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CASE P.C.

CASE P.C. ANDREA JOHNSON. P.C. 60 year old female Hypertensive – non-compliant X 1year. PRESENTING COMPLAINT. SEVERE SOB Began while “swearing & getting on bad” Drank 1 bottle extra strength Codeine Then 20mls rum cream GOT WORSE !!!!. DENIED.

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CASE P.C.

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  1. CASE P.C. ANDREA JOHNSON

  2. P.C. • 60 year old female • Hypertensive – non-compliant X 1year

  3. PRESENTING COMPLAINT • SEVERE SOB • Began while “swearing & getting on bad” • Drank 1 bottle extra strength Codeine • Then 20mls rum cream • GOT WORSE !!!!

  4. DENIED • Chest, abdominal or back pain • Palpation • Nausea or vomiting • Diaphoresis • Cough • fever • Previous episodes of SOB • History of immobilization

  5. PMH • NO previous admission to QEH • No Diabetes Mellitus/heart disease • Admission to Psyche hospital for “social reasons ?!!” - ? # times • On no medication • Given Natrilix on 1 occasion ~ 1year previously

  6. EXAMINATION • Obvious CP distress • Mm pink, hydration adequate • No pedal oedema • Temperature 36o C axillary

  7. RESPIRATORY SYSTEM • OXYGEN SAT (room air)- 78% • RR 40/min, use of accessory muscles • BS vesicular • Creps – laterally + posteriorly • Wheeze – throughout posteriorly

  8. CARDIOVASCULAR SYS • Distal pulses palpable + = bilaterally • JVP not elevated • PULSE 107/min, regular, synchronous • BP 260 / 145 mmHg • Normal heart sounds • No murmurs

  9. ABDOMEN • Soft, non-tender • No masses or organomegaly • Normal BS

  10. MUSCULOSKELETAL • No calf swelling or tenderness

  11. DIASCAN • 22.3 MMOL / L

  12. ASSESSMENT • 1. ACUTE PULMONARY OEDEMA • r/o Acute Myocardial Infarction • 2. Uncontrolled HTN – 2o non-compliance • 3. ? Newly Diagnosed Diabetic

  13. PLAN • Oxygen 15 L / min- nonbreather face mask • GTN 2 puffs – X 2 • Nitroglygerin infusion @ 1mcg/kg/min (100mcg/min) • Enalapril 1.25mg IV • Lasix 60mg IV • Aspirin 300mg stat • Soluble insulin 10u IV

  14. PLAN • ECG (RT sided leads subsequently) ABG • Cardiac enzymes • FBC PT PTT n/a . Urea and electrolytes CXR Urethral catheter + urinalysis

  15. RESULTS • ECG: sinus, regular • LVH with Strain • ST depression II, aVF • ? ST elevation vs high J point V1-V3 • Right sided leads - NAD

  16. RESULTS • CXR- fluffy opacity throughout • ABG – 15 L O2 • O2 sat 93.2% • pO2 - 74.3 • pCO2 – 39.6 • HCO3 – 18.1

  17. RESULTS • Hb 15.1 • WBC 19.8 • PLT 332 • Sodium 137 • Potassium 3.6 • Chloride 101 • Urea 9.9 • Creatinine 125 • CK 120 • CKMB 41 • Troponin I 0.22

  18. FURTHER MX • Referred To Med on Call • 1 hour after seen significant improvement • RR 32/ min, BP 195 / 109, pulse 85/min • 2 hours later • 1000 mls urine emptied • Admitted to MED

  19. ON WARD • Treated for UTI • Day 4 aggressive, speaking loudly • Seen by psyche • Diagnosis ? Paranoid Schizophrenia vs • Delusional disorder • ? Hypomanic symptoms

  20. DISCHARGE • DAY 7 • F/U: MOPD + Psyche Hospital • TTH: Lasix 40mg od • Norvasc • Tritace • ASA • Lipitor • Diamicron MR 30mg od • Complete Septrin

  21. ACUTE CARDIOGENIC PULMONARY OEDEMA • ANDREA JOHNSON

  22. DEFINITION • Leakage of fluid from the pulmonary capillaries and venules into the alveolar space as a result of increased hydrostatic pressure • Inability of left ventricle to effectively handle its pulmonary venous return • MATTU ET AL

  23. PATHOPHYSIOLOGY • Angiotensin I Angiotensinogen (LIVER) RENIN ACE Angiotensin II ALDOSTERONE VASOCONSTRICTION

  24. PATHOPHYSIOLOGY ↓ CARDIAC OUTPUT INCREASED PCWP ACTIVATIONOF RENIN ANGIOTENSIN SYSTEM ACTIVATION OF S/S SYSTEM SYMTOMATIC DECOMPENSATION CARDIAC ISCHAEMIA ↓ LEFT VENTRICULAR FUNCTION INCREASED HEART RATE INCREASED SYSTEMIC VASCULAR RESISTANCE INCREASED PRELOAD

  25. PRECIPITATING FACTORS • Myocardial ischaemia or infarction • Arrhythmias • Uncontrolled HTN/HTN crisis • Medication Non-compliance • Thyrotoxicosis • Fluid overload • Anaemia • Pulmonary & other infections • Inappropriate medications- -ve inotropes, NSAIDS

  26. CLINICAL FEATURES • SOB • Orthopnoea - sensitivity 5% • - specificity 77% • PND • Tachycardia •  BP • Wheezing – sensitivity 22% • - specificity 58% • Crepitations - sensitivity 6% • - specificity 78% • EMERGENCY MEDICINE PRACTICE DEC 2006

  27. DIFFERENTIAL DIAGNOSIS • Physicians only 80% accurate at differentiating Acute Heart Failure from other disease processes

  28. DIFFERENTIAL DIAGNOSIS • ASTHMA • COPD • PULMONARY EMBOLISM • PNEUMONIA

  29. INVESTIGATIONS • 1. Blood • 2. Electrocardiography • 3. Radiologic

  30. BLOOD INVESTIGATIONS • ABG • FBC – anaemia, infection • U & Es • CARDIAC MARKERS

  31. CARDIAC MARKERS • CARDIAC ENZYMES • OTHER CARDIAC MARKERS

  32. OTHER CARDIAC MARKERS • B – NATRIURETIC PEPTIDE (BNP) • N-TERMINAL PRO BNP PRE-PRO BNP BNP + NT PRO-BNP

  33. B – NATRIURETIC PEPTIDE (BNP) • EFFECTS • 1.Vasodilation • 2. Diuresis • 3. Natriuresis • 4. Suppression of Renin Angiotensin Sys

  34. IMPORTANCE OF BNP IN HF • 1. Useful in Diagnosis • 2. Assessing Severity • 3. Predicting short & long-term CVS mortality

  35. WHAT LEVELS ? • NO HEART FAILURE • BNP< 100pg / dl • NT PRO-BNP< 300pg / dl • HEART FAILURE • BNP >500pg / dl • NT PRO-BNP > 1000pg / dl • 80% Sensitivity for heart failure

  36. PROBLEMS !!! • GRAY AREA: 100pg/dl – 500pg/dl • BNP  in non-cardiac conditions • Renal disease •  Age • Pulmonary Embolism • Cor pulmonale • BNP  in CCF • OBESITY: BMI inversely related to BNP

  37. USEFULNESS OF BNP • Does not add much when diagnosis certain from clinical presentation • Uncertain diagnosis when BNP < 100pg/dl • Known baseline in certain conditions • 20% obese patients with acute heart failure have values < 100pg/dl

  38. ELECTROCARDIOGRAM • Ischaemia / infarction • Arrhythmia – A fib • LVH • Prolonged QRS

  39. CHEST RADIOGRAPH • FINDINGS IN HEART FAILURE • Cardiomegaly – 74% sensitive, 78% specific • Vascular redistribution • Interstitial oedema • Pleural effusions (right sided/bilateral)

  40. CXR – BUT !! • 20% patients with Acute heart failure have none of the “typical features” • No longstanding HF- Normal size heart • Longstanding CCF – lymphatics • COPD – minimal findings

  41. Other investigation • Echocardiography • 1.Identify reversible cause eg tamponade • 2.Distinguish between systolic and diastolic dysfunction

  42. TREATMENT • AIMS • ABCs • Decrease Preload (right-sided filling) • Increase left-sided emptying • ↓ Afterload,  Cardiac output • ± improve LV contractility – inotropes • Overall aim- Redistribute fluid out of lungs!

  43. AVAILABLE TREATMENT • OXYGEN • PHARMACOTHERAPY • INOTROPIC RX • NONINVASIVE POSITIVE PRESSURE VENTILATION

  44. PHARMACOTHERAPY • AVAILABLE • 1. NITRATES • 2. DIURETICS • 3. ACE INHIBITORS • 4. MORPHINE • 5. NATRIURETIC PEPTIDES

  45. NITRATES • NITROGLYCERIN • MECHANISM OF ACTION • Venodilation (low dose)↓PRELOAD • Arteriolar dilatation (higher dose) •  ↓ AFTERLOAD • ↓pulmonary hydrostatic pressure

  46. NITROGLYCERIN • DOSE • SL: 0.4mg q 5-10 min • IV: titrate up to 3 – 5mcg /kg /min • Topical: may be unreliable in poor perfusion • Effect seen within minutes !!!

  47. NITROPRUSSIDE • ↓ Afterload • Useful in • Pulmonary oedema unresponsive to standard therapy • Severe HTN • Severe mitral/aortic regurge

  48. NITROGLYCERIN • Excellent single agent for acute pulmonary oedema !!

  49. ACE INHIBITORS • MECHANISM OF ACTION • Sublingual or IV • ↓ Afterload • ↓ Preload • ↓ Pulmonary Capillary Wedge Pressure • Down-regulate renin-angiotensin system

  50. ACE INHIBITORS • Sublingual • 12.5mg Captopril Sys BP < 110 • 25mg Captopril Sys BP >110 • Intravenous • Enalapril - 0.004mg/kg bolus • - 1mg infusion over 2 hrs • - 1.25 mg bolus • Effect seen within 10 minutes!!!!

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