ED: SOB, orthopnea, rales, JVD, S3 gallop, bilateral pitting edema; prior MI/HTN
ABCDE
Sit upright; oxygen only if SpO₂ <90% (target ≥90%) — routine high-flow O₂ not indicated; IV access + monitoring; GTN + IV furosemide; start CPAP/BiPAP early if SpO₂ <90% or RR >25 despite O₂; treat arrhythmia/ischaemia.
Sit upright + Oxygen only if SpO₂ <90% (target ≥90%); routine high-flow O₂ not indicated; continuous oximeter
Initial orders: Furosemide 40 mg IV + Nitroglycerin (paste/IV) + O₂ if SpO₂ <90%; CXR, ECG, ABG. Natriuretic peptides aid diagnosis when uncertain (rule-out BNP <100, NT-proBNP <300 pg/mL) — but never delay treatment to wait for them in florid pulmonary edema. Morphine no longer routine
Move clock 15–30 min: if urine made → improving. If NOT → check response at 2 h (urine output / spot urine Na); if inadequate, double the IV dose — do not redose blindly; recheck vitals q15–30 min
Most useful test = ECG → if arrhythmia (VT/AFib/flutter) causing it → immediate synchronized cardioversion
Still not responding to preload reduction: add IV nitroglycerin; consult cardiology + critical care (CCS)
Max preload Rx + persistent hypoxia → ICU: Persistent hypoxia despite NIV → intubation. Inotropes (dobutamine) only if SBP <90 mm Hg WITH hypoperfusion; norepinephrine if shock
Order set
- Sit up; O₂ only if SpO₂ <90%
- IV furosemide
- GTN (paste/IV/infusion)
- ECG + troponin
- CXR portable
- ABG/VBG
- U&E, BNP/NT-proBNP (rule-out <100 / <300 pg/mL)
Monitor
- 0 minO₂, furosemide, nitrate; ECG, ABG
- 15–30 minUrine output + vitals; re-dose loop if no urine
- 1 hReassess oxygenation; escalate NIV → intubation if failing; dobutamine only if SBP <90 + hypoperfusion
- 2–6 hFluid balance, electrolytes, response
Escalate / ICU
- Persistent hypoxia despite max preload reduction
- Needs inotrope/vasopressor (only if SBP <90 mm Hg with hypoperfusion)
- NIV (CPAP/BiPAP) failure
- Rising PaCO₂ / exhaustion → intubate
- Cardiogenic shock
Criteria
AdmitAll acute pulmonary oedema
ICURefractory hypoxia, shock, or NIV failure
IntubateExhaustion, ↓GCS, or refractory hypoxaemia despite NIV
VentilateFailing oxygenation on max NIV
VasopressorsCardiogenic shock — noradrenaline ± inotrope
DischargeEuvolaemic on oral therapy, SpO₂ stable on air, cause addressed, HF meds started + follow-up
Never
- Consult cardiology on a single-best-answer Q — manage it yourself
Key
- Most patients respond to preload reduction alone. Loop alt if furosemide absent = bumetanide/torsemide.
- Start CPAP/BiPAP early if SpO₂ <90% or RR >25 despite O₂ — early therapy, not last rescue.
- Early bedside echo (immediate if shock/arrest); identify precipitant.
- Urine catheter + strict fluid balance; daily weights.
- VTE thromboprophylaxis (LMWH) unless contraindicated.
- Initiate/up-titrate GDMT before discharge (STRONG-HF, Class I-B); in-hospital SGLT2 inhibitor start is supported (EMPULSE).
- Acetazolamide 500 mg IV daily may augment decongestion (ADVOR).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- SpO₂ <90% on max therapy
- Rising PaCO₂/exhaustion
- Hypotension/shock
Differentials
- Pneumonia
- ARDS
- PE
- COPD exacerbation
Common mistakes
- Excess fluids
- Relying on BNP when picture is obvious
- Delaying NIV
Disposition & follow-up
Improve → ward + HF workup; refractory/hypoxic → HDU/ICU.
Discharge package
MedicationsLoop diuretic; start/continue HF therapy (ACEi/ARNI, β-blocker, MRA, SGLT2i)
Follow-upHF clinic 1–2 wk; echo if new
LifestyleDaily weights, fluid/salt restriction
Warning symptomsWorsening breathlessness, weight gain >2 kg in 2 days, ankle swelling, chest pain
💊 Treatment detail — doses & preparation
Furosemide IVloop diuretic
Dose40–80 mg IV slow push; if on home furosemide give ≥1–2.5× the oral dose IV (DOSE); infusion 5–40 mg/h in refractory congestion
Preparation20 mg/2 mL ampoule undiluted over 2–5 min (ototoxic if fast); infusion 250 mg in 50 mL NS via pump
MonitorUrine output, K⁺, Mg²⁺, creatinine, volume status; check response at 2 h (urine output / spot urine Na); do not redose blindly
Glyceryl trinitrate (nitroglycerin)IV/SL vasodilator
DoseSL 400 mcg spray/tablet; IV 10–200 mcg/min infusion
Preparation50 mg in 250 mL D5W (200 mcg/mL) in glass bottle/non-PVC set; start 10 mcg/min, titrate q5 min
MonitorOnly if SBP >110 mm Hg; avoid with PDE5 inhibitors, RV infarction, severe aortic stenosis; BP, headache; tolerance after 24 h — nitrate-free interval
0.9% Sodium chloridecrystalloid
DoseFluids are NOT routine in cardiogenic pulmonary edema — avoid IV fluids unless true hypovolemia (e.g., RV infarct, over-diuresis); consider fluid restriction 1.5–2 L/day in dilutional hyponatremia
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorDaily weights + strict fluid balance; reassess volume status — excess fluids worsen pulmonary edema
Dobutamineinotrope
Dose2.5–10 mcg/kg/min IV infusion
Preparation250 mg in 250 mL D5W/NS (1 mg/mL) via pump; central line preferred
MonitorHR, arrhythmias, urine output; vasodilates — combine with noradrenaline if hypotensive
📖 ESC Acute & Chronic Heart FailureReviewed July 2026