15.1 Acute Heart Failure
Key Takeaways
- SCAPE is hypertensive flash pulmonary edema: high-dose nitroglycerin plus NIV, sit the patient up, and do not hang a drowning liter.
- Cold-and-wet cardiogenic shock needs a pressure floor (usually norepinephrine) and an inotrope for a weak squeeze—not 30 mL/kg.
- Right-ventricular infarct is preload-dependent: cautious fluid only if the left ventricle is empty, and no nitrates or high PEEP.
- Afterload reduction unloads a drowning left ventricle; preload fills a starving right ventricle—sort the picture before the first bag.
- In the cabin, do the NIV oxygen math, sit the patient up if the aircraft allows, and leave defibrillator pads on.
Acute heart failure is a pump-and-plumbing problem you sort before the first liter. Domain 4.B.2 of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests hypertensive flash edema, cold cardiogenic shock, and isolated right-ventricular failure—three pictures that share a wet name and demand opposite fluids and destinations. Chapter 9 taught cardiogenic shock as a failed pump. Here, sit the drowning left ventricle (LV) up, do not flood it, and use noninvasive ventilation (NIV) as a drug, not a delay (Chapter 7).
Three pictures: SCAPE, cold-and-wet shock, and the right ventricle
Sympathetic crashing acute pulmonary edema (SCAPE) is flash left-sided failure from a catecholamine surge and sky-high afterload. The patient is upright, diaphoretic, pink-frothy, and usually hypertensive. The LV is drowning; the tank is not empty. Cardiogenic shock is the cold, wet, hypotensive cousin: mottled skin, a narrow pulse pressure, oliguria, and a pump that cannot generate a mean arterial pressure (MAP) high enough to feed the coronaries. Isolated right-ventricular (RV) failure—an inferior ST-elevation myocardial infarction (STEMI) with RV infarct, or a strained RV after massive pulmonary embolism (PE)—has clearer lungs, jugular venous distention (JVD), and an underfilled LV.
Preload, afterload, and why a liter can kill
Preload is end-diastolic stretch. Afterload is the wall stress of ejection—systemic vascular resistance (SVR) for the LV, pulmonary vascular resistance for the RV. SCAPE is an afterload crisis: drop SVR with nitroglycerin, unload the LV with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), and the patient often pinks up before the pad. A cold-and-wet LV already has high filling pressure; more crystalloid raises lung water without raising stroke volume. An RV infarct is preload-dependent: a cautious fluid challenge can fill the LV if the RV is empty, but high positive end-expiratory pressure (PEEP) and nitrates steal the only filling it has.
| Picture | Blood pressure / lungs | First flight move | What not to do |
|---|---|---|---|
| SCAPE / flash edema | High pressure, froth, upright | High-dose nitroglycerin plus NIV; sit up | A liter of crystalloid; delayed intubation if the mask fails |
| Cold-and-wet LV shock | Low pressure, wet lungs, cool skin | Norepinephrine for coronary perfusion; add dobutamine | 30 mL/kg; isolated high-dose nitroprusside |
| RV infarct / isolated RV | Low pressure, clearer lungs, JVD | Small fluid challenges if the LV looks empty | Nitroglycerin, morphine-driven preload dump, high PEEP |
Nitroglycerin, NIV, and inotropes
Hypertensive SCAPE is a nitroglycerin and mask disease
For SCAPE, nitroglycerin is the afterload drug. Many programs start with repeated intravenous (IV) boluses (often taught as several hundred micrograms) or a high infusion, then titrate to systolic blood pressure (SBP) and work of breathing. Those milligrams are clinical teaching, not BCEN numbers. Hold nitrates in RV infarct, recent phosphodiesterase-5 inhibitor use, and profound hypotension. Pair nitroglycerin with NIV: CPAP usually suffices for flash edema because one pressure recruits alveoli and cuts LV preload and afterload. Sit the patient up if the aircraft allows. If they vomit, become sleepy, or cannot protect the airway, intubate on the ramp (Chapter 7).
Cold-and-wet needs a pressure floor, not a bag
Cold-and-wet cardiogenic shock (Chapter 9) is not SCAPE. Restore coronary perfusion pressure with norepinephrine. Add dobutamine when MAP is just high enough but the squeeze is still weak. Milrinone vasodilates and can dump SVR; keep a pressor running. Dopamine is no longer first-line for most programs. A 250 mL challenge is a test only if the lungs are dry and the LV is not already full. Destination is percutaneous coronary intervention (PCI) or a mechanical-support center (section 15.4), not a clinic that can only hang another bag.
Right-sided failure, the cabin, and pads
Fluids for the empty LV, not the drowning one
An RV infarct usually rides with inferior STEMI: ST elevation in II, III, aVF, and often V4R. The lungs are relatively clear. Nitrates and morphine that help SCAPE collapse this patient. Give oxygen, restore a usable rate if complete heart block is stealing filling time (section 15.2), and use small, repeated fluid boluses only while the LV looks underfilled and the lungs stay dry. Stop when JVD rises, the RV balloons, or froth appears. Norepinephrine supports RV coronary perfusion better than a fourth liter. Avoid high PEEP after intubation.
Cabin rules: oxygen, position, and electricity
NIV in a helicopter is an oxygen-consumption and seal problem (Chapter 7). Calculate tank duration before lift. High-fraction of inspired oxygen (FiO2) CPAP empties portable cylinders faster than a nonrebreather. Watch the leak graphic you cannot hear over the rotor. Sit the patient up if the cabin and spine allow. Put defibrillator pads on every acute-failure patient before takeoff—SCAPE and RV infarct both deteriorate into ventricular tachycardia (VT) or ventricular fibrillation (VF) (section 15.2). Dalton's law drops inspired oxygen as cabin altitude rises; request a lower cabin or raise FiO2 rather than watching an ischemic LV desaturate.
- Sort SCAPE, cold-and-wet LV shock, and RV failure before you hang fluid or nitroglycerin.
- Treat hypertensive flash edema with nitroglycerin plus NIV; do not give a liter to a drowning LV.
- Support cold-and-wet shock with a pressor, then an inotrope; fly to PCI or mechanical support.
- Give cautious fluid only to an underfilled RV; withhold nitrates and high PEEP.
- Sit the patient up if the aircraft allows, do the NIV oxygen math, and leave pads on.
A diaphoretic, upright patient with a systolic pressure of 220 mm Hg is drowning in pink froth on the ramp. What is the correct first flight plan?
A cool, wet, hypotensive anterior-STEMI patient remains mottled after a small fluid test. Which circulatory plan matches cold-and-wet left-ventricular failure?
An inferior STEMI with ST elevation in V4R is hypotensive, has relatively clear lungs, and shows jugular venous distention. What is the right-ventricular plan?