ICU Knowledge Map

R2Initial ICU Management

Initial Presentation

Hypertensive Acute Pulmonary Edema (SCAPE Phenotype)

A 65-year-old man with ischemic cardiomyopathy develops abrupt severe dyspnea over 45 minutes. He is sitting upright, diaphoretic and using accessory muscles.

Vital Signs

128/min

228/124 mmHg

38/min

SpO2

81% on room air

Key Bedside Findings

Marked hypertension with acute pulmonary edema and sympathetic activation — a phenotype often described as SCAPE, although 'SCAPE' is a clinical descriptor rather than a separate formal guideline diagnosis.
Diffuse crackles and frothy sputum with ultrasound B-lines.
JVP is elevated; total-body volume status and precipitants still need assessment because acute redistribution and chronic congestion can coexist.

How this R2 case develops

Stabilization → investigation → initial treatment → reassessment

1. Initial framing2. Early ICU management3. Treatment response4. Next-step planning

More uncertainty, competing reasonable options, treatment sequencing.

Learning targets

• Recognize the hypertensive/afterload-driven acute pulmonary-edema phenotype while evaluating for ACS, acute MR/AR, aortic syndrome, renal failure, arrhythmia and other precipitants.
• Use CPAP/BiPAP promptly in suitable patients with severe respiratory distress and hypoxemia.
• Use rapidly titratable IV vasodilator therapy when severe hypertension is driving pulmonary edema and no contraindication exists.
• Use loop diuretics when clinical congestion/volume excess is present rather than assuming all flash pulmonary edema is purely fluid redistribution.