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Acute CHF & Aortic
     Disasters




 Troy W. Pennington DO, MSHPE, FAAEM
          EMS Director- ARMC

                  1
WHY HOLD THE
           LASIX?
AMR 713 Victorville

85 y/o male SOB x 1 day

  3-4 word dyspnea

  Warm to touch

  Cough

  Pedal edema

                      2
Acute SOB
      66 y/o man presents with acute sob developing over
      the last 8 hours



History   of HTN, and tobacco use

Diaphoretic,   normal mental status

Afebrile,   HR 110, BP 180/110, RR30, pulse ox. 86%

   Lungs crackles, JVD, pedal edema

                               3
Acute SOB

What  is the optimal treatment in the next 5-10
minutes?

    ! A. morphine

    ! B. Lasix

    ! C. Morphine + lasix



                        4
Acute SOB

What  is the optimal treatment in the next 5-10
minutes?

    ! A.

    ! B.

    ! C.

                        5
Acute Pulmonary Edema


Preload…tries   to fill lungs

LV   Function…emptys heart

Afterload…size   of hose to empty heart



                          6
Acute Pulmonary Edema

What   do you do if the Bathtub is overflowing?



Turn   off water….Preload

Pump   it out…LV Function


                             7
Preload Reduction

   MS

   Lasix

   Nitrates




                 8
Morphine as Preload
          Reducer
   Disadvantges

   May increase catecholimines

Respiratory   depression

Direct   myocardial depressant…decreased SV

No good evidence that it is a central preload
reducer
                            9
Morphine Swan Studies


Preload   increased
Worsening   cardiac index


                10
Lasix

Increased   catecholine output… activates
renin..angiotensin system early on

Dieuresis   is delayed…at least 90 minutes

Decrease    stroke volume and cardiac output drop

Increases   afterload

                           11
Nitroglyercin


 Better than morphine or lasix for preload
reduction

Safer   than morphine or lasix

Rapid   effective iniation of treatment

                          12
Ace Inhibitors

   Reduces afterload & some preload benefits

Works   within 15 minutes

Decreases   intubation and ICU admission rates

Combined    ith NTG exceeds benefit of either
alone

                         13
WHY HOLD THE
                  LASIX?
   Top Articles in 2006
       Evaluation of Prehospital use of Furosemide in
        patients with Respiratory Distress
       Use of Lasix prior to adequate preload and
        afterload reduction can be harmful
    Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197



                                      14
WHY HOLD THE LASIX?
    Lasix given improperly up to 30%
    of the time
    Patients that received lasix and/or
    morphine had increased mortality
    2.2 to 22%
    Use of NTG not associated with
    worse outcome even if given
    inappropriately
!   !    Wuerz (Ann Emerg Med 1992)
What about CPAP or
            BIPAP?
Non-Invasive Positive Pressure Ventilation

In an Austrialian meta-analysis 23 trials were reviewed

They found that when either CPAP or BiPAP were used
there was decreased mortality

Decreased need for mechanical ventilation


   Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163

                                      16
SOB & Funny looking
     T-Waves



AMR 145

  40 y/o female CC- general weakness & SOB

  DM, HTN, ESRD on dialysis 3x wk.

  Sinus rhythm with peaked T-waves
                    17
Acute SOB & Renal
        Failure
Medic 314
 57 y/o female w/ acute resp distress

 Unable to speak

 Retractions, JVD, no pedal edema

 ESRD

 Bp 250/150 HR 140 RR 30’s SATS 80-90’s

                   18
Case #1

37 y/o man presents in respiratory distress

History of HTN

Missed last 2 dialysis sessions

Exam is consistent with pulmonary edema,
severe hypoxia (pulse ox 80%)

Initial EKG…


                     19
Initial EKG




              20
Case # 1

Only mild improvement with NRB mask

Decision made to intubate

   Etomidate

   Succinylcholine

Rhythm changes, interpreted as VT…


                     21
Case # 1

The patient is given a bolus of lidocaine and his
rhythm changes to…




                     23
Case # 1




   24
Ventricular Tachycardia
 Wide complex regular rhythm

 No obvious pqrs association

 Heart Rate must be >= 120

    If HR < 120 BPM, consider

       Hyperkalemia

       Type IA medication toxicity (incl. TCA &
       Cocaine toxicity

       Reperfusion arrhythmias (AIVR)

                      25
Ventricular
       Tachycardia
What’s the problem why don’t just go ahead and treat
with lidocaine, procainimide, amniodarone…



V- Tach Mimics
   Treatment of slow “VT” may induce asystole

   Mclean, et al (Ann Emerg Med, 2000)

      WCT due to hyperkalemia misdiagnosed
      as VT
                   26
61 year-old man with
palpitations and
79 year-old man; 45 minutes after receiving
 thrombolytic therapy for acute myocardial
6. Answer
52. 62 year-old man with renal failure
 complains of dyspnea and orthopnea
after missing his last two hemodialysis
                sessions
52. Answer…
52.
Answer
Heart Blocks


Blocks are like relationships

   1st Degree

   2nd Degree Mobitz I “Wenckebach”

   2nd Degree Mobitz II

   3rd Degree Block- complete disassociation

                    34
The Electrical Pacemakers
Home
Home

       12. Answer
Home

       42. Answer
Home
       Third Degree Heart
             Block
57. 54 year-old man with five days of
    anorexia, nausea, and vomiting
57. Answer
68. 41 year-old man with weakness
    after missing hemodialysis
68. Answer
69. 45 year-old woman with left chest
      and arm pain and dyspnea
69. Answer
69. Answer
79. 68 year-old man unconscious with
       blood pressure 108/60
89. 44 year-old chronic alcoholic with
    persistent vomiting, becomes
    unresponsive during the ECG
89. Answer
100. 26 year-old woman with history
  renal failure, reports nausea and
        generalized weakness
V Tach Mimics-
        Summary

Beware Slow V Tach HR < 120 BPM

  Consider hyperkalemia, TCA OD, AIVR

  Avoid Lidocaine and other antidysrhythmics

  When in doubt try HCO3




                  53
THANK
 YOU




     Questions?

You can contact me at:

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Acute CHF & Aortic Disasters

  • 1. Acute CHF & Aortic Disasters Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC 1
  • 2. WHY HOLD THE LASIX? AMR 713 Victorville 85 y/o male SOB x 1 day 3-4 word dyspnea Warm to touch Cough Pedal edema 2
  • 3. Acute SOB 66 y/o man presents with acute sob developing over the last 8 hours History of HTN, and tobacco use Diaphoretic, normal mental status Afebrile, HR 110, BP 180/110, RR30, pulse ox. 86%  Lungs crackles, JVD, pedal edema 3
  • 4. Acute SOB What is the optimal treatment in the next 5-10 minutes? ! A. morphine ! B. Lasix ! C. Morphine + lasix 4
  • 5. Acute SOB What is the optimal treatment in the next 5-10 minutes? ! A. ! B. ! C. 5
  • 6. Acute Pulmonary Edema Preload…tries to fill lungs LV Function…emptys heart Afterload…size of hose to empty heart 6
  • 7. Acute Pulmonary Edema What do you do if the Bathtub is overflowing? Turn off water….Preload Pump it out…LV Function 7
  • 8. Preload Reduction  MS  Lasix  Nitrates 8
  • 9. Morphine as Preload Reducer  Disadvantges  May increase catecholimines Respiratory depression Direct myocardial depressant…decreased SV No good evidence that it is a central preload reducer 9
  • 10. Morphine Swan Studies Preload increased Worsening cardiac index 10
  • 11. Lasix Increased catecholine output… activates renin..angiotensin system early on Dieuresis is delayed…at least 90 minutes Decrease stroke volume and cardiac output drop Increases afterload 11
  • 12. Nitroglyercin  Better than morphine or lasix for preload reduction Safer than morphine or lasix Rapid effective iniation of treatment 12
  • 13. Ace Inhibitors  Reduces afterload & some preload benefits Works within 15 minutes Decreases intubation and ICU admission rates Combined ith NTG exceeds benefit of either alone 13
  • 14. WHY HOLD THE LASIX?  Top Articles in 2006  Evaluation of Prehospital use of Furosemide in patients with Respiratory Distress  Use of Lasix prior to adequate preload and afterload reduction can be harmful Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197 14
  • 15. WHY HOLD THE LASIX? Lasix given improperly up to 30% of the time Patients that received lasix and/or morphine had increased mortality 2.2 to 22% Use of NTG not associated with worse outcome even if given inappropriately ! ! Wuerz (Ann Emerg Med 1992)
  • 16. What about CPAP or BIPAP? Non-Invasive Positive Pressure Ventilation In an Austrialian meta-analysis 23 trials were reviewed They found that when either CPAP or BiPAP were used there was decreased mortality Decreased need for mechanical ventilation Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163 16
  • 17. SOB & Funny looking T-Waves AMR 145 40 y/o female CC- general weakness & SOB DM, HTN, ESRD on dialysis 3x wk. Sinus rhythm with peaked T-waves 17
  • 18. Acute SOB & Renal Failure Medic 314 57 y/o female w/ acute resp distress Unable to speak Retractions, JVD, no pedal edema ESRD Bp 250/150 HR 140 RR 30’s SATS 80-90’s 18
  • 19. Case #1 37 y/o man presents in respiratory distress History of HTN Missed last 2 dialysis sessions Exam is consistent with pulmonary edema, severe hypoxia (pulse ox 80%) Initial EKG… 19
  • 21. Case # 1 Only mild improvement with NRB mask Decision made to intubate Etomidate Succinylcholine Rhythm changes, interpreted as VT… 21
  • 22.
  • 23. Case # 1 The patient is given a bolus of lidocaine and his rhythm changes to… 23
  • 24. Case # 1 24
  • 25. Ventricular Tachycardia Wide complex regular rhythm No obvious pqrs association Heart Rate must be >= 120 If HR < 120 BPM, consider Hyperkalemia Type IA medication toxicity (incl. TCA & Cocaine toxicity Reperfusion arrhythmias (AIVR) 25
  • 26. Ventricular Tachycardia What’s the problem why don’t just go ahead and treat with lidocaine, procainimide, amniodarone… V- Tach Mimics Treatment of slow “VT” may induce asystole Mclean, et al (Ann Emerg Med, 2000) WCT due to hyperkalemia misdiagnosed as VT 26
  • 27. 61 year-old man with palpitations and
  • 28.
  • 29. 79 year-old man; 45 minutes after receiving thrombolytic therapy for acute myocardial
  • 31. 52. 62 year-old man with renal failure complains of dyspnea and orthopnea after missing his last two hemodialysis sessions
  • 34. Heart Blocks Blocks are like relationships 1st Degree 2nd Degree Mobitz I “Wenckebach” 2nd Degree Mobitz II 3rd Degree Block- complete disassociation 34
  • 36. Home
  • 37. Home 12. Answer
  • 38. Home 42. Answer
  • 39. Home Third Degree Heart Block
  • 40. 57. 54 year-old man with five days of anorexia, nausea, and vomiting
  • 42. 68. 41 year-old man with weakness after missing hemodialysis
  • 44. 69. 45 year-old woman with left chest and arm pain and dyspnea
  • 47. 79. 68 year-old man unconscious with blood pressure 108/60
  • 48.
  • 49. 89. 44 year-old chronic alcoholic with persistent vomiting, becomes unresponsive during the ECG
  • 51. 100. 26 year-old woman with history renal failure, reports nausea and generalized weakness
  • 52.
  • 53. V Tach Mimics- Summary Beware Slow V Tach HR < 120 BPM Consider hyperkalemia, TCA OD, AIVR Avoid Lidocaine and other antidysrhythmics When in doubt try HCO3 53
  • 54. THANK YOU Questions? You can contact me at:

Editor's Notes

  1. Time for a case discussion. \nThink about what your response to this patient will be. \n\nCheck if they know ambulance codes.\n(note: change of modes to maintain interest)\n
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