Congestive Heart Failure :Congestive Heart Failure Developed by: Russell K. Miller Jr. MD, FACEP Assistant Professor of Surgery and Internal Medicine The University of Texas Medical Branch Galveston Lynn K. Wittwer, MD, MPD Clark County EMS


Objectives :Objectives Overview of CHF Review cardiac physiology and pathophysiology Early recognition of CHF Early and aggressive management of CHF


Heart Failure :Heart Failure The inability of the heart to maintain an output adequate to maintain the metabolic demands of the body.


Pulmonary Edema :Pulmonary Edema An abnormal accumulation of fluid in the lungs.


CHF :CHF Pulmonary Edema due to Heart Failure (Cardiogenic Pulmonary Edema)


Statistics :Statistics US Health and Human Services. 5 million Americans suffer from CHF. $17.8 billion spent annually. 400,000 new cases reported each year.


Etiology :Etiology Arteriosclerotic Cardiovascular Ischemia Hypertension


People Live with Atherosclerosis – But Die of Thrombosis! :People Live with Atherosclerosis – But Die of Thrombosis! The formation, progression and rupture of an atherosclerotic plaque


Slide 9:Occlusion of Proximal Cx RAO view - Baseline During Rotational Ablation Rotastenting 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


Slide 10: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.  


Hypertension :Hypertension Hypertrophic Cardiomyopathy


Morbidity & Mortality :Morbidity & Mortality Dramatically Affects: Quality & Length of Life 5 Year Mortality: Males 62% Females 42% 6 Year Mortality: Both Sexes 75%


Physiology :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


: Infiltration of Interstitial Space Normal Micro- anatomy Micro-anatomy with fluid movement.


Preload :Preload Primarily a venous and diastolic function


Afterload :Afterload Primarily arterial and systolic function


Three Pathophysiological Causes of Failure :Three Pathophysiological Causes of Failure Increased work load (HTN) Myocardial Dysfunction (ASCVD) Decreased Ventricular Filling (Misc.)


Decompensation :Decompensation Increased Pulmonary Venous Pressure (PAWP) Interstitial Edema Alveolar Edema


Compensatory Mechanisms to Failure :Compensatory Mechanisms to Failure Increased Heart Rate (Sympathetic = Norepinephrine) Dilation (Frank Starling = Contractility) Neurohormonal (Redistribution of Blood to the Brain)


CHF Vicious Cycle :CHF Vicious Cycle Low Output Increased Preload Increased Afterload Norepinephrine Increased Salt Vasoconstriction Renal Blood Flow Renin Angiotension I Angiotension II Aldosterone


Symptoms :Symptoms Fatigue Nocturia DOE PND GI Symptoms Chest Pain Orthopnea Profound Dyspnea


Slide 22:Acute Pulmonary Edema is a true Life Threatening Emergency for which the clinical picture is hard to forget!


Laboratory Findings :Laboratory Findings CXR - Single most useful clinical tool EKG - Non Specific Lab - Non Specific


Physical Exam :Physical Exam Anxious Pale Clammy Dyspnea Tachypnea Confusion Edema Hypertension Diaphoretic Rales Ronchi Tachycardia S3 Gallop JVD Pink Frothy Sputum Cyanosis Displaced PMI


Precipitating Causes :Precipitating Causes Non Compliance with Meds and Diet Acute MI Arrhythmia Pneumonia Increased Sodium Diet (Holiday Failure) Anxiety Pregnancy


EMS Management :EMS Management Sit upright High Flow O2 NTG (If SBP > 100) Diuretics (Lasix) Rotating Tourniquets (Controversial) Ventilatory Support CPAP intubation/ventilation


Emergency Dept. ManagementEMS Therapy Plus: :Emergency Dept. ManagementEMS Therapy Plus: Morphine Dopamine Dobutrex Antihypertensives Digitalis


Antihypertensives :Antihypertensives Nitroprusside ACE Inhibitors (Enalapril) Calcium Channel Blockers (Nefedipine) Beta Blockers (With Caution) Hydralazine Phosphodiesterase Inhibitors (Amrinone)


Chronic CHF TreatmentAdjunctive Treatment: :Chronic CHF TreatmentAdjunctive Treatment: Lifestyle changes Weight loss Decrease dietary salt Increase O2


Drugs :Drugs Treat cause Diuretics Digitalis NTG Antihypertensives


Introduction :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.


Key Points of CPAP :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.


CPAP Mechanism :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


Prehospital Indications :Prehospital Indications Congestive Heart Failure Pulmonary Edema associated with volume overload ( renal insufficiency, iatrogenic volume overload, liver disease , etc) Near Drowning


Absolute Contraindications :Absolute Contraindications Respiratory Arrest Agonal Respirations Unconscious Shock associated with cardiac insufficiency Pneumothorax Facial Anomalies e.g. burns, fractures, etc. Facial trauma


Relative Contraindications :Relative Contraindications Decreased L.O.C. COPD Asthma Claustrophobia Patient Intolerance to equipment (e.g. mask) Tracheostomy (If lacking the adaptor)


Hazards :Hazards Gastric Distention (19 cm H2O pressure) Corneal Drying Hypotension Pneumothorax


Important Points :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.


Important Points (Continued) :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


Study Introduction :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.


Slide 43:Data Summary 1996 – 1997 September – May Total Intubations 22 Hospital Stay 14.8 Days ICU Admission 100%


Slide 44: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%


Slide 45:Data Comparison 1996 – 1997 1997 – 1998 Intubated 22 8 CPAP 0 50 Hospital Stay 14.8 8 ICU Admission 100% 48%


CPAP vs. Intubation :CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Does not require sedation Comfortable Intubation Invasive Usually don’t extubate in field Potential for infection Requires highly trained personnel Can require sedation Traumatic


Summary :Summary CPAP provides an adjunct between oxygen by NRB and endotracheal intubation. Reduces length of hospital admission. Reduces trauma of intubation Reduces costs