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)

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Causes

• Diffuse coronary artery disease
• Myocardial ischemia
• Myocardial infarction
• Arrhythmias
• Tachycardia
• Bradycardia

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Causes

• Valvular heart disease
• Acute Hypertensive Crisis
• Chronic Hypertension
• Idiopathic Causes

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CHF

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

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CHF

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

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Congestive Heart Failure

• Left sided
• Right sided
• Biventricular

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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

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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

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Left-Sided Heart Failure

• Common causes
• ACUTE MI
• especially if involves left ventricle
• Chronic hypertension
• Dysrhythmias
• especially tachydysrhythmias

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Left-Sided Heart Failure

• Pulmonary Signs/Symptoms

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Left Heart Failure Symptoms

• Dyspnea on exertion
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Fatigue, generalized weakness

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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)

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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

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Right Heart Failure

• Increased pressure in systemic capillaries forces
  fluid out of capillaries into interstitial spaces
• Tissue edema occurs

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Right Heart Failure Causes
Most Common CauseLeft sided Heart Failure
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Right Heart Failure Causes

• Others
• Chronic hypertension
• COPD (cor pulmonale)
• Pulmonary embolism
• Right ventricular infarction

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Right-Sided Heart Failure

• Systemic Signs/Symptoms

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Right Heart Failure Signs/Symptoms

• Tachycardia
• Jugular vein distension
• Pedal, pre-tibial, sacral edema
• Hepatomegaly
• Splenomegaly

Classic Triad of Right Ventricular FailureJVD,
Hypotension, Clear Lungs
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Right Heart Failure Signs/Symptoms

• Anasarca (generalized edema)
• Fluid accumulation in body cavities
• Ascites
• Pleural effusion
• Pericardial effusion

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Management of Heart Failure
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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

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Management

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

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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

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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

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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

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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

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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

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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

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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

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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

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CHF Management

• What if the BP is too low for the first and
  second line drug therapies?
• BP
• norepinephrine, 0.5 - 30 mcg/min IV infusion
• BP 70 but
• dopamine, 5 - 15 mcg/kg/min IV infusion
• After BP improves, treat pulmonary edema with
  first and second line therapies

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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

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Cardiogenic Shock
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Cardiogenic Shock

• Diminished cardiac output leading to impaired
  tissue perfusion
• Most extreme form of pump failure

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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

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Signs/Symptoms

• Confusion, restlessness, anxiety, stupor, coma
• Cool, clammy skin
• Pallor
• Weak or absent extremity pulses
• Tachycardia
• Slow or absent capillary refill

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Signs/Symptoms

• BP 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

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Cardiogenic Shock

• Very difficult to assess in presence of
  arrhythmias, hypovolemia, decreased vascular tone

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Cardiogenic Shock

• Treatment Priorities
• Rate
• Rhythm
• BP (Volume, Pump/Vascular tone)
• Correct major disorders of rate, rhythm before
  directly treating BP

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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

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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
  patients single daily dose up to 120 mg)
• Morphine 2 10 mg slow IV
• Nitroglycerin 0.4 mg SL
• If BP
• Vasopressors based on SBP

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Volume Problem

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

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Pump Problem

• IV/O2/ECG Monitor
• SBP
• 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

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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

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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

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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

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BP Treatment Review

• If rate, rhythm, volume adequate, treat BP with
  vasopressors
• Norepinephrine, or
• Dopamine

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Norepinephrine

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

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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

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Dopamine

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