Thanks to Dr. Lewis for today’s Morning Report!
Congestive Heart Failure: Acute Pulmonary Edema
Goal: (1) Preload Reduction (2) Afterload Reduction (3) Inotropic Support
Nitroglycerin
- short-acting, rapid onset systemic venous and arterial dilator – decreases MAP by reducing afterload and preload
- repeated SL nitro (0.4 mg) q3-5 mins = IV 60-100 mcg/min
- titrate IV nitro rapidly starting 100 mcg/min upward to 200 – 400 mcg/min or higher (650 mcg/min) until BP controlled
- High dose nitrates:
- 2007 Ann Emerg Med – hypertensive severely decompensated HF, started nitro drip at 0.3 -0.5 µg/kg/min, titrating at 20 µg/min q1-3mins, max dose of 400 µg/min (SBP <90 was absolute contraindication), all pts received initial 2 mg bolus q3-5 mins for period of 30 mins to max potential dose of 20 mg. Conclusion: pts who received high-dose nitro required intubation, BiPAP or ICU admissions less frequently
- <250 µg/min: predominantly venodilatory → preload reduction
- ≥250 µg/min: induce both venous and arterial dilation → preload & afterload reduction
- High dose nitrates:
NIPPV: BIPAP
- Decreases Preload & Afterload
- IPAP – EPAP = PEEP, reduces the need to intubate but not mortality or new MI
- opens alveoli, increases FRC, decreases dead space, increase TV and decreases intrapulmonary shunt
- Start at IPAP/EPAP = 10/5 →20/15, if pt not blowing off enough CO2→increase IPAP = increases tidal volume and alveolar ventilation, if pt not oxygenating effectively→ increase EPAP, pts with APE often require high EPAP
- Initial FIO2 setting from 21-50% (usually 40%) to maintain Sao2 88% for known PCO2 retainers, 90% if refractory hypoxemia an issue, 92% for all other patients
Lasix
- Decrease Preload → diuresis and direct venodilation
- CAUTION: pts may be volume deplete due to increase work of breathing, total body euvolemic or HYPOvolemic but shifted fluid in lungs → electrolyte abnormalities, worsened renal function, hypotension, goal is to redistribute fluid not remove
- When do they start working??
- Decrease afterload then give lasix if needed
- Dose?
Morphine
- morphine or related opiods increase need for intubation and ICU LOS= no longer recommended, can result in respiratory depression
ACEI
- reduces pre and afterload (15-30 mins to work) but little data to support use in acute situation
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Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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4 Comments
Ian deSouza · February 12, 2015 at 11:18 am
Nice post, Lewis. The literature suggests that CPAP may simply be enough for these patients and bi-level IPAP/EPAP is really not necessary. You may see pre-hospital NIPPV used more-frequently and there are some studies that support this. High-dose NTG infusions are an important concept and should provide benefit, but remember that systematically, NTG infusions are only “allowed” in intensive care units. The availability and use of NIPPV has enabled us to not only avoid some intubations, but to wean the patient off of NTG so that patient can be transferred to a medical floor instead.
Ian deSouza · February 12, 2015 at 11:20 am
A nice recent review.
Early Management of Patients With Acute Heart Failure: State of the Art and Future
Directions—A Consensus Document from the SAEM/HFSA Acute Heart Failure Working Group. ACADEMIC EMERGENCY MEDICINE 2015;22:94–112.
ISSN 1069-6563
doi: 10.1111/acem.12538
LGrodin · February 12, 2015 at 1:20 pm
You guys should check out the next issue of Common Sense (newsletter from American Academy of EM)! A bunch of EM/IMs do some reading and discussion of the evidence behind using furosemide in decompensated HF. Some food for thought: around 90% of patients admitted will end up getting it. So it is the standard of care, though it’s interesting how little data there is about how to use it.
Nathan Reisman · February 22, 2015 at 1:06 pm
FDNY is planning to starting to carry CPAP soon. BLS is now approved to use CPAP in the region, we may start seeing EMT units come in with patients on CPAP in the next few months.