Transcript Managing acute heart failure in the Emergency Department

Managing Acute Heart Failure in the Emergency Department
Patient Case Study
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Initial Diagnosis
and Care Plan
Case Introduction
1
Revised Diagnosis
and Care Plan
3
2
Teaching Points
Discussion and Conclusions
5
4
7
6
Glossary
Case Details
and Initial Triage
Diagnostic
Results
Author:
Òscar Miró, MD, PhD
Disposition
Decision
?
Questions
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Case
Introduction
Case Details
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Initial Diagnosis
and Care Plan
Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE INTRODUCTION
Òscar Miró, MD, PhD
Emergency Department, Hospital Clínic
(Barcelona, Catalonia: Spain)
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Case
Introduction
CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Background
•
This is the ED of an academic tertiary care
hospital in a large urban center. You
completed training as a board certified internal
medicine physician 5 years ago
•
You have 5 residents on duty (of different
medical specialties, but none of emergency
medicine because this specialty is not
recognized in your country), a full complement
of nurses and assistants, and 24/7 immediate
access to image explorations (CT, MR, US)
CT=computed tomography; ED=Emergency Department; MR= magnetic resonance;
US=ultrasound
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CASE INTRODUCTION
Case Details
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Background
•
Nobody in the ED is skilled in emergency
echo and the ED does not have natriuretic
peptide availability. Essentially, this ED
handles any type of emergency
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You are also in charge of a 16-bed
observation unit, located immediately adjacent
to the ED, where patients can be observed for
up to 24 hours.
•
Annual census 100,000 visits/year. Mean LOS
13 hours (4.3 for discharged patients; 17.1 for
admitted patients)
ED=Emergency Department; LOS=length of stay
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Decision
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Past History, Allergy
History, Medications,
and Social History
History of
Present Illness
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Òscar Miró, MD, PhD
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Revised Diagnosis
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Decision
Teaching Points
Discussion and Conclusions
CASE DETAILS
AND INITIAL TRIAGE
Chief complaint (11.30 am)
•
A 83 year-old woman presents at the ED by
ambulance because of worsening shortness
of breath
ED=Emergency Department
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
Vital Signs and Key Data from
Paramedics
•
Paramedic from the ambulance crew reports that she
has a previous diagnosis of chronic cardiac failure
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Vitals en route: BP: 155/70 mmHg, HR: 98 bpm,
RR: 26 brpm, Temperature: 35.9°C / 96.6°F,
O2 sat room air: 90%
•
Based on the presence of leg edema and lung rales
on auscultation the paramedic has administered
furosemide 40 mg IV and provided oxygen by mask
at a concentration of 28%
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; RR=respiration rate;
02 sat=oxygen saturation
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Initial Diagnosis
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Revised Diagnosis
and Care Plan
Disposition
Decision
History of Present Illness
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Increase of dyspnea over last 7 days, no
clear trigger
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Intensified furosemide treatment from
40 mg o.d. to 40 mg b.i.d. by her GP
3 days ago
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Last 2 days sleeping seated with three pillows
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No chest pain, no fever, no changes in
medication other than increase in
furosemide dosage
b.i.d.=twice daily; GP=General Practitioner; o.d.=once daily
Teaching Points
Discussion and Conclusions
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CASE DETAILS
AND INITIAL TRIAGE
Case Details
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Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Past History
•
Type II diabetes mellitus
– metformin 850 mg b.i.d.
•
Arterial hypertension
– enalapril 20 mg o.d.
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Persistent atrial fibrillation
– dicoumarin*
–
•
digoxin 0.25 mg/48 h
Ischemic cardiomyopathy
– inferior MI 4 years ago and post-infarct angina
– Coronary artery bypass 3x (asymptomatic since)
– ASA 100 mg o.d. and simvastatin 40 mg o.d.
*Dose dependent on coagulation test results (international normalized ratio)
ASA=acetylsalicylic acid; b.i.d.=twice daily; MI=myocardial infarction; o.d.=once daily
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Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Past History
•
Chronic heart failure
– NYHA Class II, LVEF 38%, no significant
valvular dysfunction
– last echocardiogram was 3 years previous
– furosemide 40 mg o.d.
– four previous episodes of AHF in past
12 months
•
two admitted to internal medicine ward
•
two discharged directly home from ED
AHF=acute heart failure; ED=Emergency Department; LVEF=left ventricular ejection fraction;
NYHA=New York Heart Association
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Decision
Allergy History, Medications,
and Social History
Allergies
•
NKDA
Current Medications
• Metformin 850 mg b.i.d.
• Enalapril 20 mg o.d.
• Dicoumarin and digoxin
0.25 mg/48 h
• AAS 100 mg o.d.
• Simvastatin 40 mg o.d.
• Furosemide 40 mg o.d.
Social History
•
Is functionally
independent: Barthel
index: 100 points
•
Intellectually intact:
mini-mental test:
30 points
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Is adherent to treatment
•
Lives with her daughter
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Exercises daily (30 min walk)
b.i.d.=twice daily; NKDA=no known drug allergies; o.d.=once daily
Teaching Points
Discussion and Conclusions
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Initial Diagnosis
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Revised Diagnosis
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Teaching Points
Discussion and Conclusions
Physical Examination
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Vitals at ED:
– BP: 152/78 mmHg
– HR: 110 bpm (arrhythmic)
– RR: 24 brpm
– Temperature: 36.4°C / 97.5°F
– O2 sat: 91% (on room air)
No cardiac murmurs
Rales on both pulmonary bases, clear above
Mild edema until knees
Jugular distention: 6 cm
Otherwise unremarkable
BP=blood pressure; ED=Emergency Department; HR=heart rate; RR=respiration rate; O 2 sat=oxygen saturation
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Teaching Points
Discussion and Conclusions
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Clinical Impression
(Initial Diagnosis) and
Differential Diagnosis
Initial Plan of Care
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Òscar Miró, MD, PhD
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INITIAL DIAGNOSIS
AND CARE PLAN
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Initial Diagnosis
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Revised Diagnosis
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Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
•
EM consultant and resident concur she has
acute decompensated heart failure
– based upon a history of chronic heart
failure and recent episodes of AHF
– presence of leg edema and lung rales on
admission
– other possibilities are considered unlikely
AHF=acute heart failure; EM=emergency medicine
Teaching Points
Discussion and Conclusions
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INITIAL DIAGNOSIS
AND CARE PLAN
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Initial Diagnosis
and Care Plan
Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Initial Plan of Care
(12.40 pm; +1.10 hours after ED arrival)
Treatment
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Maintain oxygen supplementation
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No more furosemide at this point
Work-up
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Check clinical response
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Check urine output
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Order X ray
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Order ECG
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Order laboratory tests including troponin
ECG=electrocardiogram; ED=Emergency Department
Teaching Points
Discussion and Conclusions
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QUESTION
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Lab Results
Chest X ray
ECG
DIAGNOSTIC RESULTS
Author:
Òscar Miró, MD, PhD
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ECG: (12.55 pm; +1.25 hours after ED arrival)
ECG=electrocardiogram; ED=Emergency Department
Teaching Points
Discussion and Conclusions
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ECG:
Interpretation
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ECG: Interpretation
•
Mild tachycardia, atrial fibrillation and left anterior
hemiblock, with non specific ST changes
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Lab Results (or Point of Care Testing
Results)
(1.26 am; +1.46 hours after ED arrival)
• Blood Tests
– Glucose
– Creatinine
– eGFR
– Troponin*
– Hemogram
– INR
201 mg/dL
1.1 mg/dL
67 mL/min/1.73 m2
<0.017 ng/mL
normal
2.7
(reference range)
(65–110 mg/dL)
(0.3–1.3mg/dL)
(>60 mL/min/1.73 m2)
(<0.05 ng/mL)
• Gas Blood Analysis (Arterial, Room Air)
– pH
– pCO2
– pO2
• Plasma Digoxin
Levels
7.42
43 mmHg
63 mmHg
0.9 ng/mL
(7.35–7.45)
(38–48 mmHg)
(95–100 mmHg)
(0.8–1.8ng/mL)
*Dimension® EXL LOCI Module (Siemens Diagnostics), Pathological value (99th percentile)=0.055 ng/mL;
Lowest limit for detection=0.017 ng/mL.
ED=Emergency Department; eGFR=estimated glomerular filtration rate; INR=international normalized ratio
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Chest X ray
Diagnostic
Results
Revised Diagnosis
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Teaching Points
Discussion and Conclusions
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Chest X ray:
Interpretation
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Discussion and Conclusions
Chest X ray: Radiology Interpretation
•
Previous sternotomy, heart enlargement, lung
interstitial edema with some patched areas with
alveolar edema
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Revised Clinical
Impression and
Differential Diagnoses
Next Actions
REVISED DIAGNOSIS AND
CARE PLAN
Author:
Òscar Miró, MD, PhD
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REVISED DIAGNOSIS
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
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Disposition
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Teaching Points
Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses
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Complementary explorations support initial diagnosis
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Tachycardia was considered to be secondary to AHF
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EM consultant and resident concur patient does not
need further investigations to confirm diagnosis
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Urine output 4 hours after ED arrival: 950 cc
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Patient feeling comfortable sat at 45° with oxygen
supplementation
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EM consultant and resident concur patient does not
need emergent cardiologist consultation
AHF=acute heart failure; ED=emergency department; EM=emergency medicine
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Discussion and Conclusions
Next Actions
Treatment
• Patient allocated to the ED observation unit (maximum allowed
stay: 24 hours; monitoring at bedside possible, but no telemetry)
• Maintain on oxygen supplementation
• Furosemide i.v., 40 mg/8 h
• Close renal function monitoring (get another creatinine in
12–24 hours)
• Maintain chronic HF medications and the remaining medications
as usual:
–
metformin
–
dicoumarin
REVISED DIAGNOSIS AND
–
digoxin
CARE PLAN
–
AAS
–
simvastatin
• Low sodium diet, vitals/8 h, capillary glucose determination/8 h,
urine output quantification
ED=emergency department; i.v.=intravenous
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Teaching Points
Discussion and Conclusions
Re-evaluation of the Patient in the
ED Observation Unit
(8.30 am; +21 hours after ED arrival)
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•
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•
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Total diuresis: 2,100 mL
Vitals: BP: 143/69 mmHg; HR: 90 bpm (arrhythmic),
RR: 20 brpm (room air), Temperature: 36.0 °C / 97 °F;
O2 sat: 95% (room air), dyspnea improved on room air
(qualitative approach)
Able to go to toilet by herself without oxygen (10 meters)
On examination, improvement of lung rales and leg edema,
although some remaining
REVISED DIAGNOSIS AND
Blood gas analysis: pH 7.45; pO2 73 mmHg; pCO2 40 mmHg
CARE
PLAN 1.0 mg/dL,
Current renal function:
creatinine
eGFR 75 mL/min/m2
Patient wanting to go home
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; ED=Emergency Department;
eGFR=estimated glomerular filtration rate; HR=heart rate; i.v.=intravenous; O2 sat=oxygen saturation;
RR=respiration rate
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H
DISPOSITION
DECISION
Disposition
•
Discharge or not discharge?
(that’s the question)
Disposition
Decision
Teaching Points
Discussion and Conclusions
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H
DISPOSITION
DECISION
Assessing Home Setting
• Patient understanding: fine
• Patient independence: fine
• Patient autonomy: fine
• Dyspnea at baseline: mild effort (NYHA class II)
• Main caregiver: daughter
• Caregiver availability: 24 hours (unemployed)
• GP: patient and family happy with her, has had the
same GP during last 15 years, easily avalilable
EM Consultant and Resident Final Action
• Patient is discharged
EM=emergency medicine; GP=General Practitioner; NYHA=New York Heart Association
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Discussion and
Conclusions
Teaching Points
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Òscar Miró, MD, PhD
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Discussion and Conclusions
Discussion and Conclusions
•
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•
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Discharge is usually based on physician experience
and judgement (subjective data)
No risk scales are currently widely used in the ED for risk
stratification
There is no definition regarding the target level of risk that can be
reasonably assumed when a patient is discharged directly from
the ED
Two main objectives should be achieved after ED discharge:
–
–
•
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avoid short-term mortality
avoid short-term ED representation
Definition of standards for mortality and representation
needed
One tool that could be used to assess the patient at discharge
is the EHMRG* score
–
–
classifies patients as ‘low’, ‘intermediate’ or ‘high’ risk for
death during the next 7 days
this patient is classified as ‘intermediate’ risk for mortality
*Available at https://ehmrg.ices.on.ca/#. Please note, the EHMRG Risk Score has not been prospectively
validated. Clinical judgement is important. ED=Emergency Department; EHMRG=Emergency Heart Failure
Mortality Risk Grade
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Teaching Points
•
Patients with a well-established diagnosis of
chronic heart failure and a good initial clinical
response to treatment can be safely
discharged directly from the ED after a short
observation period
•
A proper home setting is key to success
•
Objective risk stratification should help to
minimize risk
ED=Emergency Department
Teaching Points
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Teaching Points
Discussion and Conclusions
Management Considerations
•
Vasodilators could have been used in present case (SBP
152 mmHg at ED arrival): clinical evidence seems to favor
but strong scientific data are still lacking
•
Arterial blood gases are sometimes overused in patients
with dyspnea: in the present case, it could probably have
been avoided
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Monitoring of renal function (and electrolytes) in patients
with a borderline dysfunction is crucial, especially if a patient
is discharged home in less than 24 hours. Minimal worsening
with decongestion is acceptable.
•
Atrial fibrillation does not necessarily mean it is the
precipitant of the AHF episode and does not always need to
be treated: this was the case with our patient
AHF=acute heart failure; bpm=beats per minute; ED=Emergency Department; SBP=systolic blood pressure
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Teaching Points
Discussion and Conclusions
Local Variation
• An ED observation unit is highly needed if you
want to discharge a portion of patients with AHF
without hospitalization (not present in all
countries)
• In some countries, many patients are assessed
at the ED using natriuretic peptides and echo
• The EHMRG scale (used for risk stratification)
was derivated and validated in a Canadian
cohort, so it should be ascertained in other
countries
ADHF=acute decompensated heart failure; ED=Emergency Department; EHMRG=Emergency Heart Failure
Mortality Risk Grade
Glossary of terms
Acute Medicine
Also known as emergency medicine ward
CHA2DS2-VASC
A clinical prediction rule for estimation of
stroke risk in patients with atrial fibrillation
EHMRG
Emergency Heart Failure Mortality Risk Grade. A
tool that could be used to assess mortality risk at
discharge. Note, this tool has not been
prospectively validated. Clinical judgement is
important
CHEM7
US terminology. A basic metabolic panel
including Na, K, Cl−, HCO3− or CO2, blood
urea nitrogen, creatinine and glucose
GP
General practitioner. UK terminology.
The equivalent role in the US would be family
physician
Community heart failure team
UK terminology. A specialist community
heart failure nursing service working in
partnership with Hospital Trusts
R/O
Ruled out
Consultant
UK terminology. The equivalent role in the
US would be an attending/staff physician
C/O
Complaining of
Stat
statim (Latin) referring to speed
Specialist
UK terminology. See consultant