Acute Decompensated Heart Failure & SCAPE

Upright Positioning, Immediate
dangling off the stretcher. Immediately apply CPAP (10 cm H O) or BiPAP (IPAP 12–15 cm H₂O / EPAP 5–8 cm H₂O, FiO₂ 1.0) [1,2,3]. While nursing secures IV access, place Nitroglycerin (GTN) 0.4 mg SL × 2–3 tablets simultaneously under the tongue if SBP ≥ 160 mmHg [1,2].

Tight-fitting Full-
circuit; Sublingual tablets; 2× 18G IVs

Positive intrathoracic pressure (PITP)
tm LV ITP
(afterload reduction), decreases systemic venous return (preload reduction), and recruits flooded alveoli to reverse intrapulmonary shunt (3CPO meta-analysis: NNT = 13 to prevent intubation, NNT = 25 to save a life) [1,3].

High-Dose IV Push Nitroglycerin
mg) IV push over 1–2 minutes, and simultaneously start a high-dose IV Nitroglycerin infusion at 100–200 mcg/min, titrating upward every 2–3 minutes up to 300–400 mcg/min until SBP < 140 mmHg and work of breathing resolves [1,2,4].

Dedicated IV line +

Low-dose GTN (< 50 mcg/min) only
afterload crisis and restoring forward stroke volume within 3–5 minutes [4].

Phased-Array Probe

Bilateral sonographic B-lines have 94%

Hemodynamic Phenotyping (Forrester "Wet/Dry & Warm/Cold") & Targeted Decongestion: Distinguish SCAPE (fluid redistribution into lungs with euvolemia/hypovolemia — withhold early loop diuretics) from Classic Subacute Congestive ADHF (systemic volume overload with peripheral edema/ascites/weight gain). For Congestive ("Wet") ADHF, administer Furosemide IV bolus at 1.0–2.5× total daily oral home dose (or 40–80 mg IV if loop-diuretic naive) [1,2,5].

Peripheral IV push; Foley catheter if strict hourly urine output monitoring required

In SCAPE, total body water is normal or contracted; early furosemide transiently activates the Renin-Angiotensin-Aldosterone System (RAAS), worsening systemic vascular resistance before diuresis occurs. In true hypervolemic ADHF, high-dose IV furosemide (2.5× home dose per DOSE trial) inhibits the luminal Na⁺-K⁺-2Cl⁻ (NKCC2) cotransporter in the thick ascending limb of Henle to achieve rapid natriuresis [1,2,5].

Cold & Wet (Hypoperfused/Cardiogenic Shock) Inopressor & Sequential Nephron Rescue: If "Cold & Wet" (CI < 2.2 L/min/m , SBP < 90 mmHg, lactate > 2.0 mmol/L, cool mottled extremities), start Norepinephrine 2–20 mcg/min IV first to restore MAP ≥ 65 mmHg [1,8], then add Dobutamine 2.5–10 mcg/kg/min IV (or Milrinone 0.125–0.375 mcg/kg/min if on chronic β-blockers and BP adequate) [1,2]. In diuretic resistance, add Acetazolamide 500 mg IV once daily (ADVOR trial) [6] or Metolazone 5 mg PO / Chlorothiazide 500 mg IV [1,2].

Central Venous Line / Arterial Line; Smart Infusion Pumps

Norepinephrine restores coronary perfusion pressure (CPP = DBP − LVEDP) with significantly fewer arrhythmias and lower mortality than dopamine or epinephrine (SOAP II & OptimaCC trials) [1,8]. Acetazolamide blocks proximal tubular Carbonic Anhydrase, preventing proximal NaHCO₃ reabsorption and delivering massive Na⁺ loads to the loop of Henle (ADVOR trial: +46% decongestion) [6].