Rural treatment of acute cardiogenic pulmonary edema: applying the evidence to achieve success with failure.

Rural management of acute cardiogenic pulmonary edema should be based on avoidance of adverse outcomes such as in-hospital mortality, the need for intensive care unit care, and the need for intubation and mechanical ventilation. Current evidence suggests that early noninvasive continuous positive airway pressure and early aggressive preload reduction with intravenous nitroglycerin are first-line interventions. Afterload reduction with sublingual captopril, with or without nitroglycerin, improves outcomes and is a second-line intervention. Furosemide is associated with adverse outcomes when used alone and should be given only after vasodilator therapy as a third-line intervention. Inotropes should be used only with demonstrably poor perfusion as they do not improve outcomes and may indeed be associated with increased mortality. Concurrent vasodilator therapy should be considered as soon as possible. Morphine should not be used as it is associated with adverse outcomes. If sedation is desirable, benzodiazepines should be considered.