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Congestive Heart Failure

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Congestive Heart Failure. Developed by: Russell K. Miller Jr. MD, FACEP ... pulmonary edema secondary to congestive heart failure. ... Congestive Heart Failure ... – PowerPoint PPT presentation

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Title: 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
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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
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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
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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
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