Transcript Approach to Congestive Heart Failure and Vascular Emergencies

Approach to Congestive
Heart Failure and Vascular
Emergencies
Dan O’Donnell
9/12/06
What Are we Going to Talk
About
A little bit of everything
Discuss some of the causes and treatment
of pulmonary edema
Explain why those D&@m ER docs want
us to keep using nitrates all of the time
What to do when the big vessels get into
trouble
How bad Michigan is going to beat on ND
Case #1
Called to respond to “Difficulty Breathing”
Find a 68 y/o male with known hx of CAD
and other “water problems” diaphoretic
speaking in one-two word sentences
PMHx: CAD, HTN
Meds: Doesn’t know and hasn’t been
taking them
PE
Gen: Patient in distress
P 125, BP 255/135, SaO2 82% on NRB
Lungs: Crackles up to mid lung
LE: 3+ Edema
Diagnosis
Congestive Hear Failure
– Secondary to hypertensive emergency
Congestive Heart Failure
Vascular congestion in either the
pulmonary bed, systemic bed, or both.
Caused by dysfunction of the heart
Resulting in edema in the lungs and or
periphery
A fluid problem
– Either too much or what is there is not being
pushed around enough
Cardiac Physiology
Preload- blood volume available to pump
After load- resistance against which pump
operates
Contractility- intrinsic ability of pump to
function
If one of these is affected you will have
CHF
Causes of Increased Pre-Load
Medication non-compliance
Inability to get rid of fluid
– I.E. Renal failure
Fluid retention from dietary noncompliance
Goal: Get rid of the pre-load
Causes of Increased Afterload
Remember afterload=resistance
Hypertension
Some obstruction (I.e. Aortic Stenosis)
Goal: Decrease the resistance
Causes of Decrease
Contractility
Causes an inability to respond to
increased pre-load and afterload
Systolic vs. Diastolic dysfunction
Systolic Dysfunction-Not able to push
enough forward
Diastolic Dysfunction-Not able to relax and
fill up
Systolic vs. Diastolic
Dysfunction
Systolic
Ischemia
Infection (myocarditis)
Toxic (iron, CO)
Trauma
Diastolic
Tamponade
LVH
Tachycardia
– A-fib with RVR
Always ask WHY THEY WENT INTO
FAILURE???????????
Left vs. Right Heart Failure
Left Heart Failure
SOB
Crackles
Wheezes
Orthopnea
Coughing up pink
frothy sputum
Right Heart Failure
Edema
JVD
Hepatic Congestion
Enough O’Donnell Back to our
Case
Treatment
If SBP is 110 mm Hg or Greater administer
0.4mg dose of NTG and repeat every 3-5
minutes as long as the SBP is at or above
110 mm Hg
Cardiac Monitor (ischemia?)
IV
Lasix 40mg slow IVP if SBP 110 or greater
Why Do the Docs Love Nitro?
Causes relaxation of smooth muscle in
vascular beds
Decreases preload and afterload
Quick and easy fix
Dose dependent results
Proven to have better results in the long
term
Always Nitro???
Do Not administer NTG to any patient who has taken
Viagra or other ED drugs in the past week
Lasix
Does increase urine output and can help
decrease fluid
Theoretical dilation of pulmonary
vasculature
Takes time to work
Not effective if the kidneys don’t work
Definitive Treatment
Positive Pressure Ventilation
Will greatly improve pulmonary edema
Oxygen doesn’t really hurt anybody
Summary of CHF
There are many causes
Always ask yourself why they are in CHF
– Are they having a big MI
Nitro, Nitro, Nitro (except in Viagra,
Levitra, Cialis, etc…)
Lasix is okay but no need to redose
New Case
Called for “Abdominal and Back Pain”
Upon arrival you find a 62 y/o male with
long history of hypertension and
“Something wrong with my “Horta”
Describe sudden onset of ripping pain in
lower back and abdomen for 2 hours
PE
Patient is diaphoretic and extremely
uncomfortable
P 132, BP 70/P, Sa02 98% on NRB
Abdomen is rigid and you might feel a
pulsitile mass
Diagnosis?
Abdominal Aortic Aneurysm
Dilation of the Aorta that can occur
anywhere along the Aorta
Most commonly below the renal arteries
Most commonly found in elderly
Risk factors are hypertension, vascular
disease, connective tissue problems
Presentation of Ruptured AAA
Syncope
– Occurs from sudden loss of blood flow to the
brain
Severe back or abdominal pain
– Typically sudden onset
Sudden death
– Usually occurs due to intraperitoneal rupture
of the aneurysm
Physical Exam Findings
A pulsating abdominal mass
Abdominal tenderness to palpation
Ecchymosis around the umbilicus or on
the flanks
May have normal distal pulses
Hypotension is common
Diagnosis
History + Physical Exam + Strong
Suspicion= Diagnosis
Treatment
Most important role of EMS and
Emergency Physician is rapid diagnosis
and transfer to a surgeon for operative
repair.
What Can We Do Prehospital?
Two large-bore IVs
Cardiac monitor
Oxygen
Fluid resuscitation
Drive Fast and Safe
Summary of AAA
High Mortality
Combination of history and high suspicion
will lead in diagnosis
Need surgical repair
This person is essentially dying from
hemorrhagic shock
Case # 3
Dispatched for “Chest Pain”
59 y/o male c/o sudden onset of “tearing”
chest pain that began in left chest and
radiated to his back
Pain is unlike his previous MI
PMHx: Hypertension, CAD s/p Stent
Meds: Clonidine, Metoprolol, Norvasc,
NTG to name a few
Case #3 Cont…
P 115, BP 200/110, SaO2 94% on RA
Sinus tachy on monitor
ECG unremarkable
CV: Tachy no M/R
Lungs: CTA B
Abd: Soft, NT, ND
En Route
Pain suddenly worsens and he feels it
moving down his back
You note
En Route Cont…
Patient becomes unconscious and goes
into PEA
What besides AMI happened?
Aortic Dissection
May occur anywhere along the aorta
Most common site is in the chest just past
the origin of the left subclavian artery
Occurs when a tear in the lining of the
aorta allows blood to get in between layers
of the vessel
Predisposing Factors for
Dissection
Hypertension
Hypertension
Hypertension (notice a trend here?)
Connective tissue disease (i.e. Marfan’s)
Pregnancy
Congenital heart disease
Trauma
Presentation
90% of patients present with sudden onset
of severe, tearing chest pain radiating to
the back.
May have stroke symptoms
– Occurs when dissection includes origin of
carotid arteries
May have paraplegia
– Occurs when dissection includes origin of
spinal arteries
Physical Exam
May have a normal exam
Findings are related to ischemia from
disruption at the origin of aortic branches.
Diagnosis requires imaging
– Angiography or CT scan
Prehospital Treatment
Two large bore IVs
Oxygen
Cardiac Monitoring
Rapid transport
Aggressive blood pressure control
May require surgery
Summary
Aortic Dissection can present in many
ways
Diagnosis often lies in the history
Treat similar to ruptured AAA prehospital
Questions?