Heart Failure

1. Heart Failure EMS Professions Temple College

2. Heart Failure Inability of heart to pump blood out as rapidly as it enters Often referred to as congestive heart failure (CHF)

3. Congestive Heart Failure Congestion of pulmonary or systemic circulation (backward failure) Reduced output to body tissues (forward failure)

4. Causes Diffuse coronary artery disease Myocardial ischemia Myocardial infarction Arrhythmias Tachycardia Bradycardia

5. Causes Valvular heart disease Acute Hypertensive Crisis Chronic Hypertension Idiopathic Causes

6. CHF May develop acutely or may be a chronic disease Acute Onset CHF: Suspect Acute MI Dysrhythmia Hypertensive Crisis

7. CHF Chronic CHF may worsen acutely from: Respiratory infection Pulmonary embolism Emotional stress Increased salt and water intake

8. Congestive Heart Failure Left sided Right sided Biventricular

9. Left-Sided Heart Failure Left ventricle fails as effective pump Left ventricle cannot eject blood delivered from right heart through pulmonary circulation Blood backs up into pulmonary circulation

10. Left-Sided Heart Failure Increase pressure in pulmonary capillaries forces blood serum out of capillaries into interstitial spaces and alveoli Increase respiratory work and decrease gas exchange occur

11. Left-Sided Heart Failure Common causes ACUTE MI especially if involves left ventricle Chronic hypertension Dysrhythmias especially tachydysrhythmias

12. Left-Sided Heart Failure Pulmonary Signs/Symptoms

13. Left Heart Failure Symptoms Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Fatigue, generalized weakness

14. Left Heart Failure Signs Anxiety, confusion, restlessness Persistent cough Pink, frothy sputum Tachycardia Tachypnea Noisy, labored breathing Rales, wheezing (�cardiac asthma�) Cyanosis (late) Third heart sound (S3)

15. Right-sided Heart Failure Right ventricle fails as effective pump Right ventricle cannot eject blood returning through vena cavae Blood backs up into systemic circulation

16. Right Heart Failure Increased pressure in systemic capillaries forces fluid out of capillaries into interstitial spaces Tissue edema occurs

17. Right Heart Failure Causes

18. Right Heart Failure Causes Others Chronic hypertension COPD (cor pulmonale) Pulmonary embolism Right ventricular infarction

19. Right-Sided Heart Failure Systemic Signs/Symptoms

20. Right Heart Failure Signs/Symptoms Tachycardia Jugular vein distension Pedal, pre-tibial, sacral edema Hepatomegaly Splenomegaly

21. Right Heart Failure Signs/Symptoms Anasarca (generalized edema) Fluid accumulation in body cavities Ascites Pleural effusion Pericardial effusion

22. Management of Heart Failure

23. Goals of Management Improve oxygenation, ventilation Decrease venous return to heart Decrease cardiac work, O2 demand Improve cardiac output by Reducing afterload Increasing myocardial contractility

24. Management Sit patient up, dangle feet Do not lay flat Oxygen by non-rebreather mask Consider positive pressure ventilation

25. Management Consider intubation if: O2 saturation cannot be kept >90% on 100% O2 PaO2 cannot be kept >60 torr on 100 % O2 Patient displays signs of worsening cerebral hypoxia PaCO2 progressively increases Patient becoming exhausted

26. Management Monitor ECG Hypoxia, increased heart wall tension leads to dysrhythmias IV NS TKO via microdrip or lock Limit Fluids If RVF only, fluid challenges to ? preload

27. CHF First Line Drug Therapy Nitroglycerin 0.4mg SL q 5 min prn Systolic BP should be > 90 - 100 mm Hg Nitrate therapy before IV is started Reduces preload/afterload Improves coronary artery perfusion Caution in RVF NTG, Lasix or MS may worsen hypotension Use inotropes if fluid does not improve BP following NTG administration

28. CHF First Line Drug Therapy Furosemide (Lasix�) - 40 mg (0.5 - 1 mg/kg) slow IV Patients already on furosemide may have tolerance Increase dose to 2X daily oral dose Direct vasodilation leads to decreased venous return Diuresis leads to decreased intravascular volume May cause hypokalemia, dysrhythmias especially dangerous if patient on digitalis May worsen hypotension in RVF

29. CHF First Line Drug Therapy Morphine Sulfate 2 mg IV push slowly q 10-15 min Peripheral vasodilation leads to Decreased preload Decreased afterload Decreased venous return leads to Decreased cardiac work Decreased O2 demand Decreased anxiety Decreased release of catecholamines Monitor Ventilations and BP Systolic BP should be > 90 - 100 mm Hg

30. CHF Second Line Therapy Dobutamine 2 - 20 mcg/kg/min Potent ?1 stimulation Increases contractility Increases level of cardiac output Drug of choice if systolic BP >100 and diastolic BP <110

31. CHF Second Line Therapy Nitroglycerin 10 mcg/min increased by 5-10 mcg/min q 5 min Vasodilation Decreased venous return leads to Decreased cardiac work Decreased O2 demand Decreased afterload leads to increased cardiac output

32. CHF Third Line Drug Therapy Bronchodilators (beta agonists) May be useful if wheezing is present Mild peripheral vasodilator Myocardial and respiratory stimulant May cause arrhythmias in hypoxic patients or those with coronary artery disease

33. CHF Management What if the BP is too low for the first and second line drug therapies? BP < 70 mm Hg norepinephrine, 0.5 - 30 mcg/min IV infusion BP > 70 but < 100 mm Hg dopamine, 5 - 15 mcg/kg/min IV infusion After BP improves, treat pulmonary edema with first and second line therapies

34. CHF Management Long Term Management usually includes Fluid minimization Diuretics (+ Potassium if non-potassium sparing) Diet restrictions Increase contractility Digitalis Blood pressure control ACE Inhibitors Coronary artery perfusion Nitroglycerin

35. Cardiogenic Shock

36. Cardiogenic Shock Diminished cardiac output leading to impaired tissue perfusion Most extreme form of pump failure

37. Cardiogenic Shock Occurs in about 15% of acute MI patients Usually occurs when 40% or more of the left ventricular muscle mass infarcts Mortality is 85% or more with treatment

38. Signs/Symptoms Confusion, restlessness, anxiety, stupor, coma Cool, clammy skin Pallor Weak or absent extremity pulses Tachycardia Slow or absent capillary refill

39. Signs/Symptoms BP < 90 systolic or > 30mmHg below normal BP is NOT the same as perfusion Shock can be present with a �normal� BP Evaluate signs of peripheral perfusion in addition to BP

40. Cardiogenic Shock Very difficult to assess in presence of arrhythmias, hypovolemia, decreased vascular tone

41. Cardiogenic Shock Treatment Priorities: Rate Rhythm BP (Volume, Pump/Vascular tone) Correct major disorders of rate, rhythm before directly treating BP

42. Goals of Management Improve oxygenation and peripheral perfusion Avoid increasing cardiac workload myocardial oxygen demand

43. Management Primary assessment & Focused Hx Identify source of problem Acute pulmonary edema Volume problem Pump problem Rate problem

44. Acute Pulmonary Edema First line interventions IV/O2/ECG Monitor If BP > 90-100 mm Hg: furosemide 0.5 � 1.0 mg/kg slow IV (or twice patient�s single daily dose up to 120 mg) Morphine 2 � 10 mg slow IV Nitroglycerin 0.4 mg SL If BP < 90 mm Hg: Vasopressors based on SBP

45. Volume Problem IV/O2/ECG Monitor Fluid challenge until rales or if evidence of anterior wall AMI Vasopressors based on SBP

46. Pump Problem IV/O2/ECG Monitor SBP <70 mmHg: norepinephrine 0.5 � 30 mcg/min IV inf SBP 70 � 100 mm Hg & shock dopamine 5 � 15 mcg/kg/min IV inf SBP > 100 mm Hg w/o shock dobutamine 2 � 20 mcg/kg/min IV inf

47. Management Keep patient supine Difficult in presence of pulm edema Do not elevate lower extremities Oxygenate via NRB Consider assisting ventilations Decrease work of breathing may benefit patient in shock Consider intubation Monitor ECG

48. Management IV TKO with microdrip set or lock Limit fluids unless suspect RVF Correct major disorders of rate, rhythm Increase rate in bradycardias Terminate tachycardias with cardioversion Suppress frequent ectopic beats

49. Management If rate/rhythm adequate, treat BP Consider fluid challenge of 250cc LR over 10-15 minutes if relative or absolute hypovolemia possible, including RVF and NO pulmonary edema Avoid use of vasopressors until volume deficits corrected or pulmonary edema presents

50. BP Treatment Review If rate, rhythm, volume adequate, treat BP with vasopressors: Norepinephrine, or Dopamine

51. Norepinephrine 0.5 - 30 mcg/min Inotropic and vasoconstrictive properties Can be used if systolic BP < 70 If systolic BP > 70, use dopamine instead DO NOT use until hypovolemia corrected DO NOT allow infiltration

52. Dopamine 2 - 20 mcg/kg/min Place 200 mg/250cc of D5W Begin at 5 mcg/kg/min In 2 - 10 mcg/kg/min range, ? effects dominate > 20 mcg/kg/min ? effects dominate Use lowest dose that produces good perfusion Use as initial vasopressor if BP 70-100 systolic If dopamine infusion rate is > 20 mcg/kg/min use norepinephrine

53. Dopamine May cause tachycardia, ectopy, nausea DO NOT use until hypovolemia is corrected DO NOT allow to infiltrate