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Congestive Heart Failure,  Pulmonary Edema,  and CPAP James Pointer, MD, FACEP Medical Director Alameda County EMS
Objectives <ul><li>Review cardiac physiology and pathophysiology of CHF </li></ul><ul><li>Early recognition of CHF </li></...
Terminology <ul><li>Heart Failure:   The inability of the heart to maintain an output adequate to maintain the metabolic d...
Etiology <ul><li>Arteriosclerotic Cardiovascular Ischemia </li></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Ischem...
People Live With Atherosclerosis  – But Die of Thrombosis!   Arteriosclerotic plaques gradually narrow the coronary arteri...
Hypertension <ul><li>Hypertrophic Cardiomyopathy </li></ul>
Heart Failure - Concepts <ul><li>Frank-Starling Length:  Tension Ratio </li></ul><ul><li>Ejection Fraction </li></ul><ul><...
Three Pathophysiological Causes of Failure <ul><li>Increased work load (HTN) </li></ul><ul><li>Myocardial Dysfunction (ASC...
Compensatory Mechanisms <ul><li>Increased Heart Rate </li></ul><ul><ul><li>Sympathetic = Norepinephrine </li></ul></ul><ul...
CHF Vicious Cycle Low Output Increased Preload  Increased Afterload Norepinephrine Increased Salt Vasoconstriction Renal B...
Decompensation <ul><li>Increased Pulmonary Venous Pressure (PAWP) </li></ul><ul><li>Interstitial Edema </li></ul><ul><li>A...
Infiltration of Interstitial Space <ul><li>Normal  </li></ul><ul><li>Micro-anatomy </li></ul><ul><li>Micro-anatomy with fl...
Acute Pulmonary Edema a true life- threatening emergency
Precipitating Causes <ul><li>Non Compliance with Meds and Diet </li></ul><ul><li>Acute MI </li></ul><ul><li>Arrhythmia (e....
Symptoms <ul><li>Fatigue </li></ul><ul><li>Nocturia </li></ul><ul><li>DOE </li></ul><ul><li>PND </li></ul><ul><li>GI Sympt...
Physical Exam <ul><li>Anxious </li></ul><ul><li>Pale </li></ul><ul><li>Clammy </li></ul><ul><li>Tachypnea </li></ul><ul><l...
 
EMS Management <ul><li>Sit upright </li></ul><ul><li>High Flow O 2 </li></ul><ul><li>NTG (If SBP > 100) </li></ul><ul><li>...
CPAP - Introduction <ul><li>CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without...
Key Points of CPAP <ul><li>CPAP has been successfully demonstrated as an effective adjunct in the management of pulmonary ...
CPAP Mechanism <ul><li>Increases pressure within airway. </li></ul><ul><li>Airways at risk for collapse from excess fluid ...
Prehospital Indications <ul><li>Congestive Heart Failure </li></ul><ul><li>Pulmonary Edema associated with volume overload...
<ul><li>Patient, age  >  8, in severe respiratory distress who meets one of the following criteria: </li></ul><ul><ul><li>...
Absolute Contraindications <ul><li>Age < 8 </li></ul><ul><li>Respiratory or Cardiac Arrest </li></ul><ul><li>Agonal Respir...
Relative Contraindications <ul><li>History of Asthma/COPD </li></ul><ul><li>History of Pulmonary Fibrosis </li></ul><ul><l...
Complications <ul><li>Hypotension </li></ul><ul><li>Pneumothorax  </li></ul><ul><li>Corneal Drying </li></ul>
Using the Machine <ul><li>Turn all three control knobs   fully clockwise   to the   OFF position </li></ul><ul><li>Turn th...
Important Points <ul><li>Pulmonary edema patients, properly selected, quickly improve with CPAP in a matter of minutes. </...
Important Points  (cont.) <ul><li>COPD and Asthmatic patients do  NOT  respond predictably to CPAP. </li></ul><ul><ul><li>...
CPAP vs. Intubation <ul><li>CPAP </li></ul><ul><ul><li>Non-invasive </li></ul></ul><ul><ul><li>Easily discontinued </li></...
CPAP Study 1996 – 1997 1997 – 1998   September – May    September – May Intubated 22 8 CPAP 0 50 Hospital Stay(d) 14.8 8 I...
Alameda County Data <ul><li>22 Patients </li></ul><ul><li>19 lived / 3 died / 2 patients to ICU </li></ul><ul><li>Respirat...
Alameda County CPAP Policy
Summary <ul><li>CPAP provides an adjunct between oxygen by NRB mask and endotracheal intubation </li></ul><ul><li>Eliminat...
 
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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)

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

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