Sit patient up

1. Record Vital signs
2. O₂ at 15L per minute via non-rebreather mask with reservoir bag
3. If systolic BP > 100mg Hg, give GTN 2 puffs sublingually or 5-10mcg/min transdermal
4. IV access, bloods for FBC, U&E, Troponin and VBG
5. If systolic BP remains > 100mg Hg start nitrate infusion per Resus Protocol

COMMENCE INFUSION AT LOWER DOSES IN ELDERLY PATIENTS

7. If BP < 100mmHg seek senior advice and consider inotropic support
8. Consider CPAP 100% O₂ 5cm PEEP (discuss all cases with senior)

Indications                
Severe pulmonary oedema with failure to respond to conventional treatment within 15 minutes

Contraindications     
Respiratory arrest
Unable to cooperate
Airway obstruction

The ITU Registrar should be informed as soon as the patient is commenced on CPAP.

9. Consider frusemide 40-80mg IV but use caution in volume depleted patients. Most patients presenting with acute pulmonary oedema are euvolaemic. Treatment is NIV and vasodilators (if BP permits)
10. Request portable CXR and 12 lead ECG
11. Recheck VBGs