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CHF in the ED Bryce C Inman, MD Loma Linda University Medical Center
 
 
Loma Linda University Medical Center
Loma Linda Medical Center <ul><li>Level I trauma center with 50,000 patients per year & 65,000 patients per year at our af...
Congestive Heart Failure <ul><li>Congestive heart failure is an imbalance in pump function in which the heart is unable to...
CHF:  2 types <ul><li>Systolic </li></ul><ul><li>EF < 40% </li></ul><ul><li>Impaired ventricular contraction </li></ul><ul...
 
Prognosis <ul><li>Heart failure has an overall poor prognosis </li></ul><ul><li>Symptoms predict outcome </li></ul><ul><ul...
Diagnosis:  History <ul><li>Dyspnea at rest </li></ul><ul><li>Dyspnea upon exertion </li></ul><ul><li>Orthopnea </li></ul>...
Diagnosis:  Exam <ul><li>Acute pulmonary edema:  Severe respiratory distress , relative hypertension, diaphoretic skin.  B...
Imaging <ul><li>1/5 CHF patients admitted to the hospital lacked signs on CXR </li></ul><ul><li>Congestive signs on CXR ar...
Pleural effusion
Pulmonary Edema
What about labs and EKG? <ul><li>Lack sensitivity and specificity </li></ul><ul><ul><li>Occasionally you might see an elev...
Natriuretic peptides <ul><li>70 y/o M presents with respiratory distress.  His 02 saturations are in the 70’s, he has mild...
What else looks like acute CHF?
TREAT! <ul><li>70 y/o M presents with respiratory distress.  His 02 saturations are in the 70’s, he has mild retractions, ...
Airway Management <ul><li>Airway management supercedes all other priorities in these patients, particularly those who are ...
Intubation vs NIPPV <ul><li>Intubation </li></ul><ul><li>Typically for those in severe distress or those who are non-coope...
Pressure Control <ul><li>Systolic pressure acceptable? </li></ul><ul><ul><li>Start nitroglycerin (0.4 mg PO q2-3 min)  </l...
Don’t venodilate when…. <ul><li>Preload dependent states exist such as; </li></ul><ul><ul><li>Right ventricular infarct </...
Most require only oxygen, blood pressure control, and diuresis -Vasoconstricted patients require vasodilators. -Congested ...
Diuresis <ul><li>First line therapy is a diuretic such as furosemide. </li></ul><ul><ul><li>10-20 mg IV for symptomatic CH...
If hypotensive… <ul><li>Inotropes including dobutamine and dopamine are used primarily </li></ul><ul><ul><li>Dopamine star...
Admit or go home? <ul><li>With few exceptions, most patients presenting with symptoms of CHF require admission.  Those who...
In conclusion <ul><li>Airway management is goal </li></ul><ul><ul><li>IF NIPPV easily available, begin immediately and mon...
References <ul><li>Mueller C, Laule-Kilian K, Frana B, et al. Use of B-type natriuretic peptide in the management of acute...
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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
  • Transcript of "Emergency lectures - Congestive heart failure"

    1. 1. CHF in the ED Bryce C Inman, MD Loma Linda University Medical Center
    2. 4. Loma Linda University Medical Center
    3. 5. Loma Linda Medical Center <ul><li>Level I trauma center with 50,000 patients per year & 65,000 patients per year at our affiliated hospital </li></ul><ul><li>900 Beds in hospital </li></ul><ul><li>Emphasis on Pediatric Emergency Medicine and International Medicine </li></ul>
    4. 6. Congestive Heart Failure <ul><li>Congestive heart failure is an imbalance in pump function in which the heart is unable to maintain adequate forward blood flow. </li></ul><ul><li>10% of those > 80 years old </li></ul><ul><li>Most common cause of death is progressive heart failure </li></ul>
    5. 7. CHF: 2 types <ul><li>Systolic </li></ul><ul><li>EF < 40% </li></ul><ul><li>Impaired ventricular contraction </li></ul><ul><li>Most commonly from ischemic heart disease </li></ul><ul><li>Diastolic </li></ul><ul><li>EF > 60% </li></ul><ul><li>Impaired ventricular relaxation </li></ul><ul><li>Most commonly from chronic HTN and LVH </li></ul>
    6. 9. Prognosis <ul><li>Heart failure has an overall poor prognosis </li></ul><ul><li>Symptoms predict outcome </li></ul><ul><ul><li>5-10% mortality per year in moderate CHF </li></ul></ul><ul><ul><li>30-40% mortality per year in severe CHF </li></ul></ul>
    7. 10. Diagnosis: History <ul><li>Dyspnea at rest </li></ul><ul><li>Dyspnea upon exertion </li></ul><ul><li>Orthopnea </li></ul><ul><li>Cough: Frothy pink sputum highly predictive of CHF </li></ul><ul><li>Nonspecifics: weakness, dizziness, malaise, etc. </li></ul>
    8. 11. Diagnosis: Exam <ul><li>Acute pulmonary edema: Severe respiratory distress , relative hypertension, diaphoretic skin. Bilateral crackles can typically be heard </li></ul><ul><li>An S3 has 99 percent specificity for an elevated capillary wedge pressure (but 20% sensitivity) </li></ul><ul><li>JVD has 94 percent specificity for elevated capillary wedge pressure (but 39% sensitivity) </li></ul>
    9. 12. Imaging <ul><li>1/5 CHF patients admitted to the hospital lacked signs on CXR </li></ul><ul><li>Congestive signs on CXR are unreliable in chronic CHF </li></ul><ul><li>Sensitivity for CHF with a portable CXR is poor. </li></ul><ul><li>CXR findings often lag behind clinical manifestions by several hours </li></ul><ul><li>However, a CXR is useful to exclude other processes (e.g., pneumothorax) </li></ul>
    10. 13. Pleural effusion
    11. 14. Pulmonary Edema
    12. 15. What about labs and EKG? <ul><li>Lack sensitivity and specificity </li></ul><ul><ul><li>Occasionally you might see an elevated AST/ALT or prerenal azotemia </li></ul></ul><ul><ul><li>EKG may show ischemia or previous MI, dysrhythmias, etc. </li></ul></ul>
    13. 16. Natriuretic peptides <ul><li>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. </li></ul><ul><ul><li>Is this CHF or COPD? </li></ul></ul><ul><li>A BNP of <100 almost entirely excludes CHF </li></ul>
    14. 17. What else looks like acute CHF?
    15. 18. TREAT! <ul><li>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. </li></ul>
    16. 19. Airway Management <ul><li>Airway management supercedes all other priorities in these patients, particularly those who are critically ill. </li></ul><ul><li>Hypoxia is a greater risk than hypercarbia so CO2 retention is not an immediate concern </li></ul><ul><li>What is the best way to manage the airway? </li></ul>
    17. 20. Intubation vs NIPPV <ul><li>Intubation </li></ul><ul><li>Typically for those in severe distress or those who are non-cooperative. </li></ul><ul><li>BiPAP/CPAP </li></ul><ul><li>May decrease the need for intubations, but no significant change in mortality </li></ul>
    18. 21. Pressure Control <ul><li>Systolic pressure acceptable? </li></ul><ul><ul><li>Start nitroglycerin (0.4 mg PO q2-3 min) </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Not working?  IV nitroprusside may be required </li></ul></ul><ul><li>The failing heart is sensitive to increases in afterload; these measures alleviate the pulmonary edema from CHF. </li></ul>
    19. 22. Don’t venodilate when…. <ul><li>Preload dependent states exist such as; </li></ul><ul><ul><li>Right ventricular infarct </li></ul></ul><ul><ul><li>Critical aortic stenosis </li></ul></ul><ul><ul><li>Volume depletion </li></ul></ul>
    20. 23. 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
    21. 24. Diuresis <ul><li>First line therapy is a diuretic such as furosemide. </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Metolazone, a thiazide diuretic, can be added for effect. </li></ul>
    22. 25. If hypotensive… <ul><li>Inotropes including dobutamine and dopamine are used primarily </li></ul><ul><ul><li>Dopamine starts at 5 mcg/kg/min IV and increase at 5 mcg/kg/min increments to a 20 mcg/kg/min dose </li></ul></ul><ul><ul><li>Dobutamine starts at 2.5 mcg/kg/min IV; generally therapeutic in the range of 10-40 mcg/kg/min </li></ul></ul>
    23. 26. Admit or go home? <ul><li>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. </li></ul><ul><li>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 </li></ul>
    24. 27. In conclusion <ul><li>Airway management is goal </li></ul><ul><ul><li>IF NIPPV easily available, begin immediately and monitor for progress or decline </li></ul></ul><ul><li>Control Pressure </li></ul><ul><ul><li>Use nitroglycerin and titrate to effect </li></ul></ul><ul><ul><li>If known diastolic CHF, attempt to reduce afterload </li></ul></ul><ul><li>Pressor support if hypotensive </li></ul><ul><ul><li>Dobutamine/dopamine </li></ul></ul>
    25. 28. References <ul><li>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.  </li></ul><ul><li>Grossman, S. Congestive Heart Failure and Pulmonary Edema. Emedicine.medscape.com. Accessed 28Aug2010 </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Tintinalli, JE. Congestive Heart Failure and Acute Pulmonary Edema. Emergency Medicine 6 th Edition. 364-372 </li></ul>
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