Transcript Heart Failure - SchultzMedic

 Left
Ventricular
Failure

Pathophysiology


Results in increased
back pressure into the
pulmonary circulation
Causes

MI, valvular disease,
chronic hypertension,
and dysrhythmias
 Right
Ventricular
Failure

Pathophysiology


Results in increased
back pressure into
the systemic venous
circulation
Causes


Left ventricular
failure
Pulmonary
Embolism
 Congestive

Pathophysiology

Reduction in the heart’s stroke volume causes fluid
overload throughout the body’s other tissues


Heart Failure
Starling’s law no longer able to compensate
Manifestation


In the acute setting, pulmonary edema, pulmonary
hypertension, or myocardial infarction
In the chronic setting as cardiomegally, left ventricular
failure, or right ventricular failure
 Field


Check ABC’s and manage life threats
Chief Complaint

OPQRST


Assessment
Paroxysmal Nocturnal Dyspnea (PND)
Medications:


Diuretics
Medications to increase cardiac contractile force


Lanoxin
Home oxygen
 Mental

Status
Mental status changes indicate impending
respiratory failure
 Breathing



Signs of labored breathing
Tripod positioning
“Number of pillows”
 Skin


Color changes
Peripheral and/or sacral edema
 Complications


Pulmonary edema may lead to respiratory
failure
Pulsus paradoxus


Systolic blood pressure drops more than 10 mmHg with
inspiration
Pulsus alternans

Pulse alternates between weak and strong
 Management

General management:



Maintain the airway



Avoid supine positioning
Avoid exertion such as standing or walking
Administer oxygen
Administer Nitroglycerine as soon as possible
CPAP
 Monitor
ECG
 Establish IV access

Limit fluid administration
 Consider


Nitrates
Angiotensin-converting enzyme (ACE) inhibitor




medication administration:
Catopril
Enalopril
Albuterol
Vasopressor

Dopamine
 Avoid
patient refusals if at all possible
 Continuous
Positive
Airway Pressure
(CPAP)

Can often prevent the
need for
endotracheal
intubation and
mechanical
ventilation
© Scott Metcalfe
 Continuous
(CPAP)

Maintains a constant pressure within the
airway throughout the respiratory cycle



Positive Airway Pressure
CPAP will force excess fluid out of the alveoli
PEEP is applied only during expiration
Use the lowest effective pressure when
applying CPAP

A pressure of 2.5–5 cm/H2O is adequate
 Asthma,
COPD,
pulmonary edema,
CHF, or pneumonia
Awake and able to
follow commands
 >12 years old and
able to fit the CPAP
mask
 Able to maintain an
open airway

 Exhibits
two or
more of the
following
A respiratory rate
greater than 25
breaths per minute
 SpO2 of less than
94% at any time
 Use of accessory
muscles during
respirations

 Any
patient who is in respiratory arrest or
apnea
 Pneumothorax or has suffered trauma to
the chest
 Tracheotomy
 Patient who is actively vomiting or has
upper GI bleeding
 Epidemiology

Pathophysiology




and Pathophysiology
Result of fluid accumulation between visceral pericardium
and parietal pericardium
Increased intrapericardial pressure impairs diastolic filling
Typically worsens progressively until corrected
Epidemiology


Acute onset typically the result of trauma or MI
Benign presentations may be caused by cancer,
pericarditis, renal disease, and hypothyroidism
 Field

Patient History



Assessment
Determine precipitating causes
Patient relates a history of dyspnea and orthopnea
Exam






Rapid, weak pulse
Decreasing systolic pressure
Narrowing pulse pressures
Pulsus paradoxus
Faint, muffled heart sounds
Electrical alternans

Less than normal voltage in waveforms
 Management
Maintain airway
 Administer oxygen
 Establish IV access
 Consider medication administration:





Morphine sulfate
Nitrous oxide
Furosemide
Dopamine/dobutamine
 Rapid
Transport
 Pericardiocentesis

Pericardiocentesis is the definitive treatment

Insertion of a cardiac needle and aspiration of fluid
from the pericardium
Procedure should be performed only if allowed
by local protocol
 Procedure should be performed only by
personnel adequately trained in the procedure

 Hypertensive

Causes




Emergency
Typically occurs only in patients with a history of
hypertension
Primary cause is noncompliance with prescribed
antihypertensive medications
Also occurs with toxemia of pregnancy
Incidence

Risk Factors


Age-related factors
Race-related factors
 Field

Initial Assessment


Assessment
Alterations in mental state
Signs and Symptoms






Headache accompanied by nausea and/or vomiting
Blurred vision
Shortness of breath
Epistaxis
Vertigo
Tinnitus
 History


Known history of hypertension
Compliance with medications
 Exam





BP >160/90
Signs of left ventricular failure
Strong, bounding pulse
Abnormal skin color, temperature, and
condition
Presence of edema
 Management
Maintain airway
 Administer oxygen
 Establish IV access
 Consider medication administration:




Nitroglycerin
Sodium nitroprusside (Nipride)
Labetalol (Trandate, Normodyne)
 Pathophysiology

General





Inability of the heart to meet the body’s metabolic
needs
Often remains after correction of other problems
Severe form of pump failure
High mortality rate
Causes




Tension pneumothorax and cardiac tamponade
Impaired ventricular emptying
Impaired myocardial contractility
Trauma
 Field


Initial Assessment
Chief Complaint



Assessment
Chief complaint is typically chest pain, shortness of
breath, unconsciousness, or altered mental state
Onset may be acute or progressive
History


History of recent MI or chest pain episode
Presence of shock in the absence of trauma
 Mental

Restlessness progressing to confusion
 Airway


Status
and Breathing
Dyspnea, labored breathing, and cough
PND, tripod position, accessory muscle
retraction, and adventitious lung sounds
 ECG

Tachycardia and atrial dysrhythmias
 Circulation


Hypotension
Cool, clammy skin
 Management

Maintain airway




Administer oxygen
Identify and treat underlying problem
Establish IV access


CPAP
Consider aggressive fluid therapy
Consider medication administration:

Dopamine, dobutamine, norepinephrine
Click here to view the Cardiogenic Shock diagram.
 The

absence of ventricular contraction
Immediately results in systemic circulatory
failure
 Sudden
death is any death that occurs
within 1 hour of symptom onset
 Severe atherosclerotic disease is common

Risk factors
 Acid-base
imbalance
 Drowning
 Drug intoxication
 Electrocution
 Electrolyte
imbalance
 End-stage renal
disease
 Hyperkalemia
(high
levels of potassium)
 Hypothermia
 Hypoxia
 Pulmonary embolism
 Stroke
 Trauma
 Patients
who suffer a cardiac arrest
resulting from ventricular fibrillation go
through several phases leading up to
biological death



Electrical
Circulatory
Metabolic
 Prehospital
intervention required depends
on the phase the patient is in
 Electrical
Phase
Begins at the time of the cardiac arrest and
ends at approximately 3 to 4 minutes postarrest
 Adequate oxygen at the level of the myocardial
cells



Cells are able to maintain energy production through
aerobic metabolism
The only beneficial treatment is immediate
defibrillation
 Circulatory


4–10 minutes post-arrest
Oxygen levels in the myocardial cells are
inadequate


Phase
Shift to anaerobic metabolism
Survival from cardiac arrest during this phase is
better if at least 90 seconds of CPR is provided
before the application of defibrillation

Epinephrine beneficial
 Metabolic


Begins approximately 10 minutes after the
onset of cardiac arrest
Failure of the sodium-potassium pump




Phase
Sodium begins to diffuse into the cell
Water follows sodium
Cellular swelling and eventually lysis
Current resuscitative measures do not improve
survival during the metabolic phase
 Field

Initial Assessment


Unresponsive, apneic, pulseless patient
ECG


Assessment
Dysrhythmias
History



Prearrest events
Bystander CPR
“Down time”
 Management

Terms





Resuscitation
Return of Spontaneous Circulation
Survival
Role of Basic Life Support
General Guidelines




Manage specific dysrhythmias
CPR
Advanced airway management
Establish IV access
 Pharmacological






considerations
Amiodarone
Atropine sulfate
Epinephrine
Lidocaine
Magnesium sulfate
Vasopressin
 Follow
medications in arrest with a bolus
of fluid
Click here to view the Cardiac Arrest diagram.
Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Care,” Circulation 2005, Volume 112, IV-59. © 2005 American Heart Association.
 Manage
dysrhythmias and problems as
presented.
Be alert for PEA
 Transport rapidly:


Take care to protect intubation and IV access
 Withholding




resuscitation
Rigor mortis
Dependent lividity
Decapitation, decomposition, incineration
Valid advance directive
 Terminating

Resuscitation
Inclusion criteria for termination of
resuscitation:






Patient over 18 years old
Cause is presumed cardiac in origin
Successful endotracheal intubation
ACLS standards applied throughout the arrest
On-scene effort >25 minutes, or four rounds of drug
therapy
ECG remains asystolic or agonal
 Terminating

Exclusion Criteria:








Resuscitation
Patient under 18 years old
Arrest is of a treatable cause
Present or recurring VF/VT
Transient return of a pulse
Signs of neurological viability
Witnessed arrest
Family or others opposed to termination of
resuscitation
Always follow local protocols related to
termination of resuscitation
 Atherosclerosis

Pathophysiology



Progressive degenerative disease of the medium-sized
and large arteries
Results from the buildup of fats on the interior of the
artery
Fatty buildup results in plaques and eventual stenosis
of the artery
Arteriosclerosis
 Claudication

 Aneurysm

Pathophysiology


Ballooning of an arterial wall, usually the aorta, that
results from a weakness or defect in the wall
Types





Atherosclerotic
Dissecting
Infectious
Congenital
Traumatic
 Abdominal
Aortic
Aneurysm
Often the result of
atherosclerosis
 Signs and
symptoms:





Abdominal pain
Back/flank pain
Hypotension
Urge to defecate
 Dissecting



Aortic Aneurysm
Caused by degenerative changes in the smooth
muscle and elastic tissue
Blood gets between and separates the wall of
the aorta
Can extend throughout the aorta and into
associated vessels
 Acute

Pathophysiology



Pulmonary Embolism
Blockage of a pulmonary artery by a blood clot or
other particle
The area served by the pulmonary artery fails
Signs and Symptoms



Dependent upon size and location of the blockage
Onset of severe, unexplained dyspnea
History of recent lengthy immobilization
 Acute

Arterial Occlusion
Pathophysiology


Sudden occlusion of arterial blood flow due to trauma,
thrombosis, tumor, embolus, or idiopathic means
Frequently involves the abdomen or extremities
 Vasculitis

Pathophysiology


Inflammation of the blood vessels
Commonly stems from rheumatic diseases and
syndromes
 Noncritical

Peripheral Arterial Atherosclerotic Disease




Can be acute or chronic
Often associated with diabetes
Extremities exhibit pain, coldness, numbness, and
pallor
Deep Venous Thrombosis




Peripheral Vascular Conditions
Blood clot in a vein
Typically occurs in the larger veins of the thigh and
calf
Swelling, pain, and tenderness, with warm, red skin
Varicose Veins

Dilated superficial veins, common with pregnancy and
obesity
 General
Assessment and Management of
Vascular Disorders

Assessment


Initial Assessment
Circulatory Assessment





Pallor
Pain
Pulselessness
Paralysis
Paresthesia
 Assessment

Chief Complaint


(cont.)
OPQRST
Physical Exam


Prior history of vascular problems
Differences in pulses or blood pressures
 Management




Maintain the airway
Administer oxygen if respiratory distress or
signs of hypoperfusion present
Consider administration of analgesics
Transport rapidly if signs of hypoperfusion
present
 Assessment
of the Cardiovascular Patient
 Management of Cardiovascular
Emergencies
 Managing Specific Cardiovascular
Emergencies