CHF, Acute Pulmonary Edema Flashcards
Pt presents in acute pulmonary edema from heart failure. What causes should come to mind and be ruled out?
Atrial fibrillation or dysrhythmia
Acute MI or ischemia, including right sided infarction
Valvular dysfunction
Non-compliance with medications
Increased sodium load
Drug induced impairment of cardiac function
Physical overexertion
What are the clinical features of acute decompensated heart failure and pulmonary edema?
SOB with increased WOB
Tachycardia with HYPERtension
Pink or white frothy sputum
Cardiac irritability with A-fib or ectopy
L Heart Failure: pulmonary edema, orthopnea, PND, decreased exercise tolerance, HTN, large left heart
R Heart Failure: edema, hepatomegaly, JVD, hepatojugular reflex
What are the most severe causes to be ruled out first?
MI, Acute valvular failure, Dysrhythmia
Pt presents with SOB and findings suggestive of pulmonary edema from acute CHF. What are the first steps of assessment and intervention?
1) Breathing comes first: Give O2 if needed, If severe WOB, start BiPAP or consider intubation
2) Assess the heart: EKG to rule out dysrhythmia, MI, listen for signs of acute valvular issue, maybe US
3) Nitroglycerin: rule out R side MI and ask about recent ED drug use. 0.4mg SL every 1–5 minutes, start a drip if no response or there is ischemia on EKG, titrate rapidly to BP and symptom improvement
4) After nitrates, start a diuretic
5) Watch for hypotension
6) Get CXR and labs
What are the basic interventions for acute CHF with pulmonary edema?
O2, Preload and afterload reduction, diuretics, inotropic agents, breathing support
What workup is needed for CHF with acute pulmonary edema and why?
EKG: MI, R side infarction, dysrhythmia causing the acute decompensation
CXR: looking for edema and other causes of SOB—COPD, PTX, PNA, ARDS, Effusions, etc.
CBC: r/o anemia, signs of infection
BMP: lytes for cardiac function and diuretic use, kidney function as renal failure can precipitate and dialysis would be needed
BNP: signs of overload
Troponin: to rule out MI
Dimer?: if needed for PE
Blood gas: trend breathing adequacy
You plan to give SL nitroglycerin for the first time to a patient, what is the first step?
EKG for R MI, check BP, be sure no PDE-5 inhibitors in the last 24 hours
Patient is given SL nitro x 3 without any effect, what is next step?
Start a Nitro drip: 0.4mcg/kg/min and titrate rapidly to achieve BP and symptomatic improvement
After airway management and nitroglycerin, what is the next step in management?
Start a diuretic Furosemide 40–80mg Bumetanide 0.5–1.0mg Torsemide 10mg Watch electrolytes
Pt is being treated with nitroglycerin what adverse effect are we watching for and what is the intervention?
Hypotension Decrease or stop the nitro Consider fluid bolus 250–1,000mL Worry about valvular pathology or R MI If refractory hypotension, consider management for cardiogenic shock
Pt is being treated with nitro drip but BP is not coming down. What next?
Consider nitroprusside 0.3mcg/kg/min titrated
What is the disposition for these patients?
ICU if severe breathing issues or hemodynamic instability
Tele bed for MI, dysrhythmias, hypertension
Home if chronic and respond well to diuretics in the ED and have good follow up
