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:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Disposition
Decision
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Questions
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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
Ekaterini Lambrinou, RN, BSc, MSc,
PhD, NFESC
Nursing Department, School of Health Sciences,
Cyprus University of Technology
(Limassol; Cyprus)
•
Assistant Professor
•
Director, MSc in Advanced Acute and
Intensive Cardiology Care
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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
Background
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This is the ED of a tertiary care hospital in an
urban center, in Cyprus, which handles any type
of emergency
During the morning shift there are four certified
GPs on duty working as emergency physicians
and a full complement of eight registered nurses
All the staff, doctors and nurses, are
knowledgeable in Advanced Life Support and
Pre-Hospital Trauma Life Support
The nurse in charge of the specific shift has
completed training as a board-certified Acute
Care Nurse Practitioner
Cardiologists are requested as needed by
emergency physicians
Echo capabilities are used at the judgment of
specialists
A catheterization laboratory (24-hour access) is
available in this hospital
ED=emergency department; GP=general practitioner
Teaching Points
Discussion and Conclusions
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Case
Introduction
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Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Past History, Allergy
History, Medications,
and Social History
History of Present Illness
and Review of systems
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
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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
CASE DETAILS
AND INITIAL TRIAGE
Chief Complaint
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A 56-year-old male was transferred from his
home to the ED at 7.30 am due to sudden
onset SOB and chest tightness
The onset occurred during his daily morning
swimming activity at 7.05 am
The ambulance staff were immediately alerted
and responded at 7.20 am
ED=Emergency department; SOB=shortness of breath
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE DETAILS
AND INITIAL TRIAGE
A rapid nursing assessment is necessary in
order to optimize the triage of patients to
the appropriate level of care and contribute
to the management therapeutic plan
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CASE DETAILS
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Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Vital Signs (on arrival)
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BP: 180/100 mmHg
HR: 120/min
RR: 40/min
Temperature: 36.0 ºC / 96.8 ºF
O2 sat: 88% on 15 L O2/min supplied by a non
rebreathing mask
BP=blood pressure; HR=heart rate; RR= respiratory rate; O2 sat= oxygen saturation
Teaching Points
Discussion and Conclusions
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CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
History of Present Illness/
Review of Systems
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The onset was sudden. Patient was in his
usual state of health, doing his usual
swimming exercise. He suddenly developed
chest pain and shortness of breath and
ambulance was called
Other history of present illness and review of
systems limited by acute condition
Teaching Points
Discussion and Conclusions
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CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Past History
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Hypertension – diagnosed 5 years ago
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Allergy History, Medications,
and Social History
Allergies
• NKDA
Current Medications
• Enalapril
10 mg o.d.
• HCTZ
12.5 mg o.d.
Social History
• Married and lives
with wife
HCTZ=hydrochlorothiazide; NKDA=no known drug allergies; o.d.=once daily
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CASE DETAILS
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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
Physical Examination
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General: the patient is having difficulty breathing, is unable to
speak in full sentences, and appears fatigued
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Chest: The patient is suffering from extreme breathlessness,
increased respiratory effort with the use of accessory
respiratory muscles, diaphoresis, agitation and confusion
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Auscultation of the lungs reveals generalized crackles in all the
lung fields, along with the presence of rhonchi and wheezing
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CV: regular rhythm, a prominent third heart sound [(+) S3],
(-) S4, (-) murmurs or rubs
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Abdomen: distended, (+) hepatojugular reflux
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Extremities: 1+ pitting edema to knees, 2+ DP and PT pulses
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Capillary Refill Time of 2 sec
CV=cardiovascular; DP=dorsalis pedis , PT=posterior tibial
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Determine the hemodynamic profile
• The Forrester Classification describes four groups according clinical
and haemodynamic status. Clinically, the patients are classified upon
peripheral hypoperfusion and pulmonary congestion and
hemodynamically upon a reduced cardiac index. As a general rule,
most ED patients are wet and warm.
SIGNS OF LOW
PERFUSION
Cool extremities
Low urine output
Altered mental status
Inadequate response
to IV diuretic
Prerenal azotemia
Congestion
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Perfusion
Case
Introduction
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Dry and
Warm
Wet and
Warm
Dry and
Cold
Wet and
Cold
SIGNS OF
CONGESTION
 JVD
 HJR
Peripheral edema
S3
DOE/SOA
Orthopnea/PND
Rales
Recent weight gain
Adapted from Nohria A, et al. JAMA 2002;287:628–640.
Reproduced with permission from Dr Lynne Warner Stevenson (Harvard Medical School, Boston, MA, USA)
=increased; =positive; –=negative; ED=emergency department; DOE=dyspnea on exertion;
HJR=hepatojugular reflux; JVD=jugular venous distention; PND=paroxysmal nocturnal dyspnea; S 3=ventricular
filling murmur; SOA=shortness of air.
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
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Clinical Impression
(Initial Diagnosis) and
Differential Diagnosis
INITIAL DIAGNOSIS
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
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INITIAL DIAGNOSIS
AND CARE PLAN
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
Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
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The diagnosis of pulmonary edema (ACPE)
was strongly suspected, based both on history
and the clinical examination1
Given the rapid onset of symptoms during
exercise, ACS as a cause of AHF is of
concern
1. Nieminen MS et al. Eur Heart J 2005;26:384–416)
ACPE=acute cardiogenic pulmonary edema; ACS=acute coronary syndrome; AHF=acute heart failure
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QUESTION
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INITIAL DIAGNOSIS
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Revised Diagnosis
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What are some specific nursing
concerns in a patient with ACPE?
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Impaired gas exchange related to
ventilation/perfusion mismatching or
intrapulmonary shunting
Decreased cardiac output related to
alterations in preload, contractility, heart rate
and rhythm
Minimal activity tolerance related to
cardiopulmonary dysfunction
ACPE=acute cardiogenic pulmonary edema
Teaching Points
Discussion and Conclusions
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Initial Diagnosis
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Revised Diagnosis
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Decision
Teaching Points
Discussion and Conclusions
Lab Results
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Initial Plan
of Care
Chest X ray
Ancillary
Imaging
ECG
DIAGNOSTIC RESULTS
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
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DIAGNOSTIC
RESULTS
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
Diagnostic testing
• Non invasive monitoring
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Blood pressure
Respiratory rate
Heart rate
Pulse oximetry for continuous monitoring of
oxygen saturation
• ECG
– A 12-lead ECG. It may identify a potential cause
such as arrhythmia or MI
– Continuous ECG monitoring
• Blood tests
– Urea, electrolytes and full blood count: To
Identify potential contributing factor, such as
renal failure, Troponin: Identify MI as potential
cause of AHF
– Plasma BNP/NT-Pro BNP: high concentrations
in heart failure
AHF=acute heart failure; BNP=B-type natriuretic peptide; ECG=electrocardiogram; MI=myocardial infarction;
NT-proBNP=N-terminal pro-B-type natriuretic peptide
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Diagnostic testing (cont’d)
• Chest X ray
– Assess pulmonary congestion
– Heart size
– Exclude other pulmonary cause of symptoms
• Cardiac ultrasound
– Assess heart function: overall ventricular
function and regional myocardial dysfunction,
valve function etc
Teaching Points
Discussion and Conclusions
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DIAGNOSTIC
RESULTS
Case Details
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Initial Diagnosis
and Care Plan
ECG
ECG=electrocardiogram
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
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ECG:
Interpretation
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Teaching Points
Discussion and Conclusions
ECG: Interpretation
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The 12 lead ECG was performed within 10 minutes
upon the patients arrival in the ED and revealed
Sinus Tachycardia with a pre-existing Left Bundle
Branch Block, according to a previous ECG
ECG=electrocardiogram; ER=Emergency department
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Discussion and Conclusions
Initial Plan of Care
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i.v.=intravenous
Relieve symptoms of congestion
Ensure hemodynamic stability
Minimize risk for adverse events
Relieve feelings of discomfort, fear and anxiety
Ensuring adequate oxygenation, improve signs and
symptoms, improve hemodynamics
Non-Invasive Positive Pressure Ventilation (NIPPV),
in the absence of any contra-indications
Nitrates, diuretics as well as morphine to reduce the
preload and the afterload of the ventricles
In this patient 4 mg/h isosorbide dinitrate was
commenced. In addition, 40 mg furosemide i.v. and
3 mg morphine were given as start doses
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!
DIAGNOSTIC
RESULTS
Key Point
• Reassess frequently! At minimum, at least
every 30 minutes
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Discussion and Conclusions
Lab Results
• Venous blood sample was extracted 5 minutes after
the patient’s arrival to the ED for:
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CBC
Serum electrolyte measurements
Blood urea and creatinine determinations
CK-MB levels
TnT quantitation
• The following abnormal findings were identified:
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TnT 0.3 ng/mL
CKMB 27 U/L
K+ 3.3 mmol/L
Creatinine 1.28 mg/dL
Reference range
(<0.12 ng/mL)
(0–25 U/L)
(3.5–5.00 mmol/L)
(0.67–1.17 mg/dL)
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CBC=complete blood count; CKMB= serum creatine kinase MB; ED=emergency department; TnT=troponin T
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Teaching Points
Discussion and Conclusions
Lab Results (Cont’d)
• The arterial blood gas analysis revealed the
following parameters:
Reference range
– pH 7.16
(7.35–7.45)
– PCO2 59 mmHg
(35–45 mmHg)
– PaO2 71 mmHg
(80–100 mmHg)
– HCO3- 16.7 mmol/L (23–28 mmol/L)
• Respiratory and metabolic acidosis: Mixed
acidosis/respiratory fatigue and then metabolic
acidosis
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Discussion and Conclusions
Need for potassium (K+) Correction
and Renal Evaluation
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K+ was replaced in the form of 20 mL of KCl 10%
diluted in 250 mL of D/W 5%, at an infusion rate of
125 mL/h
Close monitoring of the effects of pharmacologic
therapy
Fluid and electrolyte monitoring:
– fluid intake and output balance
– body weight
– K+ and sodium (Na+) Levels
D/W=dextrose/water
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Discussion and Conclusions
Chest X ray
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Chest X ray:
Interpretation
(30 min after presentation in ED)
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ER=emergency department
QUESTION
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Chest X ray: Radiology Interpretation
•
Chest X ray showed pulmonary edema
Teaching Points
Discussion and Conclusions
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RESULTS
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Diagnostic
Results
Revised Diagnosis
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Ancillary Imaging
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An echocardiogram was performed by the oncall cardiologist, within 30 minutes after
request
Teaching Points
Discussion and Conclusions
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Ancillary imaging:
Interpretation
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Discussion and Conclusions
Ancillary Imaging: Interpretation
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The main findings consisted of:
– diffused LV hypokinesia, less at the posterior wall
– LVEF 40%
– dilated LV
– ascending aorta dilatation
– no specific wall motion abnormalities were noted
beyond diffuse hypokinesia
LV=left ventricle; LVEF=left ventricle ejection fraction
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Revised Clinical
Impression
and Differential
Diagnoses
H
REVISED DIAGNOSIS AND
CARE PLAN
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Disposition
Decision
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REVISED DIAGNOSIS
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Case Details
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
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Teaching Points
Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses
•
The initial diagnosis remained ACPE as a clinical
entity characterizing AHF, which may be:
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the first presentation of HF (‘de novo’ AHF)
caused by an abnormality of cardiac function such
as Acute Coronary Syndrome (ACS) or Hypertensive
Crisis or an acute valve problem
• mildly elevated troponin concerning. Needs to be
repeated along with repeat ECG1
1. McMurray et al. European Heart Journal 2012;33: 1787–47
ACPE=acute cardiogenic pulmonary edema; ACS=acute coronary syndrome; AHF=acute heart failure;
ECG=electrocardiogram; HF=heart failure
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Teaching Points
Discussion and Conclusions
Revised Plan of Care
Decision for NIPPV
•
In the absence of any contra-indications, NIPPV was
prescribed for this patient, according to the criteria of
the Local Evidence Based Nurse-led Protocol for
NIPPV Implication for patients with ACPE patients
– these criteria include age ≥18 years, symptom of
dyspnea of sudden onset, tachypnea ≥20/min,
hypoxemia manifesting with a ventilation ratio*
<300 mmHg, and radiological findings compatible
with ACPE
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*The ventilation ratio is the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PO 2/FiO2)
ACPE=acute cardiogenic pulmonary edema; NIPPV=non-invasive positive pressure ventilation
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Teaching Points
Discussion and Conclusions
Decision for NIPPV (Cont’d)
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In the presence of the intensivist on call, an
interdisciplinary management plan was determined in
case of NIPPV therapy failure, according to the
predefined protocol’s criteria for the need of ETI
The IBW of the patient was estimated on 80 kg
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ETI=endotracheal intubation; IBW=ideal body weight; NIPPV=non-invasive positive pressure ventilation
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Teaching Points
Discussion and Conclusions
NIPPV initiation
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The BiPAP device was initially adjusted on
IPAP 15 cmH2O, EPAP: 7 cmH2O, and FiO2 1.0
Respectively, while initiating NIPPV, an administration
of an additional intravenous dose of 2 mg of
morphine sulphate and a reduction in isosorbide
dinitrate in 2 mg/hour (started with 4 mg/hour) was
performed
According
to the predefined
goals
REVISED
DIAGNOSIS
ANDthe initial
IPAP/EPAP adjusted to 18/7 cmH2O
CARE PLAN
Patient – ventilator synchrony and patient’s comfort:
excellent
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ETI=endotracheal intubation; EPAP= expiratory positive airway pressure; IBW=ideal body weight;
IPAP=inspiratory positive airway pressure; NIPPV=non-invasive positive pressure ventilation
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Teaching Points
Discussion and Conclusions
NIPPV initiation (cont’d)
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The patient should be continuously assessed!
Careful attention to clinical signs and symptoms,
continuous telemetry monitoring including oxygen
saturation should be closely monitored. Comfort and
continued improvement with NIPPV is important to
monitor
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NIPPV=non-invasive positive pressure ventilation
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Teaching Points
Discussion and Conclusions
Response to NIPPV
•
Since the patient featured optimal response to the
targeted therapy, one hour after the NIPPV
implementation and along with the absence of
admission symptoms and the regained normal vital
signs, respectively, efforts of titration for weaning from
the ventilator were commenced
NIPPV=non-invasive positive pressure ventilation
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Discussion and Conclusions
H
DISPOSITION
DECISION
NIPPV weaning and removal
• Two hours post initial implementation:
• Improvement in ABGs (pH 7.36, PCO2 40 mmHg, PaO2
205 mmHg, HCO3– 28 mmol/L) and RR
• Urinary output 600 mL in 2 hours, along with the
absence of increased cardiorespiratory workload
• Patient weaned from BiPAP
• Admitted to CCU
• Repeat TnT, elevated at 1 ng/mL – further ACS
management was continued with a loading dose of
ASA 300 mg p.o., Clopidogrel 300 mg p.o., enoxaparin
sodium 80 mg s.c. and lovastatin 20 mg p.o.
• More comprehensive nursing history revealed important
new insights. The patient complained of mild shortness
of breath and slight limitation of his ordinary daily
activity, during the last 2 months as well as slowly
progressing lower extremity edema
ABG=arterial blood gas; ACS=acute coronary syndrome; ASA=acetylsalicylic acid; CCU=Coronary Care Unit;
NIPPV=non-invasive positive pressure ventilation; p.o.=by mouth; RR=respiration rate; s.c.=subcutaneous;
TnT=troponin T
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Discussion and
Conclusions
Teaching Points
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
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TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
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Revised Diagnosis
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Teaching Points
•
Nurses have to be familiar with:
– indications for NIV
– monitoring of patients with NIV
– available protocols regarding NIV
NIV=non-invasive ventilation
Disposition
Decision
Teaching Points
Discussion and Conclusions
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TEACHING POINTS,
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Decision
Discussion and Conclusions
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Nurses are the health professionals central to
the continuity of care. Careful evidence-based
protocols for nursing-led NIPPV
implementation and maintenance is important
Such protocols must be developed in a way to
achieve the optimal standardization of care in
a relatively heterogeneous population.
Importantly, clear communication between the
entire care team is critical
NIPPV=non-invasive positive pressure ventilation
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Supplemental Material
Teaching Points
Discussion and Conclusions
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DISCUSSION AND
CONCLUSIONS
Case Details
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Initial Diagnosis
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Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Nursing Management Algorithm
Immediate assessment (ABCDE)
Vital signs (BP, HR, RR, T, SatO2)
Triage
Initial clinical assessment and short history
(peripheral i.v. line, ECG, CXR, blood test,
non invasive monitoring)
Bedside ECHO
Determine precipitant of AHF
Determine the hemodynamic profile
Start pharmacological therapy
Follow-up assessment
Psychosocial assessment and support
Monitor the effects of pharmacological therapy
(including for side-effects)
Monitor fluid management
Monitor mental status
Monitor dyspnea symptoms
Determine the trigger of decompensation
Assess educational needs
Successful
communication
on and
management
of the
multi-disciplinary
team
Discharge
Planning
Introduction to an effective
multi-disciplinary HF management
program
AHF=acute heart failure; BP=blood pressure; CXR=chest x-ray; ECG=electrocardiogram; HR=heart rate;
i.v.=intravenous; RR=respiratory rate; O2 sat= oxygen saturation; T=temperature