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Congestive heart failure

  1. 1. Objectives s  Definitions: s  Types: s  Causes of H.F. s  ASA Physical Status Classification s  Clinical Manifestations of H.F. s  Management:
  2. 2. Definition: s heart failure means inability of the heart to supply sufficient oxygenated blood for the body needs.
  3. 3. Types:   Left ventricle failure: Failure occurs solely in the left ventricle ---s/s are related to congestion of lung. Right ventricle failure: Failure occurs solely in the right ventricle – s/s are related to systemic congestion. Combination of both left and right ventricles failure = congestive heart failure there are both pulmonary &systemic congestion.
  4. 4. l Left  ventricle  failure:   l Right  ventricle  failure:   congestive  heart  failure
  5. 5. Heart  Physiology  
  6. 6. Causes of H.F. Congenital heart disease s  coarcatation of aorta. s  pulmonary stenosis. s  Cardiomyopathy s  Bacterial endo carditis s  Rheumatic carditis.
  7. 7. Congenital  heart  disease  as   –                coarctation  of  aorta.     pulmonary  stenosis.     Cardiomyopathy     Bacterial  endo  carditis     Rheumatic  carditis.  
  8. 8. ASA Physical Status Classification for CHF. s  ASA-I: No dyspnea, no fatigue with normal exertion. s  ASA-II: Mild dyspnea, or fatigue during exertion. s  ASA-III: activity. Dyspnea or fatigue with normal s  ASA-IV: Dyspnea, orthopnea and undue fatigue at all times.
  9. 9. s  ASA-I: No special modification in dental ttt. s  ASA-II: Can be managed normally Can use stress reduction prot. s  ASA-III: there is ^^^Risk in dental ttt. so Before any dental management : ask for medical consultation apply stress reduction protocol.
  10. 10. s  ASA-IV: s  Dental treatment should be withheld for all elective procedures until the cardiovascular disorder is controlled. s  Dental emergencies as pain or infections should be managed with medication s  If intervention is necessary the patient should be hospitalized under a physician care before , during and after dental treatment.
  11. 11. Clinical  Manifestations  
  12. 12. Clinical Manifestations of H.F. s  Left ventricular failure: s  s  Weakness and undue fatigue. Dyspnea:……..degrees of dyspnea s  Dyspnea on exertion accompanied by: s  s  s  s  s  Tachypnea. Cough and expectoration. Increased urination at night (nocturia). Orthopnea. Paroxysmal nocturnal dyspnea (exaggerated form of orthopnea).
  13. 13. s  NB, s  The patient awakens from sleep acutely, having shortening of breath and gasping for air with respiratory difficulty. s  There may be inspiratory and expiratory wheeze ……>> cardiac asthma.
  14. 14. s  s  Pale, sweaty, cool …skin. Vital Signs: blood pre……pulse pre….. s  Usually increased blood pressure more in diastolic pr. s  Pulse pressure narrow. s  H.R. increased. s  Pulses alternans (alternating strong and weak heart beats). s  Tachypnea, hyperventilation.
  15. 15. Right Ventricular H.F: s/s of systemic venous congestion: s  Peripheral edema: s  Swelling of feet and ankles: more in day and in night. Dependent or pitting edema in bedridden -in sacral region. s  Weakness and fatigue. s  Cyanosis: especially in mucous membrane.
  16. 16. Right    side  heart  failure Peripheral  edema:          Swelling  of  feet  and        ankles:                 Cyanosis:       Prominent  jugular  veins       Hepatomegaly:        splenomegaly.      abdominal  edema  …..    ascites.    GIT  congestion   …….anorexia,  nausea,    …… vomiting.   CNS.  Edema    -­‐    headache,       insomnia,  irritability.    
  17. 17. s  Prominent jugular veins in nect. s  Hepatomegaly: splenomegaly. s  With progress of edema – abdominal edema known as ascites. s  GIT congestion - anorexia, nausea, vomiting. s  CNS. Edema - headache, insomnia, irritability.
  18. 18. s  3) Combined left and right vent. V. s  All previous s/s are present. s  In addition: s  Hyperventilation – respiratory alkalosis: s  Cold hands. s  Tingling fingers.. s  Anxiety.
  19. 19. Management s  R. Recognize H.F.: Left ventricular f. Right ventricular f. Congestive H.F. s  T. Terminate dental procedure: - Remove dental materials.
  20. 20. s  P. s  Position Care: Should be in comfortable in most cases – upright position is good s  this allows sitting of fluid down in base of lung and good ventilation for the rest of lung tissue. s  N.B. If patient looses consc. >>>> place him in supine position.
  21. 21. s  ABCD (basic life support) as needed s  M: Call for medical emergency. s  ….. send to hospital… for other medial treatment as phlebotomy, O2, drugs, as digitalis, s  Calm the patient. diuretics.
  22. 22. s  Definitive Care: s  Give O2. s  Monitor vital signs. s  Alleviate symptoms. s  Eg: ***** ^ blood pres………. By : - phlebotomy (by tourniquets). - Vasodilators: as
  23. 23. - Nitroglycerin: s  Dose : 8 – 1.2 mg/every 5 mint. s  NB: Blood pressure should be above 100 mg to give nitroglycerin.
  24. 24. s  *****of apprehension[…fear..] e.g. by opioid like drugs as meperidine I.M. 25 mg. s  Subsequent dental ttt… s  Episodes of H.F. should be considered.
  25. 25. Dental  considerations   s  Patient  position  (partially  recline  or  erect  position).   s  Dental  treatment  may  precipitate  dysrhythmias,   angina,  or  heart  failure.   s  For  patient  with  mild  controlled  cardiac  failure,   routine  dental  care  can  usually  be  provided  with  little   modification.  Anxiety  must  be  minimized  and  pain   control  must  be  fully  effective.   s  For  patient  with  poorly  controlled  or  uncontrolled   cardiac  failure,  medical  attention  should  be  obtained   before  any  dental  treatment.    
  26. 26. Dental  considerations   s  Elective  dental  treatment  should  be  delayed  until  the   condition  has  been  stabilized  medically.   s  Emergency  dental  care  should  be  conservative,   principally  with  analgesics,  and  antibiotics.   s  Appointments  should  be  short.   s  Patients  are  best  treated  in  the  late  morning.   s  An  aspirating  syringe  should  be  used  to  give  LA.   Epinephrine  may  increase  hypertension  and   precipitate  dysrhythmias.    
  27. 27. Dental  considerations   s  Effective  analgesia  must  be  provided.   s  Patient  on  medication  such  as  diuretics  may  cause   orthostatic  hypotension,  and  therefore  patients   should  be  raised  slowly  to  upright  position.      

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