Beaches Emergency Team
What triggers acute heart failure?Primary cardiac dysfunction – ischaemic, valve failure, tamponadeDecompensation of chronic HF with precipitant eg infection, HTN, rhythm disturbance, or without precipitant‘CHAMP’C ACSH Hypertension emergencyA ArrhythmiaM Acute mechanical causeP PEHow is acute heart failure classified?What Investigations should we do for patients presenting in acute heart failure?CXR – erect, not supine – congestion, diagnosis of another causeECG – arrhythmia, ischemia, underlying cardiac diseaseBedside echo –Especially if new onset acute heart failure with no cardiac Hx and in cardiogenic shockLooks for mechanical cause – acute valve failure, free wall rupture, tamponadeBloods – BNP? Trop, EUC, FBC, LFT, CMP, CRP?, D dimer? VBG, TFTHow do we manage these patients in ED?Fix the underlying cause eg STEMI, mechanical, dysrhythmiaFix the ventilation problemO2 if hypoxic, CPAP/BIPAP if respiratory distress or respiratory failureFor APO – decreased mortality, intubation rate, shorter hospital stayHow does NIV work in these patients?Decreased WOBDecreased LV preload may help, decreased afterload helps increase cardiac output Increased alveolar pressure moves fluid back out of alveolar spaceAlveolar recruitment improves complianceMedicationsDiuretics?If hypertension (predominates) with congestion – vasodilator first, then diureticIf congestion predominates – diuretic, vasodilatorRemember APO is usually due to fluid redistribution rather than fluid overloadMost pts only have minimal excess weight on their usual dry weightc/w pt’s who have had several weeks of gradually worsening heart failure symptoms – this may be due to fluid overload – use diuretics for theseDiuretics may cause harm if given to people without fluid overload – cause arterial vasoconstriction due to activation of renin-angiotensin system, which may reduce COUse small doses if using – eg equivalent to pre-existing oral dose or if naive, 20-40mg IVVasodilatorsVenodilate – reduce preload (in lower dose)Arteriodilate – reduce afterload (in higher dose)Reduces pulmonary vascular pressure – helps shift fluid back into intravascular spaceCan give SL dose first – eg 300-600mcg SL – equates to aprox 80mcg/minCan use higher initial doses of IV nitrates for immediate afterload reductionHas been shown to reduce intubation rates, ICU admission, MI without significant hypotensionMade up in infusion with dextrose 5% 50mg in 100ml = 500mcg/mlUsual starting range is 0.6-3ml/hr = 5-25mcg/min then increase by 1ml/hr every 5 mins until target BP achievedLoading dose 2mg may be given prior to starting infusionIntermittent boluses do seem to reduce intubation rates, ICU admissions but no significant effect on mortalityWhat about morphine?Guidelines varySome harm including – myocardial depression, reduced HR, decreased CO, resp depressionProbably best avoided ................
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