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chf by mruby

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									Heart Failure

 EMS Professions
 Temple College
         Heart Failure
Inability of heart to pump blood
   out as rapidly as it enters

Often referred to as congestive
     heart failure (CHF)
 Congestive Heart Failure
Congestion of pulmonary or
   systemic circulation
    (backward failure)

 Reduced output to body
 tissues (forward failure)
              Causes
Diffuse   coronary artery disease
  » Myocardial ischemia
Myocardialinfarction
Arrhythmias
  » Tachycardia
  » Bradycardia
            Causes
Valvular heart disease
Acute Hypertensive Crisis
Chronic Hypertension
Idiopathic Causes
             CHF
May develop acutely or may
   be a chronic disease

Acute   Onset CHF: Suspect
 »Acute MI
 »Dysrhythmia
 »Hypertensive Crisis
                CHF

Chronic   CHF may worsen acutely
 from:
 » Respiratory infection
 » Pulmonary embolism
 » Emotional stress
 » Increased salt and water intake
Congestive Heart Failure

     Left sided
     Right sided
    Biventricular
   Left-Sided Heart Failure
Left ventricle fails as effective
 pump
Left ventricle cannot eject
 blood delivered from right
 heart through pulmonary
 circulation
Blood backs up into pulmonary
 circulation
   Left-Sided Heart Failure
Increase  pressure in
 pulmonary capillaries forces
 blood serum out of capillaries
 into interstitial spaces and
 alveoli
Increase respiratory work and
 decrease gas exchange occur
  Left-Sided Heart Failure
Common     causes
 » ACUTE MI
    especially   if involves left ventricle
 » Chronic hypertension
 » Dysrhythmias
    especially   tachydysrhythmias
Left-Sided Heart Failure

     Pulmonary
  Signs/Symptoms
 Left Heart Failure Symptoms
Dyspnea  on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Fatigue, generalized weakness
      Left Heart Failure Signs
 Anxiety, confusion, restlessness
 Persistent cough
  » Pink, frothy sputum
 Tachycardia
 Tachypnea
 Noisy,   labored breathing
  » Rales, wheezing (“cardiac asthma”)
 Cyanosis (late)
 Third heart sound (S3)
  Right-sided Heart Failure
Right  ventricle fails as
 effective pump
Right ventricle cannot eject
 blood returning through vena
 cavae
Blood backs up into systemic
 circulation
      Right Heart Failure
Increased  pressure in systemic
 capillaries forces fluid out of
 capillaries into interstitial
 spaces
Tissue edema occurs
Right Heart Failure Causes

    Most Common Cause:
   Left sided Heart Failure
 Right Heart Failure Causes
Others
 » Chronic hypertension
 » COPD (cor pulmonale)
 » Pulmonary embolism
 » Right ventricular infarction
Right-Sided Heart Failure


      Systemic
   Signs/Symptoms
         Right Heart Failure
          Signs/Symptoms
Tachycardia
Jugular vein distension
Pedal, pre-tibial, sacral edema
Hepatomegaly
Splenomegaly

   Classic Triad of Right Ventricular Failure:
        JVD, Hypotension, Clear Lungs
       Right Heart Failure
        Signs/Symptoms
Anasarca   (generalized edema)
Fluid accumulation in body
 cavities
  » Ascites
  » Pleural effusion
  » Pericardial effusion
Management of Heart Failure
     Goals of Management
Improve oxygenation, ventilation
Decrease venous return to heart
Decrease cardiac work, O2
 demand
Improve cardiac output by
  » Reducing afterload
  » Increasing myocardial contractility
            Management
Sit   patient up, dangle feet
  » Do not lay flat
Oxygen  by non-rebreather mask
Consider positive pressure
 ventilation
         Management
Consider   intubation if:
 » O2 saturation cannot be kept >90%
   on 100% O2
 » PaO2 cannot be kept >60 torr on
   100 % O2
 » Patient displays signs of
   worsening cerebral hypoxia
 » PaCO2 progressively increases
 » Patient becoming exhausted
           Management
Monitor   ECG
 » Hypoxia, increased heart wall
   tension leads to dysrhythmias
IV NS TKO via microdrip or
 lock
 » Limit Fluids
 » If RVF only, fluid challenges to 
   preload
 CHF First Line Drug Therapy
 Nitroglycerin
  »   0.4mg SL q 5 min prn
  »   Systolic BP should be > 90 - 100 mm Hg
  »   Nitrate therapy before IV is started
  »   Reduces preload/afterload
  »   Improves coronary artery perfusion
  »   Caution in RVF
        NTG,  Lasix or MS may worsen hypotension
        Use inotropes if fluid does not improve BP
         following NTG administration
   CHF First Line Drug Therapy
 Furosemide        (Lasix®) -
  » 40 mg (0.5 - 1 mg/kg) slow IV
      Patients already on furosemide may have
       tolerance
      Increase dose to 2X daily oral dose

  » Direct vasodilation leads to decreased
    venous return
  » Diuresis leads to decreased intravascular
    volume
  » May cause hypokalemia, dysrhythmias
      especially   dangerous if patient on digitalis
  » May worsen hypotension in RVF
 CHF First Line Drug Therapy
 Morphine       Sulfate
  » 2 mg IV push slowly q 10-15 min
  » Peripheral vasodilation leads to
     Decreased preload
     Decreased afterload

  » Decreased venous return leads to
     Decreased cardiac work
     Decreased O2 demand

  » Decreased anxiety
     Decreased    release of catecholamines
  » Monitor Ventilations and BP
     Systolic   BP should be > 90 - 100 mm Hg
 CHF Second Line Therapy
Dobutamine
 » 2 - 20 mcg/kg/min
 » Potent 1 stimulation
    Increases contractility
    Increases level of cardiac output

 » Drug of choice if systolic BP >100
   and diastolic BP <110
   CHF Second Line Therapy
Nitroglycerin
  » 10 mcg/min increased by 5-10
    mcg/min q 5 min
  » Vasodilation
     Decreased  venous return leads to
       » Decreased cardiac work
       » Decreased O2 demand
     Decreased afterload leads to increased
      cardiac output
  CHF Third Line Drug Therapy
Bronchodilators   (beta agonists)
 » May be useful if wheezing is present
 » Mild peripheral vasodilator
 » Myocardial and respiratory
   stimulant
 » May cause arrhythmias in hypoxic
   patients or those with coronary
   artery disease
          CHF Management
 Whatif the BP is too low for the first
 and second line drug therapies?
  » BP < 70 mm Hg
      norepinephrine,   0.5 - 30 mcg/min IV infusion
  » BP > 70 but < 100 mm Hg
      dopamine,   5 - 15 mcg/kg/min IV infusion
      BP improves, treat pulmonary
 After
 edema with first and second line
 therapies
            CHF Management
 Long   Term Management usually includes
  » Fluid minimization
     Diuretics (+ Potassium if non-potassium sparing)
     Diet restrictions

  » Increase contractility
     Digitalis

  » Blood pressure control
     ACE   Inhibitors
  » Coronary artery perfusion
     Nitroglycerin
Cardiogenic Shock
  Cardiogenic Shock

Diminished cardiac output
leading to impaired tissue
        perfusion

Most extreme form of pump
          failure
       Cardiogenic Shock
Occurs   in about 15% of acute MI
 patients
Usually occurs when 40% or more
 of the left ventricular muscle mass
 infarcts
Mortality is 85% or more with
 treatment
       Signs/Symptoms
Confusion,  restlessness,
 anxiety, stupor, coma
Cool, clammy skin
Pallor
Weak or absent extremity
 pulses
Tachycardia
Slow or absent capillary refill
       Signs/Symptoms
BP< 90 systolic or > 30mmHg
below normal
 » BP is NOT the same as perfusion
 » Shock can be present with a
   “normal” BP
 » Evaluate signs of peripheral
   perfusion in addition to BP
  Cardiogenic Shock

Very difficult to assess in
presence of arrhythmias,
hypovolemia, decreased
     vascular tone
      Cardiogenic Shock
Treatment   Priorities:
 » Rate
 » Rhythm
 » BP (Volume, Pump/Vascular tone)
Correct  major disorders of
 rate, rhythm before directly
 treating BP
    Goals of Management
Improve  oxygenation and
 peripheral perfusion
Avoid increasing cardiac
 workload
  » myocardial oxygen demand
         Management
Primary   assessment & Focused
 Hx
Identify source of problem
  » Acute pulmonary edema
  » Volume problem
  » Pump problem
  » Rate problem
   Acute Pulmonary Edema
First   line interventions
  » IV/O2/ECG Monitor
  » If BP > 90-100 mm Hg:
     furosemide  0.5 – 1.0 mg/kg slow IV
      (or twice patient’s single daily dose
      up to 120 mg)
     Morphine 2 – 10 mg slow IV
     Nitroglycerin 0.4 mg SL

  » If BP < 90 mm Hg:
     Vasopressors   based on SBP
       Volume Problem
IV/O2/ECG  Monitor
Fluid challenge until rales or if
 evidence of anterior wall AMI
Vasopressors based on SBP
          Pump Problem
IV/O2/ECGMonitor
SBP <70 mmHg:
 » norepinephrine 0.5 – 30 mcg/min IV
   inf
SBP   70 – 100 mm Hg & shock
 » dopamine 5 – 15 mcg/kg/min IV inf
SBP   > 100 mm Hg w/o shock
 » dobutamine 2 – 20 mcg/kg/min IV inf
           Management
Keep   patient supine
  » Difficult in presence of pulm
    edema
  » Do not elevate lower extremities
Oxygenate via NRB
Consider assisting ventilations
  » Decrease work of breathing may
    benefit patient in shock
  » Consider intubation
Monitor   ECG
            Management
IV   TKO with microdrip set or lock
 » Limit fluids unless suspect RVF
Correct   major disorders of rate,
 rhythm
 » Increase rate in bradycardias
 » Terminate tachycardias with
   cardioversion
 » Suppress frequent ectopic beats
          Management
  rate/rhythm adequate, treat
If
 BP
  » Consider fluid challenge of 250cc
    LR over 10-15 minutes if relative
    or absolute hypovolemia possible,
    including RVF and NO
    pulmonary edema
  » Avoid use of vasopressors until
    volume deficits corrected or
    pulmonary edema presents
      BP Treatment Review
Ifrate, rhythm, volume
 adequate, treat BP with
 vasopressors:
  » Norepinephrine, or
  » Dopamine
           Norepinephrine
 0.5 - 30 mcg/min
 Inotropic and vasoconstrictive
  properties
 Can be used if systolic BP < 70
 If systolic BP > 70, use dopamine
  instead
 DO NOT use until hypovolemia
  corrected
 DO NOT allow infiltration
               Dopamine
2   - 20 mcg/kg/min
  » Place 200 mg/250cc of D5W
  » Begin at 5 mcg/kg/min
  » In 2 - 10 mcg/kg/min range,  effects
    dominate
  » > 20 mcg/kg/min  effects dominate
  » Use lowest dose that produces good
    perfusion
 Useas initial vasopressor if BP 70-100
 systolic
  » If dopamine infusion rate is > 20
    mcg/kg/min use norepinephrine
          Dopamine
May  cause tachycardia, ectopy,
 nausea
DO NOT use until hypovolemia
 is corrected
DO NOT allow to infiltrate

								
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