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
Further Case Details
Case Introduction
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Glossary
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Disposition
Decision
Case Details
and Initial Triage
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Diagnostic
Results
Questions
Author:
Peter S. Pang,
MD, MS, FACE, FAAEM FAHA, FACC
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Teaching Points
Discussion and Conclusions
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Case
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Initial Diagnosis
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Diagnostic
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Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE INTRODUCTION
Peter S. Pang, MD, MSc, FACEP,
FAAEM, FAHA, FACC
Indiana University School of Medicine
(Indianapolis, IN; USA)
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Associate Professor, Emergency
Medicine
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Associate Director, Clinical Research
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Introduction
CASE INTRODUCTION
Case Details
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Initial Diagnosis
and Care Plan
Diagnostic
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Disposition
Decision
Teaching Points
Discussion and Conclusions
Background
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It is 11pm and shift change
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You are the senior attending physician in an
academic, urban, level 1 trauma center that sees
115,000 visits/year. You completed your board
certification in emergency medicine 8 years ago and
oversee 1 senior resident (PGY-4), 3 junior residents,
and 2 medical students. The ED always has at least
2 attending physicians
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You will likely see 40 patients in the next 8 hours. All
ancillary services and support are available, including
radiology, laboratory and consultation. There is no
emergent echo available in less than 4 hours, but you
are skilled in bedside point of care ultrasound
ED=Emergency Department
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Disposition
Decision
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Reassessment
ECG
Immediate
Assessment/
Action
Chief complaint
Teaching Points
Discussion and Conclusions
ECG
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Immediate
Assessment/Action
Diagnostic
Results
X ray
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Lab
Results
CASE DETAILS
AND INITIAL TRIAGE
Author:
Peter S. Pang,
MD, MS, FACE, FAAEM FAHA, FACC
Reassessment
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CASE DETAILS
AND INITIAL TRIAGE
Chief complaint
“I ….can’t… breathe” (gasps the patient)
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Chief Complaint (Cont’d)
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Paramedics bring in a 75 year old female sitting
upright, leaning forward, with a non-rebreather
(NRB) for oxygen
She is clearly tachypneic, dyspneic and gasping
The medics report a distressed call
15 minutes PTA, with a BP of 224/115 mmHg, HR
of 137 bpm, RR 40 brpm and O2 sats of 85% on
RA, now 90% with 100% NRB
They were unable to obtain any further history
given the severity of the patients breathlessness
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; NRB=non re-breather; O2
sat=oxygen saturation; RA=room air; RR=respiration rate
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CASE DETAILS
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Immediate Assessment/Action 1*
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The patient is sick
You consider endotracheal intubation and ask
that all airway meds be ready as you prepare
all equipment.
At the same time, you order non-invasive
ventilation STAT at 10/5 cm H20 and apply
bedside positive end-expiratory pressure
(PEEP) with a bag-valve mask using a PEEP
valve.
– (this delivers 100% oxygen with a goal of
improved O2 saturation)
*time duration for all assessments/actions = <3 minutes
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Immediate Assessment/Action 2*
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Your team has already established 2 large bore
peripheral i.v. lines and blood is held for any testing
you order
A focused physical exam demonstrates:
– a patient who can state their name in 1 word
sentences
– diaphoresis
– rales all the way up both lungs
– tachycardia with regular rhythm and no murmur
– tachypnea with RR in the 40’s
– clear JVD is visualized
– no lower extremity edema
Patient is on a monitor, ECG is in the process of being
performed, and a rhythm strip is brought to you
*time duration for all assessments/actions = 3 minutes
ECG=electrocardiogram; i.v.=intravenous; JVD=jugular venous distension; RR=respiration rate
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Rhythm Strip
• Sinus rhythm, HR ~140 bpm
Disposition
Decision
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Immediate Assessment/Action 3*
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While the patient could have other causes of
respiratory distress, your clinical impression is
pulmonary edema from AHF
You order 2 nitroglycerin (400 µg) sub lingual
tablets to be given immediately and order
nitroglycerin i.v.
– you ask the nurse to be ready to give
additional nitroglycerin sub lingual
You also order furosemide 80 mg i.v.
*time duration for all assessments/actions = 3 minutes
AHF=acute heart failure; i.v.=intravenous
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Immediate Assessment/Action 4*
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Portable CXR is standing by
ECG is done
Respiratory technician has applied NIV
You order complete blood count, chem-7, Mg,
point of care troponin and BNP
nitroglycerin i.v. arrives from pharmacy and
you start at 50 µg/min with instructions to
titrate every 35 minutes for SBP <180 mmHg
or symptom improvement
*time duration for all assessments/actions = 3 minutes
BNP=B-type natriuretic peptide; CXR=chest X ray; ECG=electrocardiogram; i.v.=intravenous;
NIV=non-invasive ventilation; SBP=systolic blood pressure
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ECG (within 10 minutes of presentation)
ECG=electrocardiogram
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Re-assessment and Vital Signs
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Patient nods her head ‘yes’ when you ask her
if she is feeling better (she is wearing a NIV
mask)
Patients looks to be in less respiratory distress
and is now leaning back in the stretcher
SBP is 185/85 mmHg, HR 115 bpm,
RR 22 brpm, O2 sat 98% on NIV, rectal temp
is 37.2°C / 98.9°F
ECG is done, portable CXR is done, and
urinary catheter is placed
BP=blood pressure; HR=heart rate; brpm=breaths per minute; bpm=beats per minute; CXR=chest
X ray; ECG=electrocardiogram; NIV=non-invasive ventilation; SBP=systolic blood pressure
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Portable Chest X ray
(within 15 minutes of presentation)
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Lab Results (Point of Care Testing)
• Troponin I* 0.04 ng/mL (40 pg/mL) (within normal limits)
• BNP#
1,274 pg/mL
(elevated)
BNP=B-type natriuretic peptide
*Abbott POC iStat assay. Reportable range 0.0 to 50.0 ng/mL. Upper 99% reference limit is 0.08 ng/mL.
#Abbott POC iStat assay. Upper 95% reference range is 50 pg/mL. Reportable range is 15 to 5,000 pg/mL
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Lab results:
Reference
Ranges
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Reassessment*
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Patient continues to improve clinically
nitroglycerin i.v. is currently at 100 µg/min
and you write orders to titrate to symptom
improvement or SBP 160 mmHg
– you order 2 inches of nitropaste
to be added to the patient once these
thresholds are reached and i.v. drip
will be discontinued
*within 30 minutes after initial presentation
i.v.=intravenous; SBP=systolic blood pressure
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Reassessment Cont’d*
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You ask the patient a few yes/no questions
– patients denies chest pain
– she denies fevers or cough
– she denies any history or heart disease or heart
failure, but admits to hypertension
– no known drug allergies
– she denies tobacco or illicit drug use
– one glass of wine daily
*within 30 minutes after initial presentation
i.v.=intravenous; SBP=systolic blood pressure
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History of Present Illness
and Review of Symptoms
Reassessment
Past History,
Allergy History,
Medications,
and Social History
Initial
Impression
and Plan
INITIAL DIAGNOSIS AND
FURTHER CASE DETAILS
Author:
Peter S. Pang,
MD, MS, FACE, FAAEM FAHA, FACC
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Discussion and Conclusions
Initial Impression and Plan
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Pulmonary edema from acute heart failure
due to hypertensive crisis
Plan is to continue to monitor, re-assess for
improvement and diuresis, check for other
lab results
As new onset AHF, plan for admission. Given
patient is improving, will likely be able to
discontinue i.v. infusion and NIV
AHF=acute heart failure; i.v.=intravenous; NIV=non-invasive ventilation
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Reassessment Cont’d*
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Patient now on 4 L NC (~33% FiO2) with O2 sat of
97%
Nitropaste has been applied and i.v. infusion
discontinued
Brisk diuresis (~200 cc)
SBP 159/82 mmHg, HR 100 bpm
You are now able to obtain a more thorough history
No formal echo is available at this time
*90minutes after presentation
echo=echocardiogram; HR=heart rate; i.v.=intravenous; NC=nasal cannula; SBP=systolic blood pressure
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History of Present Illness
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Patient had been feeling well. No recent
medication or dietary changes. Compliant with
all medications
About 30 minutes before calling 911, patient
began to feel unwell
She then become acutely short of breath with
chest discomfort
She denies fevers or cough or any other
complaints and reports feeling much better
now without any chest discomfort
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Review of Systems
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No cough, no fevers
No black or bloody stools
No nausea, vomiting
No back, chest, or abdominal pain
Shortness of breath
No rash or hot/cold intolerance
Teaching Points
Discussion and Conclusions
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Past History
Past Medical History
• Hypertension
Past Surgical History
• Appendectomy
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Allergy History, Medications,
and Social History
Allergies
Current Medications
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NKDA
Social History
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No cigarettes
No illicit drugs
1 glass of red wine per day
Married
NKDA=no known drug allergies; q.d.=once daily
Amlodipine 10 mg q.d.
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Revised Clinical
Impression
Lab Results
Patient Re-assessment
DIAGNOSTIC RESULTS
Author:
Peter S. Pang,
MD, MS, FACE, FAAEM FAHA, FACC
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DIAGNOSTIC
RESULTS
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Diagnostic
Results
Lab Results*
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Na
138 mEq/L
K
4.2 mEq/L
BUN
23 mg/dL
Cr
0.9 mg/dL
No leukocytosis or anemia
*All results within normal limits
*All BUN=blood urea nitrogen; Cr=creatinine
Disposition
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Revised Clinical Impression
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New onset AHF
Flash pulmonary edema secondary to acute
hypertension
AHF=acute heart failure
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Patient Re-assessment
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HR:
86 bpm
BP:
141/79 mmHg
O2 sat:
97% on 2L NC
Patient continues to diurese well
Patient looks better and reports feeling better
BP=blood pressure; bpm=beats per minute; HR=heart rate; O2 sat=oxygen saturation; NC=nasal cannula
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H
DISPOSITION
DECISION
Disposition
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Admission to telemetry ward
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although primary ACS is not a major concern,
given new onset AHF and mild chest discomfort
the patient will be monitored with serial troponin
As this is new onset AHF, patient will require:
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in-depth evaluation for potential causes
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education for heart failure self-management
ACS=acute coronary syndrome; AHF=acute heart failure
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Discussion and
Conclusions
Teaching Points
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Peter S. Pang,
MD, MS, FACE, FAAEM FAHA, FACC
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Teaching Points
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NIV combined with rapid pharmacologic
management will often prevent the need for
endotracheal intubation
For sick patients, diagnosis and treatment
occurs in parallel. Sometimes, treatment
comes first based on initial impression
NIV=non-invasive ventilation
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Discussion and Conclusions
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Overall, patients was well managed with rapid
treatment and diagnosis. Importantly, a well
experienced ER team was available as many
actions need to occur at the same time
ER=emergency room
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Local Variation
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Most US ED’s do NOT do formal
echocardiography or even bedside
echocardiography for AHF patients, as initial
management rarely changes
Blood gas are no longer routinely performed.
Clinical assessment and oxygen saturation
are used. If patients worse, ABG may be
considered.
ABG=arterial blood gas; AHF=acute heart failure; ED=Emergency Department
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
Lab results: Reference Ranges1,2
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Hematology
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D-Dimer
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Hematocrit
Male
Female
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Blood gases, arterial (ambient air)
pH
7.38–7.44
pCO2
35–45 mm Hg
(4.7–6.0 kPa)
pO2
80–100 mm Hg
(10.6–13.3 kPa)
O2 sat
≥95%
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BNP, blood
<100 pg/mL
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BUN
8–20 mg/dL
(2.9–7.1 mmol/L)
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CRP
0.0–0.8 mg/dL
(0.0–8.0 mg/L)
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Ca, serum
9–10.5 mg/dL
(2.2–2.6 mmol/L)
41%–51%
36%–47%
Hemoglobin, blood
Male
14–17 g/dL
(140–170 g/L)
Female
12–16 g/dL
(120–160 g/L)
Platelets
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<500 μg/L (0.5 mg/L)
150,000–350,000/µL
(150–350 x 109/L)
Blood, plasma and serum chemistry
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Albumin, serum
3.5–5.5 g/dL
(35–55 g/L)
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ALT
0–35 units/L*
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AST
0–35 units/L*
* Test performed at 37oC3
1. American College of Physicians, Laboratory Reference Values; 2. McMurray et al. Eur Heart J 2012:33;1787–1847;
3. http://www.surgeryencyclopedia.com/La-Pa/Liver-Function-Tests.html [accessed 20th February 2015]
ALT=aminotransferase, alanine; AST=aminotransferase, aspartate; BNP=B-type natriuretic peptide; BUN=blood urea
nitrogen; CRP=c-reactive protein
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Blood, plasma and serum chemistry
(cont’d)
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Creatinine, serum
0.7–1.3 mg/dL
(61.9–115 µmol/L)
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Electrolytes, serum
Na
136–145 meq/L
(136–145 mmol/L)
K
3.5–5.0 meq/L
(3.5–5.0 mmol/L)
Cl‾
98–106 meq/L
(98–106 mmol/L)
HCO3
23–28 meq/L
(23–28 mmol/L)
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Glucose, plasma*
70–100 mg/dL
(3.9–5.6 mmol/L)
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Lactic acid, venous blood
6-16 mg/dL
(0.67-1.8 mmol/L)
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Urea nitrogen, blood
8–20 mg/dL
(2.9–7.1 mmol/L)
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Uric acid, serum
2.5–8 mg/dL
(0.15–0.47 mmol/L)
Urine
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GFR, normal
Male
Female
130 mL/min/1.73 m2
120 mL/min/1.73 m2
1. American College of Physicians, Laboratory Reference Values; 2. McMurray et al. Eur Heart J 2012:33;1787–1847
GFR=glomerular filtration rate. *Fasting.