd be amazed. Sometimes we find people that have an underlying cardiac dysfunction lower, a lower baseline EF or untreated undiagnosed hypertension, even type two diabetes. So these people get admitted just to make sure they get the right workup. Nice. I really I'm curious to hear your thoughts about how you think you if you like, this kind of style of presentations and discussions and whether you want us to do more of these cases. Do you want anything different? Maybe more video cases. But yes I'm willing to hear any feedback from you, our lovely audience from all over the world, and we hope to continue this. Addie you have any other last words comments?

Addy:

last thing I wanna do is just some very quick take home points, especially if you are one of those people just like me, who skips to the complete end of the podcast or video or whatever this is. My big take home points and Mo please feel to add, feel free to add on. One is for SCAPE, it's early recognition. And so what you want to look for, tachycardia. Hypertension, respiratory distress. SCAPE should just be on your differential diagnosis Two Attack that blood pressure, attack it through positive pressure ventilation. So for our pre-hospital colleagues, that's CPAP for our hospital colleagues, that's BPAP as well as making sure that you go with high doses of nitroglycerin. So for the EMS people, that would be your sublingual, your IV Nitro in the hospital. Ideally, you are sticking to high doses of IV Nitro. And then three, monitor these patients frequently because you can, if you treat them aggressively enough, almost cure them of whatever is taking place acutely.

Mohamed:

Good summary! Thank you so much for tuning in and let's get ready for the next case coming up soon. And please share and thank you so much for tuning in again

Addy:

Thanks everyone. Thanks buddy. See you soon.