Acute CHF & Aortic Disasters

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Acute CHF & Aortic Disasters

  1. 1. Acute CHF & Aortic Disasters Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC 1
  2. 2. WHY HOLD THE LASIX?AMR 713 Victorville85 y/o male SOB x 1 day 3-4 word dyspnea Warm to touch Cough Pedal edema 2
  3. 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. 4. Acute SOBWhat is the optimal treatment in the next 5-10minutes? ! A. morphine ! B. Lasix ! C. Morphine + lasix 4
  5. 5. Acute SOBWhat is the optimal treatment in the next 5-10minutes? ! A. ! B. ! C. 5
  6. 6. Acute Pulmonary EdemaPreload…tries to fill lungsLV Function…emptys heartAfterload…size of hose to empty heart 6
  7. 7. Acute Pulmonary EdemaWhat do you do if the Bathtub is overflowing?Turn off water….PreloadPump it out…LV Function 7
  8. 8. Preload Reduction MS Lasix Nitrates 8
  9. 9. Morphine as Preload Reducer Disadvantges May increase catecholiminesRespiratory depressionDirect myocardial depressant…decreased SVNo good evidence that it is a central preloadreducer 9
  10. 10. Morphine Swan StudiesPreload increasedWorsening cardiac index 10
  11. 11. LasixIncreased catecholine output… activatesrenin..angiotensin system early onDieuresis is delayed…at least 90 minutesDecrease stroke volume and cardiac output dropIncreases afterload 11
  12. 12. Nitroglyercin Better than morphine or lasix for preloadreductionSafer than morphine or lasixRapid effective iniation of treatment 12
  13. 13. Ace Inhibitors Reduces afterload & some preload benefitsWorks within 15 minutesDecreases intubation and ICU admission ratesCombined ith NTG exceeds benefit of eitheralone 13
  14. 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. 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. 16. What about CPAP or BIPAP?Non-Invasive Positive Pressure VentilationIn an Austrialian meta-analysis 23 trials were reviewedThey found that when either CPAP or BiPAP were usedthere was decreased mortalityDecreased need for mechanical ventilation Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163 16
  17. 17. SOB & Funny looking T-WavesAMR 145 40 y/o female CC- general weakness & SOB DM, HTN, ESRD on dialysis 3x wk. Sinus rhythm with peaked T-waves 17
  18. 18. Acute SOB & Renal FailureMedic 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. 19. Case #137 y/o man presents in respiratory distressHistory of HTNMissed last 2 dialysis sessionsExam is consistent with pulmonary edema,severe hypoxia (pulse ox 80%)Initial EKG… 19
  20. 20. Initial EKG 20
  21. 21. Case # 1Only mild improvement with NRB maskDecision made to intubate Etomidate SuccinylcholineRhythm changes, interpreted as VT… 21
  22. 22. Case # 1The patient is given a bolus of lidocaine and hisrhythm changes to… 23
  23. 23. Case # 1 24
  24. 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
  25. 25. Ventricular TachycardiaWhat’s the problem why don’t just go ahead and treatwith 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
  26. 26. 61 year-old man withpalpitations and
  27. 27. 79 year-old man; 45 minutes after receiving thrombolytic therapy for acute myocardial
  28. 28. 6. Answer
  29. 29. 52. 62 year-old man with renal failure complains of dyspnea and orthopneaafter missing his last two hemodialysis sessions
  30. 30. 52. Answer…
  31. 31. 52.Answer
  32. 32. Heart BlocksBlocks are like relationships 1st Degree 2nd Degree Mobitz I “Wenckebach” 2nd Degree Mobitz II 3rd Degree Block- complete disassociation 34
  33. 33. The Electrical Pacemakers
  34. 34. Home
  35. 35. Home 12. Answer
  36. 36. Home 42. Answer
  37. 37. Home Third Degree Heart Block
  38. 38. 57. 54 year-old man with five days of anorexia, nausea, and vomiting
  39. 39. 57. Answer
  40. 40. 68. 41 year-old man with weakness after missing hemodialysis
  41. 41. 68. Answer
  42. 42. 69. 45 year-old woman with left chest and arm pain and dyspnea
  43. 43. 69. Answer
  44. 44. 69. Answer
  45. 45. 79. 68 year-old man unconscious with blood pressure 108/60
  46. 46. 89. 44 year-old chronic alcoholic with persistent vomiting, becomes unresponsive during the ECG
  47. 47. 89. Answer
  48. 48. 100. 26 year-old woman with history renal failure, reports nausea and generalized weakness
  49. 49. V Tach Mimics- SummaryBeware Slow V Tach HR < 120 BPM Consider hyperkalemia, TCA OD, AIVR Avoid Lidocaine and other antidysrhythmics When in doubt try HCO3 53
  50. 50. THANK YOU Questions?You can contact me at:

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