cardio.hypertensive-emergency.acute-pulmonary-edema.v1

Hypertensive emergency with acute (flash) pulmonary edema

cardiologyacuteadultacuteinpatienttransitionoutpatient

Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.hypertensive-emergency.core.v1 — narrowed to flash pulmonary edema in HTN crisis. Inherits HTN-emergency framework from parent; specializes for preload/afterload reduction paradigm (IV NTG 5-200 µg/min FIRST + IV loop diuretic per DOSE PMID 21366472 + NIPPV per 3CPO PMID 18768944 reducing intubation rate). AVOID isolated diuretic without vasodilator (incomplete unloading). Nitroprusside if refractory + non-coronary etiology + eGFR ≥30. ACS overlap → cath lab activation. Manifest pointer reuses cardio.hypertensive-emergency.core.v1 manifest. Design-brief pointer reuses parent (flash edema specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as part of HTN emergency Phase E variant batch.

Entry points (3)

vital_abnormality
SBP >180 + acute respiratory distress + bilateral B-lines / pulmonary edema on CXR (ACC/AHA 2025; Vaughan Lancet 2000 PMID 10972386)
sbp_gt_180_with_respiratory_distress
symptom
Acute dyspnea + orthopnea + pink frothy sputum (classic flash pulm edema)
acute_dyspnea_orthopnea_pink_frothy_sputum
imaging
Lung US with diffuse B-lines (LR+ 13 per Lichtenstein BLUE protocol PMID 18403664)
lung_us_b_lines_diffuse

Required inputs (12)

agerequired
demographic • used at CONTEXT
Older patients more likely to have HFpEF + flash edema phenotype (PAGE-PE PMID 33872318)
sbprequired
vital • used at TREATMENT
Goal SBP ↓ 25% in first hour; preserve perfusion (ACC/AHA 2025)
spo2required
vital • used at RED_FLAGS
O2 + NIPPV titration; SpO2 <90 RA on presentation typical
rrrequired
vital • used at RED_FLAGS
RR >25-30 + accessory muscle use → NIPPV; RR >35 + AMS → consider intubation
orthopnea_or_pndrequired
symptom • used at ENTRY
Orthopnea + PND classic for cardiogenic pulm edema vs ARDS or PNA
creatininerequired
lab • used at INITIAL_WORKUP
AKI co-presence drives diuretic dose + nitroprusside avoidance; cardiorenal syndrome common
troponinrequired
lab • used at INITIAL_WORKUP
ACS overlap possible — flash pulm edema may herald MI (route to cardio.stemi/nstemi if positive)
bnp_or_nt_probnp
lab • used at INITIAL_WORKUP
BNP >500 LR+ 8.1 for AHF (Maisel NEJM 2002 PMID 12124404); confirms cardiogenic etiology
cxr_pulmonary_edemarequired
imaging • used at INITIAL_WORKUP
Bilateral infiltrates + cephalization + Kerley B lines confirm cardiogenic edema vs ARDS
lung_us_b_lines
imaging • used at INITIAL_WORKUP
POCUS B-lines highly sensitive (LR+ 13 per BLUE protocol PMID 18403664) + bedside available
echo_post_stabilizationrequired
imaging • used at MONITORING
EF + valvular (acute MR/AS) + diastolic function (HFpEF vs HFrEF) → drives chronic GDMT path
ecgrequired
imaging • used at INITIAL_WORKUP
Rule out STEMI overlap (route to cath if ST↑); LVH typical in chronic HTN

12-phase flow (10)

1FRAME
Flash pulmonary edema with HTN — preload + afterload reduction FIRST (IV nitroglycerin); IV loop diuretic; NIPPV reduces intubation rate (3CPO PMID 18768944). Goal SBP ↓ 25% in first hour. Inherits HTN-emergency framework from parent. ACS overlap requires cath lab activation.
inputs: sbp, spo2, rr, orthopnea_or_pnd
advance: flash pulm edema phenotype confirmed
2ENTRY
Recognize acute dyspnea + orthopnea + pink frothy sputum + severe HTN + B-lines on lung US; immediate NIPPV + IV NTG + IV loop
inputs: age, sbp, spo2
advance: NIPPV + IV NTG initiated
3CONTEXT
Chronic HF history (HFpEF vs HFrEF), valvular disease, diuretic dependence, dialysis status, recent dietary indiscretion
inputs: age
advance: context complete
4RED_FLAGS
Refractory hypoxemia (SpO2 <85 on NIPPV with FiO2 100%) → intubation; ACS overlap (positive troponin, ST↑) → cath lab; cardiogenic shock SCAI C+ (SBP <90 + lactate ≥2 + organ hypoperfusion) → ICU + MCS evaluation
inputs: spo2, rr, sbp, troponin
actions: htn_emergency
advance: red flags screened + escalation plan documented
5INITIAL_WORKUP
BMP, troponin, BNP/NT-proBNP, ECG, CXR, lung US, ABG; bedside echo for EF/valvular function; consider cath lab if ACS overlap
inputs: creatinine, troponin, cxr_pulmonary_edema, ecg
actions: panel.cardiac, panel.renal
advance: workup documented
6BRANCHING_WORKUP
EF assessment: HFpEF (preserved EF + flash edema = often RAS or chronic HTN-induced diastolic failure — workup renal Doppler) vs HFrEF (initiate GDMT); valvular emergency (acute MR from papillary rupture / endocarditis) → emergent surgery
inputs: echo_post_stabilization, lung_us_b_lines
advance: EF + valvular assessment complete
7TREATMENT
IV NTG 5-200 µg/min titrate (preload + afterload reduction; rapid onset; AVOID if SBP <90 or RV infarct or PDE5 use within 24-48 h). IV furosemide 40-80 mg IV (or 1-2× home dose if chronic HF; DOSE PMID 21366472). NIPPV (CPAP 8-10 cmH2O OR BiPAP 12/5 — 3CPO PMID 18768944 reduces intubation rate). IV nitroprusside if refractory + non-coronary etiology + eGFR ≥30. AVOID isolated diuretic without vasodilator (incomplete unloading).
inputs: sbp, spo2, creatinine
advance: BP at target + oxygenation improved + UOP responding
8DISPOSITION
ICU for emergency-grade HTN + flash edema; CCU/cardiology floor if rapid response to NIPPV/NTG; cath lab if ACS overlap
advance: unit assigned
9MONITORING
Arterial line + q5-15 min BP; continuous SpO2 + ECG; hourly UOP; serial troponin q6h × 3 (rule out ACS); BMP q6h; daily weight + I/O; echo at 24-48 h for EF + valvular reassessment
inputs: sbp, creatinine, spo2
actions: panel.renal
advance: BP at target + oxygenation stable + diuresis adequate
10FOLLOWUP
Transition to oral 4-tier ladder + GDMT if HFrEF; secondary cause workup (RAS, OSA, dietary indiscretion, medication non-adherence); 1-week follow-up; cardiac rehab if first HF episode
advance: oral regimen stable + 1-wk follow-up booked