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ER32 Emergency Medicine
Medical Emergencies Toronto Notes 2019
Acute Decompensated Heart Failure (ADHF)
• forchronicmanagementofCHFseeCardiologyandCardiacSurgery,C34
Etiology
• causesofCHF:decreasedmyocardialcontractility(ischemia,infarction,cardiomyopathy,myocarditis), pressure overload states (HTN, valve abnormalities, congenital heart disease), restricted cardiac output (myocardial infiltrative disease, cardiac tamponade)
• precipitantsofacutedecompensationofCHF
■ cardiac (ischemia, infarction, arrhythmia - Afib)
■ medications (β-blockers, CCBs, NSAIDs, steroids, non-compliance)
■ dietary (increased sodium and/or water intake)
■ high output (anemia, infection, pregnancy, hyperthyroid)
■ other (renal failure, hypertensive crisis, iatrogenic fluid overload - blood transfusions or IV fluids)
Presentation
• left-sidedheartfailure
■ dyspnea, SOBOE, orthopnea, PND, nocturia, fatigue, altered mental status, presyncope/syncope,
angina, systemic hypotension
■ hypoxia, decreased air entry to lungs, crackles, S3 or S4, pulmonary edema (on CXR), pleural
effusion (usually right-sided) • right-sidedheartfailure
■ dependent bilateral pitting edema, JVP elevation and positive AJR, ascites, hepatomegaly • patientsoftenpresentwithacombinationofright-sidedandleft-sidedsymptoms
Investigations
• bloodwork:CBC,electrolytes,AST,ALT,bilirubin,Cr,BUN,cardiacenzymes,brainnatriureticpeptide • CXR: most useful test (see sidebar)
• ECG:lookforMI,ischemia(STelevation/depression,T-waveinversion),LVH,atrialenlargement,
conduction abnormalities
• bedsideultrasound:wallmotionabnormalities,ejectionfraction,ruleoutcardiactamponade
• echocardiogram:LVfunction,structuralheartdisease
• ruleoutotherseriousdiagnoses:PE,pneumothorax,pneumonia/empyema,acuteexacerbationsCOPD
Management
• ABCs,mayrequireintubationifseverehypoxia
• sit upright, cardiac monitoring, and continuous pulse oximetry • salinelockIV,Foleycatheterduetodiuretictherapy
• 100%O2bymask
■ if poor response, may require BiPAP or intubation • medical
■ diuretic (if volume overloaded): furosemide 0.5-1 mg/kg IV
■ vasodilators(ifsBP>100):nitroglycerin0.4mgSLq5minprn±topicalNitrodur®patch(0.4-0.8mg/h)
◆ if patient not responding to treatment or showing signs of ischemia (angina): nitroglycerine 5-10 μg/min IV, titrate to response
■ inotropes/vasopressors (if sBP <90)
◆ without signs of shock: dobutamine 2.5 μg/kg/min IV, titrate up to sBP >90 mmHg ◆ with signs of shock: norepinephrine 8-12 μg/min, titrate up to sBP >90 mmHg
• treatprecipitatingfactor-e.g.ratecontrol(β-blocker,calciumchannelblockers)orrhythm-control (electrical or chemical cardioversion) if new Afib
• cardiology or medicine consult
Precipitants of CHF Exacerbation
FAILURE
Forgot medication
Arrhythmia (Dysrhythmia)/Anemia Ischemia/Infarction/Infection Lifestyle (e.g. high salt intake) Upregulation of cardiac output (pregnancy, hyperthyroidism) Renal failure
Embolism (pulmonary)
CHF on CXR
• Pulmonary vascular redistribution
• Perihilar infiltrates
• Interstitial edema, Kerley B lines
• Alveolar edema, bilateral infiltrates
• May see cardiomegaly, pleural effusions • Peribronchial cuffing
• Fissural thickening (fluid in fissure)
Acute Treatment of CHF
LMNOP
Lasix® (furosemide)
Morphine
Nitroglycerin
Oxygen
Position (sit upright), Pressure (BiPAP)
Hospital Management Required if
• Acute MI
• Pulmonary edema or severe respiratory
distress
• Severe complicating medical illness (e.g.
pneumonia)
• Anasarca
• Symptomatic hypotension or syncope
• Refractory to outpatient therapy
• Thromboembolic complications requiring
interventions
• Clinically significant dysrhythmias
• Inadequate social support for safe
outpatient management
• Persistent hypoxia requiring supplemental
oxygen