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Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)
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Management of Congestive Heart Failure: An Approach for the New Millenium (1997-12-08)

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  • 1. Congestive Heart Failure, Pulmonary Edema, and CPAP James Pointer, MD, FACEP Medical Director Alameda County EMS
  • 2. Objectives
    • Review cardiac physiology and pathophysiology of CHF
    • Early recognition of CHF
    • Management of CHF
    • Use of CPAP
  • 3. Terminology
    • Heart Failure: The inability of the heart to maintain an output adequate to maintain the metabolic demands of the body.
    • Pulmonary Edema: An abnormal accumulation of fluid in the lungs.
    • CHF with Acute Pulmonary Edema: Pulmonary Edema due to Heart Failure (Cardiogenic Pulmonary Edema)
  • 4. Etiology
    • Arteriosclerotic Cardiovascular Ischemia
      • Acute MI
      • Ischemic Cardiomyopathy (Dilated Cardiomyopathy)
    • Hypertension
    • Miscellaneous
  • 5. People Live With Atherosclerosis – But Die of Thrombosis! Arteriosclerotic plaques gradually narrow the coronary arteries, but it is a rupture of the plaque and subsequent platelet aggregation and thrombosis that occludes the artery. Acute Myocardial Infarction
  • 6. Hypertension
    • Hypertrophic Cardiomyopathy
  • 7. Heart Failure - Concepts
    • Frank-Starling Length: Tension Ratio
    • Ejection Fraction
    • Cardiac Output
    • Preload
      • Primarily a venous and diastolic function
    • Afterload
      • Primarily arterial and systolic function
  • 8. Three Pathophysiological Causes of Failure
    • Increased work load (HTN)
    • Myocardial Dysfunction (ASCVD)
    • Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)
  • 9. Compensatory Mechanisms
    • Increased Heart Rate
      • Sympathetic = Norepinephrine
    • Dilation
      • Frank Starling = Contractility
    • Neurohormonal
      • Redistribution of Blood to the Brain
  • 10. CHF Vicious Cycle Low Output Increased Preload Increased Afterload Norepinephrine Increased Salt Vasoconstriction Renal Blood Flow Renin Angiotension I Angiotension II Aldosterone
  • 11. Decompensation
    • Increased Pulmonary Venous Pressure (PAWP)
    • Interstitial Edema
    • Alveolar Edema
  • 12. Infiltration of Interstitial Space
    • Normal
    • Micro-anatomy
    • Micro-anatomy with fluid movement.
  • 13. Acute Pulmonary Edema a true life- threatening emergency
  • 14. Precipitating Causes
    • Non Compliance with Meds and Diet
    • Acute MI
    • Arrhythmia (e.g. AF)
    • Pneumonia
    • Increased Sodium Diet (Holiday Failure)
    • Anxiety
    • Pregnancy
  • 15. Symptoms
    • Fatigue
    • Nocturia
    • DOE
    • PND
    • GI Symptoms
    • Chest Pain
    • Orthopnea
    • Profound Dyspnea
  • 16. Physical Exam
    • Anxious
    • Pale
    • Clammy
    • Tachypnea
    • Confusion
    • Edema
    • Hypertension
    • Diaphoretic
    • Rales
    • Rhonchi
    • Tachycardia
    • S 3 Gallop
    • JVD
    • Pink Frothy Sputum
    • Cyanosis
    • Displaced PMI
  • 17.  
  • 18. EMS Management
    • Sit upright
    • High Flow O 2
    • NTG (If SBP > 100)
    • Diuretics (furosemide) – use care
    • Morphine (base consult)
    • Ventilatory Support
      • BVM
      • CPAP
      • intubation/ventilation
  • 19. CPAP - Introduction
    • CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort.
    • CPAP is an established therapeutic modality, recently introduced into the prehospital setting.
    • In the primary phase CPAP application in cardiogenic pulmonary edema, thus far, appears to be beneficial to patient outcome.
  • 20. Key Points of CPAP
    • CPAP has been successfully demonstrated as an effective adjunct in the management of pulmonary edema secondary to congestive heart failure.
    • CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel.
  • 21. CPAP Mechanism
    • Increases pressure within airway.
    • Airways at risk for collapse from excess fluid are stented open.
    • Gas exchange is maintained
    • Increased work of breathing is minimized
  • 22. Prehospital Indications
    • Congestive Heart Failure
    • Pulmonary Edema associated with volume overload
      • renal insufficiency, iatrogenic volume overload, liver disease , etc.
    • Near Drowning
  • 23.
    • Patient, age > 8, in severe respiratory distress who meets one of the following criteria:
      • Medical history and presenting complaints consistent with cardiogenic pulmonary edema
      • Near drowning
    Prehospital Indications - Patient Assessment
  • 24. Absolute Contraindications
    • Age < 8
    • Respiratory or Cardiac Arrest
    • Agonal Respirations
    • Severely depressed LOC
    • Systolic Blood Pressure < 90
    • Pneumothorax
    • Major Trauma, esp. head injury with increased ICP or significant chest trauma
    • Facial Anomalies (e.g. burns, fractures)
    • Vomiting
  • 25. Relative Contraindications
    • History of Asthma/COPD
    • History of Pulmonary Fibrosis
    • Decreased LOC
    • Claustrophobia or unable to tolerate mask (after initial 1-2 minutes)
  • 26. Complications
    • Hypotension
    • Pneumothorax
    • Corneal Drying
  • 27. Using the Machine
    • Turn all three control knobs fully clockwise to the OFF position
    • Turn the ON/OFF valve counter-clockwise to the ON position
    • Turn the Flow Adjustment Valve about 5 complete turns counter-clockwise to the completely open position to provide full flow.
    • Turn the Oxygen Control Valve 5 complete turns counterclockwise (50-60% 0 2 ).
    on/off Flow O 2
      • You may deliver higher oxygen concentrations (up to 100%) by turning the valve
      • farther counterclockwise.
      • In the closed position (completely clockwise) the unit will deliver a minimum
      • 28-29% oxygen to the patient.
    • Verify that air is flowing to the mask.
    • Leave the oxygen and flow controls as you have just set them, then turn the ON/OFF valve fully off (clockwise).
  • 28. Important Points
    • Pulmonary edema patients, properly selected, quickly improve with CPAP in a matter of minutes.
      • CPAP is to CHF like D 50 is to insulin shock.
    • Visual inspection of chest wall movement demonstrates improved respiratory excursion.
  • 29. Important Points (cont.)
    • COPD and Asthmatic patients do NOT respond predictably to CPAP.
      • They have a higher risk of complications such as pneumothorax, and thus should not be treated in the field with CPAP
  • 30. CPAP vs. Intubation
    • CPAP
      • Non-invasive
      • Easily discontinued
      • Easily adjusted
      • Does not require sedation
      • Comfortable
    • Intubation
      • Invasive
      • Usually don’t extubate in field
      • Potential for infection
      • Traumatic
  • 31. CPAP Study 1996 – 1997 1997 – 1998 September – May September – May Intubated 22 8 CPAP 0 50 Hospital Stay(d) 14.8 8 ICU Admission 100% 48%
  • 32. Alameda County Data
    • 22 Patients
    • 19 lived / 3 died / 2 patients to ICU
    • Respiratory Rate:
      • Range: 42 - 16 / Mean Change: 7.25 (n=16)
    • SPO 2 :
      • Range: 30 - 100 / Mean Change: 19.5 (n=18)
    • RDS:
      • Range: 10 - 3 / Mean Change: 4 (n=15)
      • Unable to obtain RDS in 2 patients
    • 2 pts intubated / 1 intubated pt died
  • 33. Alameda County CPAP Policy
  • 34. Summary
    • CPAP provides an adjunct between oxygen by NRB mask and endotracheal intubation
    • Eliminates trauma of intubation
    • Reduces length of hospital stay
    • Reduces costs of care
  • 35.  

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