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By: Darryl Jamison        NREMT-PMacon County EMS Training       Coordinator
– Approximately 30-40% of       – The most common cause of  patients with CHF are           death is progressive heart  ho...
– Effects an estimated    – Responsible for 5-10% of  4.9 million Americans     all hospital admissions– 1% of adults 50-6...
– An imbalance in pump function in which the  heart fails to maintain the circulation of blood  adequately.
♦ Summarized as an imbalance in Starlings  forces or an imbalance in the degree of end-  diastolic fiber stretch proportio...
– Under normal circumstances, when fluid is  transferred into the lung interstitium with  increased lymphatic flow, no inc...
– Coronary artery          – Alcohol--chronic  disease--chronic         – MI--acute– HTN--both                – Diabetes—c...
– Preload—                        – Afterload—   • The amount of blood the         • The pressure that must be     heart m...
– When cholesterol and fatty deposits build up in  the heart’s arteries, less blood reaches the heart  muscle. This damage...
– Uncontrolled HTN doubles the chances of  failure– With HTN, the chambers of the heart enlarge  and weaken.
– Can result from disease, infection, or be  congenital– Don’t open and/or close completely   increased workload  failure
– Tachycardias decreased diastolic filling time   decreased SV.– Atrial dysrhythmias  as much as 30%  reduction in stro...
– The ischemic tissue is basically taken out of the  equation, leaving a portion of the heart to do  the work of the entir...
– Tend to be overweight– HTN– Hyperlipidemia
Types of Rhythms Associatedwith CHF
– Left Ventricular Failure with Pulmonary Edema   • Aka—systolic heart failure– Right Ventricular Failure   • Aka—diastoli...
– Occurs when the left           – When pressure  ventricle fails as an  effective forward pump           becomes to high,...
– Severe resp. distress–      – Diaphoresis—   • Evidenced by                • Results from     orthopnea, dyspnea        ...
– Jugular Venous Distention  —not directly related to  LVF.    • Comes from back pressure      building from right heart  ...
– LOC—   • may vary.   • Depends on the level of hypoxia– Chest Pain   • May in the presence of MI   • Can be masked by th...
♦ REMEMBER LEFT VENTRICULAR FAILURE IS A TRUE LIFE THREATENING EMERGENCY
– Etiology—                    – Pathophysiology—   • Acute MI—                    • Decreased right-sided       – Inferio...
– In the peripheral veins, pressures rise and the  capillary pressures increase, hydrostatic  pressure exceeds that of int...
– Marked JVD                       – Often will be on Lasix,– Clear chest                        Digoxin,– Hypotension    ...
– Neurohormonal system– Renin-angiotensin-aldosterone system– Ventricular hypertrophy
– Stimulated by decreased perfusion  secretion  of hormones   • Epi—      – Increases contractility      – Increases rate...
– Decreased renal blood flow secondary to low  cardiac output triggers renin secretion by the  kidneys   • Aldosterone is ...
– Long term compensatory mechanism– Increases in size due to increase in work load ie  skeletal muscle
COPD                CHF          PneumoniaCough         Frequent          Occasional       FrequentWheeze        Frequent ...
COPD             CHF               PneumoniaOnset         Often URI with   Orthopnea at      Gradual with              cou...
COPD              CHF                PneumoniaBarrel Chest   Common            Rare               Rare unless             ...
– Aimed at diminishing the compensatory  mechanisms of low cardiac output and also  improving contractility– Vasodilators—...
– Dilate blood vessels    – Common ACE– Often constricted due     inhibitors  to activation of the       •   Captopril  sy...
– Lasix  – Hydrochlorothiazide(HCTZ)  – Spironolactone♦ These inhibit reabsorption of Na+ into the  kidneys
– Digoxin  – Lanoxin♦ Increases the contractility of the heart   increasing the cardiac output
–   Nifedipine   – Used to dilate blood–   Diltiazem      vessels–   Verapamil    – Used mostly with CHF–   Amlodipine    ...
–   Metoprolol   – Useful by blocking the–   Atenolol       beta-adrengergic–                  receptors of the    Propano...
– The prehospital goals for managing CHF     –   Promotion of rest     –   Relief of anxiety     –   Decreasing cardiac wo...
– DO NOT make these patient’s walk– Could start a fluid “rush” into the alveoli– Try to get them to sit still if they appe...
– Often experienced– Leads to increase in O2 demand and cardiac  workload– Explain what you are doing– MS 2 mg for treatme...
–   NTG–   MS–   Lasix–   O2—High flow O2
–   ACE Inhibitors–   Digitalis–   Diuretics–   Hydralazine–   Nitrates
– Prevent the production of the chemicals that  causes blood vessels to narrow– Resulting in blood pressure decreasing and...
– Inotropic effects on the heart– Negative chronotropic effects
– Decrease the body’s retention of salt and water– Reduces blood pressure– Probably will be on potassium
– Widens the blood vessels, therefore allowing  more blood flow
– Relaxation of smooth muscle– Widens blood vessels– Lowers systolic blood pressure
– Particularly difficult in elderly– Atypical presentations– Predominant symptoms include:   •   Anorexia   •   Generalize...
–   Bubbling Rhonchi–   Coarse Crackles–   Fine Crackles–   Gurgling Rhonchi–   Rales
Chf
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Transcript of "Chf"

  1. 1. By: Darryl Jamison NREMT-PMacon County EMS Training Coordinator
  2. 2. – Approximately 30-40% of – The most common cause of patients with CHF are death is progressive heart hospitalized each year. failure, but sudden death Leading diagnosis-related may account for up to 45% group over 65. The 5 year mortality after Dx was of all deaths. reported as 60% in men and – Patients with coexisting 45% in women in 1971. In IDDM have a significantly 1991, data from the higher mortality rate. Farmington heart study showed the 5 year mortality rate remaining unchanged, with a median survival of 3.2 years for men, and 5.4 years for women, post dx.
  3. 3. – Effects an estimated – Responsible for 5-10% of 4.9 million Americans all hospital admissions– 1% of adults 50-60 – Causes or contributes to approximately 250,000– 10% adults over 80 deaths per year– Over 550,000 new cases annually– $28.7 million committed in research dollars each year– $132 million for lung cancer, affecting 390,000 Americans
  4. 4. – An imbalance in pump function in which the heart fails to maintain the circulation of blood adequately.
  5. 5. ♦ Summarized as an imbalance in Starlings forces or an imbalance in the degree of end- diastolic fiber stretch proportional to the systolic mechanical work expended in the ensuing contraction.♦ Or basically like a rubber band, the more it is stretched, the greater the releasing velocity.
  6. 6. – Under normal circumstances, when fluid is transferred into the lung interstitium with increased lymphatic flow, no increase in interstitial volume occurs.– However, when the capacity of the lymphatic drainage is exceeded, liquid accumulates in the interstitial spaces surrounding the bronchioles and lung vasculature, this creating CHF.– When increased fluid and pressure cause tracking into the interstitial space around the alveoli and disruption of alveolar membrane junctions, fluid floods the alveoli and leads to pulmonary edema
  7. 7. – Coronary artery – Alcohol--chronic disease--chronic – MI--acute– HTN--both – Diabetes—chronic– Valvular heart disease (especially aorta and mitral disease)-- chronic– Infections--acute– Dysrhythmias--acute
  8. 8. – Preload— – Afterload— • The amount of blood the • The pressure that must be heart must pump with each overcome for the heart to beat pump blood into the • Determined by: arterial system. – Venous return to heart • Dependent on the systemic – Accompanying stretch vascular resistance of the muscle fibers • With increased afterload, • Increasing preload  the heart muscles must increase stroke volume in work harder to overcome normal heart the constricted vascular • Increasing preload  bed  chamber impaired heart  enlargement decreased SV. Blood is • Increasing the afterload trapped chamber will eventually decrease enlargement the cardiac output.
  9. 9. – When cholesterol and fatty deposits build up in the heart’s arteries, less blood reaches the heart muscle. This damages the muscle, and the healthy heart tissue that remains has to work harder
  10. 10. – Uncontrolled HTN doubles the chances of failure– With HTN, the chambers of the heart enlarge and weaken.
  11. 11. – Can result from disease, infection, or be congenital– Don’t open and/or close completely  increased workload  failure
  12. 12. – Tachycardias decreased diastolic filling time  decreased SV.– Atrial dysrhythmias  as much as 30% reduction in stroke volume
  13. 13. – The ischemic tissue is basically taken out of the equation, leaving a portion of the heart to do the work of the entire heart  decreased SV CHF.
  14. 14. – Tend to be overweight– HTN– Hyperlipidemia
  15. 15. Types of Rhythms Associatedwith CHF
  16. 16. – Left Ventricular Failure with Pulmonary Edema • Aka—systolic heart failure– Right Ventricular Failure • Aka—diastolic heart failure
  17. 17. – Occurs when the left – When pressure ventricle fails as an effective forward pump becomes to high, the back pressure of blood fluid portion of the into the pulmonary blood is forced into the circulation alveoli.  pulmonary edema– Cannot eject all of the  decreased blood delivered from the oxygenation capacity right heart. of the lungs– Left atrial pressure rises  increased pressure in the – AMI common with pulmonary veins and LVF, suspect capillaries
  18. 18. – Severe resp. distress– – Diaphoresis— • Evidenced by • Results from orthopnea, dyspnea sympathetic stimulation • Hx of paroxysmal – Pulmonary congestion nocturnal dyspnea. • Often present– Severe apprehension, • Rales—especially at the bases. agitation, confusion— • Rhonchi—associated • Resulting from hypoxia with fluid in the larger • Feels like he/she is airways indicative of smothering severe failure • Wheezes—response to– Cyanosis— airway spasm
  19. 19. – Jugular Venous Distention —not directly related to LVF. • Comes from back pressure building from right heart into venous circulation– Vital Signs— • Significant increase in sympathetic discharge to compensate. • BP—elevated • Pulse rate—elevated to compensate for decreased stroke volume. • Respirations—rapid and labored
  20. 20. – LOC— • may vary. • Depends on the level of hypoxia– Chest Pain • May in the presence of MI • Can be masked by the RDS.
  21. 21. ♦ REMEMBER LEFT VENTRICULAR FAILURE IS A TRUE LIFE THREATENING EMERGENCY
  22. 22. – Etiology— – Pathophysiology— • Acute MI— • Decreased right-sided – Inferior MI cardiac output or • Pulmonary disease increased pulmonary – COPD, fibrosis, HTN vascular resistance increased right vent. • Cardiac disease Pressures. involving the left or • As pressures rise, this both ventricles increased pressure in • Results from LVF the right atrium and venous system • Higher right atrium pressures  JVP
  23. 23. – In the peripheral veins, pressures rise and the capillary pressures increase, hydrostatic pressure exceeds that of interstitial pressure– Fluid leaks from the capillaries into the surrounding tissues causing peripheral edema– Lungs are clear due to left ventricular pressures are normal
  24. 24. – Marked JVD – Often will be on Lasix,– Clear chest Digoxin,– Hypotension – Have chronic pump– Marked peripheral failure edema– Ascites, hepatomegaly– Poor exercise tolerance – The first three are for an inferior MI, describe cardiac tamponade.
  25. 25. – Neurohormonal system– Renin-angiotensin-aldosterone system– Ventricular hypertrophy
  26. 26. – Stimulated by decreased perfusion  secretion of hormones • Epi— – Increases contractility – Increases rate and pressure – Vasoconstriction  SVR • Vasopressin— – Pituitary gland – Mild vasoconstriction, renal water retention
  27. 27. – Decreased renal blood flow secondary to low cardiac output triggers renin secretion by the kidneys • Aldosterone is released  increase in Na+ retention  water retention • Preload increases • Worsening failure
  28. 28. – Long term compensatory mechanism– Increases in size due to increase in work load ie skeletal muscle
  29. 29. COPD CHF PneumoniaCough Frequent Occasional FrequentWheeze Frequent Occasional FrequentSputum Thick Thin/white Thick/yellow/ brownHemoptysis Occasionally Pink frothy occasionallyPND Sometimes after Often within 1 Rare a few hours hourSmoking Common Less common Less commonPedal edema Occasional Common with none chronic
  30. 30. COPD CHF PneumoniaOnset Often URI with Orthopnea at Gradual with cough night fever, coughChest Pain pleuritic Substernal, Pleuritic, often crushing localizedClubbing Often Rare RareCyanosis Often and severe Initially mild but May be present progressesDiaphoresis May be present Mild to heavy Dry to moistPursed Lips Often Rare Rare unless COPD
  31. 31. COPD CHF PneumoniaBarrel Chest Common Rare Rare unless COPDJVD May be present Mild to severe Rare with RVFBP Usually normal Often high NormalDysrhythmia Occasional May precipitate Common CHFWheeze Common Less common CommonCrackles Coarse, diffuse Fine to coarse, Localized to begin in gravity diffuse, coarse dependent areas
  32. 32. – Aimed at diminishing the compensatory mechanisms of low cardiac output and also improving contractility– Vasodilators—ACE inhibitors– Diuretic agents– Inotropic agents
  33. 33. – Dilate blood vessels – Common ACE– Often constricted due inhibitors to activation of the • Captopril sympathetic nervous • Lisinopril system and the renin- • Vasotec angiotensin- • Monopril aldosterone system. • Accupril– Aka—ACE inhibitors – Nitrates
  34. 34. – Lasix – Hydrochlorothiazide(HCTZ) – Spironolactone♦ These inhibit reabsorption of Na+ into the kidneys
  35. 35. – Digoxin – Lanoxin♦ Increases the contractility of the heart  increasing the cardiac output
  36. 36. – Nifedipine – Used to dilate blood– Diltiazem vessels– Verapamil – Used mostly with CHF– Amlodipine in the presence of ischemia– Felodipine
  37. 37. – Metoprolol – Useful by blocking the– Atenolol beta-adrengergic– receptors of the Propanolol sympathetic nervous– Amiodarone system, the heart rate and force of contractility are decreased could actually worsen CHF
  38. 38. – The prehospital goals for managing CHF – Promotion of rest – Relief of anxiety – Decreasing cardiac workload – Attainment of normal tissue perfusion
  39. 39. – DO NOT make these patient’s walk– Could start a fluid “rush” into the alveoli– Try to get them to sit still if they appear agitated and hypoxic
  40. 40. – Often experienced– Leads to increase in O2 demand and cardiac workload– Explain what you are doing– MS 2 mg for treatment of anxiety and for decreasing preload
  41. 41. – NTG– MS– Lasix– O2—High flow O2
  42. 42. – ACE Inhibitors– Digitalis– Diuretics– Hydralazine– Nitrates
  43. 43. – Prevent the production of the chemicals that causes blood vessels to narrow– Resulting in blood pressure decreasing and the heart pumping easier
  44. 44. – Inotropic effects on the heart– Negative chronotropic effects
  45. 45. – Decrease the body’s retention of salt and water– Reduces blood pressure– Probably will be on potassium
  46. 46. – Widens the blood vessels, therefore allowing more blood flow
  47. 47. – Relaxation of smooth muscle– Widens blood vessels– Lowers systolic blood pressure
  48. 48. – Particularly difficult in elderly– Atypical presentations– Predominant symptoms include: • Anorexia • Generalized weakness • Fatigue • Mental disturbances • Anxiety
  49. 49. – Bubbling Rhonchi– Coarse Crackles– Fine Crackles– Gurgling Rhonchi– Rales
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