The World’s Okayest Medic Podcast @PulmToilet's Crusade Against SCAPE and High-Dose Nitroglycerin
Sep 24, 2025
Dr. Nick Ghionni, a pulmonologist known as @PulmToilet, dives into the controversial diagnosis of SCAPE, questioning its validity and origins. He clarifies that SCAPE is often a hypertensive emergency with pulmonary edema rather than a unique condition. Discussing the dangers of high-dose nitroglycerin, he highlights misconceptions and recommends safer alternatives like CPAP and sublingual nitro. Dr. Ghionni calls for better evidence in EMS protocols and shares insights on the common misidentification of conditions in prehospital care.
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SCAPE Equals Hypertensive Emergency
- 'SCAPE' is not a distinct disease but a label often used for hypertensive emergency with pulmonary edema.
- Nick Ghionni argues the term encourages unneeded protocolized treatments rather than targeted evaluation.
Don't Bolus Nitroglycerin As A Loading Dose
- Do not use a bolus 'loading dose' of nitroglycerin because its half-life is short and it reaches steady state quickly.
- Avoid pharmacologic loading logic with nitroglycerin the same way you would with norepinephrine or propofol.
Evidence For High-Dose Nitro Is Weak
- Many cited studies for high-dose bolus nitroglycerin are small, retrospective, or misinterpreted.
- Ghionni highlights that some key references actually support much smaller doses (≈300 mcg) than the high-dose protocols claim.