Congestive Heart Failure

1
Congestive Heart Failure
Lynn K. Wittwer, MD, MPD Clark County EMS

• Developed by Russell K. Miller Jr. MD, FACEP
• Assistant Professor of Surgery and Internal
  Medicine The University of Texas Medical Branch
  Galveston

2
Objectives

• Overview of CHF
• Review cardiac physiology and pathophysiology
• Early recognition of CHF
• Early and aggressive management of CHF

3
Heart Failure

• The inability of the heart to maintain an output
  adequate to maintain the metabolic demands of the
  body.

4
Pulmonary Edema

• An abnormal accumulation of fluid in the lungs.

5
CHF

• Pulmonary Edema due to Heart Failure (Cardiogenic
  Pulmonary Edema)

6
Epidemiology

• .3/1000
• 3/1000 45-65
• 10/1000 65

7
Statistics

• US Health and Human Services.
• 5 million Americans suffer from CHF.
• 17.8 billion spent annually.
• 400,000 new cases reported each year.

8
Etiology

• Arteriosclerotic Cardiovascular Ischemia
• Hypertension
• Miscellaneous

9
Arteriosclerotic Cardiovascular Ischemia

• Acute Myocardial Infarction
• Chronic Ischemic Cardiomyopathy (Dilated
  Cardiomyopathy)

10
(No Transcript)
11
People Live with Atherosclerosis But Die of
Thrombosis!
The formation, progression and rupture of an
atherosclerotic plaque
12
Occlusion of Proximal Cx RAO view - Baseline
Patient with recent Non Q Wave MI If randomized
to the Invasive Arm Would have been pushed
toward Early CABG
Rotastenting of Proximal Cx RAO view - Baseline
During Rotational Ablation
13
Patient with Non Q Wave MI Cath showing
degenerated vein graft anastomosis and distal
LAD High risk for intervention because depressed
EF and occluded native coronary arteries
?
Angiographic results post Rotablator assisted
stenting of the anastomosis and distal LAD.
?
14
Hypertension

• Hypertrophic Cardiomyopathy

15
Morbidity Mortality

• Dramatically Affects Quality Length of Life
• 5 Year Mortality Males 62
• Females 42
• 6 Year Mortality Both Sexes 75

16
Physiology

• Frank-Starling
• Length Tension Ratio
• Ejection Fraction
• End diastolic volume/end systolic volume
• Cardiac Output
• Stroke volume x heart rate
• Preload
• Volume of blood delivered to heart during
  diastole
• Afterload
• Peripheral vascular resistance

17

Infiltration of Interstitial Space

• Normal Micro- anatomy
• Micro-anatomy with fluid movement.

18
Preload

• Primarily a venous and diastolic function

19
Afterload

• Primarily arterial and systolic function

20
Three Pathophysiological Causes of Failure

• Increased work load (HTN)
• Myocardial Dysfunction (ASCVD)
• Decreased Ventricular Filling (Misc.)

21
Decompensation

• Increased Pulmonary Venous Pressure (PAWP)
• Interstitial Edema
• Alveolar Edema

22
Compensatory Mechanisms to Failure

• Increased Heart Rate
• (Sympathetic Norepinephrine)
• Dilation
• (Frank Starling Contractility)
• Neurohormonal
• (Redistribution of Blood to the Brain)

23
CHF Vicious Cycle

• Low Output
• Increased Preload Increased Afterload
  Norepinephrine
• Increased Salt Vasoconstriction
  Renal Blood Flow
• Renin
• Angiotension I
• Angiotension II
• Aldosterone

24
Symptoms

• Fatigue
• Nocturia
• DOE
• PND

• GI Symptoms
• Chest Pain
• Orthopnea
• Profound Dyspnea

25

• Acute Pulmonary Edema is a true Life Threatening
  Emergency for which the clinical picture is hard
  to forget!

26
(No Transcript)
27
Laboratory Findings

• CXR - Single most useful clinical tool
• EKG - Non Specific
• Lab - Non Specific

28
Physical Exam

• Anxious
• Pale
• Clammy
• Dyspnea
• Tachypnea
• Confusion
• Edema
• Hypertension
• Diaphoretic

• Rales
• Ronchi
• Tachycardia
• S3 Gallop
• JVD
• Pink Frothy Sputum
• Cyanosis
• Displaced PMI

29
(No Transcript)
30
Precipitating Causes

• Non Compliance with Meds and Diet
• Acute MI
• Arrhythmia
• Pneumonia
• Increased Sodium Diet (Holiday Failure)
• Anxiety
• Pregnancy

31
EMS Management

• Sit upright
• High Flow O2
• NTG (If SBP 100)
• Diuretics (Lasix)
• Rotating Tourniquets (Controversial)
• Ventilatory Support
• CPAP
• intubation/ventilation

32
Emergency Dept. ManagementEMS Therapy Plus

• Morphine
• Dopamine
• Dobutrex
• Antihypertensives
• Digitalis

33
Antihypertensives

• Nitroprusside
• ACE Inhibitors (Enalapril)
• Calcium Channel Blockers (Nefedipine)
• Beta Blockers (With Caution)
• Hydralazine
• Phosphodiesterase Inhibitors (Amrinone)

34
Chronic CHF TreatmentAdjunctive Treatment

• Lifestyle changes
• Weight loss
• Decrease dietary salt
• Increase O2

35
Drugs

• Treat cause
• Diuretics
• Digitalis
• NTG
• Antihypertensives

36
Introduction

• CPAP is a non-invasive procedure that is easily
  applied and can be easily discontinued without
  untoward patient discomfort.
• CPAP is an established therapeutic modality,
  recently introduced into the prehospital setting.
• In the primary phase CPAP application in
  cardiogenic pulmonary edema, thus far, appears to
  be beneficial to patient outcome.

37
Key Points of CPAP

• CPAP has been successfully demonstrated as an
  effective adjunct in the management of pulmonary
  edema secondary to congestive heart failure.
• CPAP may prove to be a viable alternative in many
  patients previously requiring endotracheal
  intubation by prehospital personnel.

38
CPAP Mechanism

• Increases pressure within airway.
• Airways at risk for collapse from excess fluid
  are stented open.
• Gas exchange is maintained
• Increased work of breathing is minimized

39
Prehospital Indications

• Congestive Heart Failure
• Pulmonary Edema associated with volume overload (
  renal insufficiency, iatrogenic volume overload,
  liver disease , etc)
• Near Drowning

40
Absolute Contraindications

• Respiratory Arrest
• Agonal Respirations
• Unconscious
• Shock associated with cardiac insufficiency
• Pneumothorax
• Facial Anomalies e.g. burns, fractures, etc.
• Facial trauma

41
Relative Contraindications

• Decreased L.O.C.
• COPD
• Asthma
• Claustrophobia
• Patient Intolerance to equipment (e.g. mask)
• Tracheostomy (If lacking the adaptor)

42
Hazards

• Gastric Distention (19 cm H2O pressure)
• Corneal Drying
• Hypotension
• Pneumothorax

43
Important Points

• Pulmonary edema patients, properly selected,
  quickly improve with CPAP in a matter of minutes.
• CPAP is to CHF like D50 is to insulin shock.
• Visual inspection of chestwall movement reveals
  improved respiratory excursion.

44
Important Points (Continued)

• COPD and Asthmatic patients do not respond
  predictably to CPAP.
• They have a higher risk of complications such as
  pneumothorax, and thus should not be treated in
  the field with CPAP

45
Study Introduction

• IRB approval through UTMB.
• 6 hours didactic instruction
• Recognize CHF
• Differentiate CHF, COPD, Asthma Bronchitis.
• 2 hours clinical training.
• Instruction on assessment most important reason
  for success.

46
Data Summary

• 1996 1997
• September May
• Total Intubations 22
• Hospital Stay 14.8 Days
• ICU Admission 100

47
Data Summary

• 1997 1998
• September May
• CPAP 50
• Total Intubations 8 (15)
• - Primary Intubations 4 (8)
• - CPAP Failures 4 (8)
• Hospital Stay 8 days
• ICU Admission 48

48
Data Comparison
1996 1997 1997 1998 Intubated 22 8
CPAP 0 50 Hospital Stay 14.8 8 ICU
Admission 100 48
49
CPAP vs. Intubation

• CPAP
• Non-invasive
• Easily discontinued
• Easily adjusted
• Use by EMT-B
• Does not require sedation
• Comfortable

• Intubation
• Invasive
• Usually dont extubate in field
• Potential for infection
• Requires highly trained personnel
• Can require sedation
• Traumatic

50
Summary

• CPAP provides an adjunct between oxygen by NRB
  and endotracheal intubation.
• Reduces length of hospital admission.
• Reduces trauma of intubation
• Reduces costs