Emergency lectures - Congestive heart failure
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Emergency lectures - Congestive heart failure

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  • RAAS and sympathetic nervous system activation lead to increased norepin, vasopression  sodium/water retention Cardiac remodeling
  • Often missed on CXR, especially if patient is intubated and supine.
  • High output state e.g. anemia or sepsis

Emergency lectures - Congestive heart failure Emergency lectures - Congestive heart failure Presentation Transcript

  • CHF in the ED Bryce C Inman, MD Loma Linda University Medical Center
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  • Loma Linda University Medical Center
  • Loma Linda Medical Center
    • Level I trauma center with 50,000 patients per year & 65,000 patients per year at our affiliated hospital
    • 900 Beds in hospital
    • Emphasis on Pediatric Emergency Medicine and International Medicine
  • Congestive Heart Failure
    • Congestive heart failure is an imbalance in pump function in which the heart is unable to maintain adequate forward blood flow.
    • 10% of those > 80 years old
    • Most common cause of death is progressive heart failure
  • CHF: 2 types
    • Systolic
    • EF < 40%
    • Impaired ventricular contraction
    • Most commonly from ischemic heart disease
    • Diastolic
    • EF > 60%
    • Impaired ventricular relaxation
    • Most commonly from chronic HTN and LVH
  •  
  • Prognosis
    • Heart failure has an overall poor prognosis
    • Symptoms predict outcome
      • 5-10% mortality per year in moderate CHF
      • 30-40% mortality per year in severe CHF
  • Diagnosis: History
    • Dyspnea at rest
    • Dyspnea upon exertion
    • Orthopnea
    • Cough: Frothy pink sputum highly predictive of CHF
    • Nonspecifics: weakness, dizziness, malaise, etc.
  • Diagnosis: Exam
    • Acute pulmonary edema: Severe respiratory distress , relative hypertension, diaphoretic skin. Bilateral crackles can typically be heard
    • An S3 has 99 percent specificity for an elevated capillary wedge pressure (but 20% sensitivity)
    • JVD has 94 percent specificity for elevated capillary wedge pressure (but 39% sensitivity)
  • Imaging
    • 1/5 CHF patients admitted to the hospital lacked signs on CXR
    • Congestive signs on CXR are unreliable in chronic CHF
    • Sensitivity for CHF with a portable CXR is poor.
    • CXR findings often lag behind clinical manifestions by several hours
    • However, a CXR is useful to exclude other processes (e.g., pneumothorax)
  • Pleural effusion
  • Pulmonary Edema
  • What about labs and EKG?
    • Lack sensitivity and specificity
      • Occasionally you might see an elevated AST/ALT or prerenal azotemia
      • EKG may show ischemia or previous MI, dysrhythmias, etc.
  • Natriuretic peptides
    • 70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.
      • Is this CHF or COPD?
    • A BNP of <100 almost entirely excludes CHF
  • What else looks like acute CHF?
  • TREAT!
    • 70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.
  • Airway Management
    • Airway management supercedes all other priorities in these patients, particularly those who are critically ill.
    • Hypoxia is a greater risk than hypercarbia so CO2 retention is not an immediate concern
    • What is the best way to manage the airway?
  • Intubation vs NIPPV
    • Intubation
    • Typically for those in severe distress or those who are non-cooperative.
    • BiPAP/CPAP
    • May decrease the need for intubations, but no significant change in mortality
  • Pressure Control
    • Systolic pressure acceptable?
      • Start nitroglycerin (0.4 mg PO q2-3 min)
      • Nitrospray: Single spray (0.4 mg) up to a max of 1.2 mg Ointment: Apply 1-2 inches of nitropaste to chest wall IV: Start at 20 mcg/min IV and rate to effect in 5-10 mcg increments q3-5min
      • Not working?  IV nitroprusside may be required
    • The failing heart is sensitive to increases in afterload; these measures alleviate the pulmonary edema from CHF.
  • Don’t venodilate when….
    • Preload dependent states exist such as;
      • Right ventricular infarct
      • Critical aortic stenosis
      • Volume depletion
  • Most require only oxygen, blood pressure control, and diuresis -Vasoconstricted patients require vasodilators. -Congested patients required diuretics ★ Diastolic HF patients respond better to BP management than diuresis
  • Diuresis
    • First line therapy is a diuretic such as furosemide.
      • 10-20 mg IV for symptomatic CHF and diuretic naïve. 40-80 mg IV for patients already using diuretics 80-120 mg IV for patients whose symptoms are refractory to the initial dose after 1 h of its administration
    • Metolazone, a thiazide diuretic, can be added for effect.
  • If hypotensive…
    • Inotropes including dobutamine and dopamine are used primarily
      • Dopamine starts at 5 mcg/kg/min IV and increase at 5 mcg/kg/min increments to a 20 mcg/kg/min dose
      • Dobutamine starts at 2.5 mcg/kg/min IV; generally therapeutic in the range of 10-40 mcg/kg/min
  • Admit or go home?
    • With few exceptions, most patients presenting with symptoms of CHF require admission. Those who respond well to initial interventions may require only basic ward admission with telemetry.
    • Those who had a gradual onset dyspnea, rapid response to therapy, good oxygen saturations, and ACS/MI unlikely as the inciting event may be stable for discharge
  • In conclusion
    • Airway management is goal
      • IF NIPPV easily available, begin immediately and monitor for progress or decline
    • Control Pressure
      • Use nitroglycerin and titrate to effect
      • If known diastolic CHF, attempt to reduce afterload
    • Pressor support if hypotensive
      • Dobutamine/dopamine
  • References
    • Mueller C, Laule-Kilian K, Frana B, et al. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease.  Am Heart J . Feb 2006;151(2):471-7. 
    • Grossman, S. Congestive Heart Failure and Pulmonary Edema. Emedicine.medscape.com. Accessed 28Aug2010
    • Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD. Improving the diagnosis of acute heart failure using a validated prediction model.  J Am Coll Cardiol . Oct 13 2009;54(16):1515-21.
    • Collins SP, Lindsell CJ, Storrow AB. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure.  Ann Emerg Med . Jan 2006;47(1):13-8
    • Lin M, Yang YF, Chiang HT. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up.  Chest . May 1995;107(5):1379-86.
    • Tintinalli, JE. Congestive Heart Failure and Acute Pulmonary Edema. Emergency Medicine 6 th Edition. 364-372