Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.

19Sep/11Off

CHF Master Class

Please expect Master Class Pearls to be longer than usual due to the nature of these sessions

From 1st year Group:

1)   “Nitro, nitro, nitro.” – Nitroglycerin, not diuretics, is the 1st therapy to consider in patients with CHF exacerbations.  High dose nitro can produce preload and afterload reduction (both useful!).  Downside = hypotension.  If severe or persistent hypotension after nitro, consider RV infarct, tamponade, aortic stenosis, hypovolemia, or concurrent use of Viagra (things that should be considered before giving nitro).

-Non-Invasive Ventilation is the next line of the mantra (“CPAP, CPAP, CPAP”) as this will help reduce preload and help decrease work of breathing!

2)   BNP utility: In patients presenting with classic H+P for Acute Decompensated Heart Failure, BNP will not add significant diagnostic value.  Its true utility is to help distinguish ADHF from COPD or another possibility on your DDx for which your history and physical exam are equivocal.  Most useful when <100 (look for another etiology of dyspnea) or >500 (most likely ADHF); but must consider age (higher baseline BNP), renal function (higher baseline BNP), and obesity (lower baseline BNP).

- More useful study is BMP as this will help define renal function and allow you to know if Diuretic can be given safely.  Lasix is not necessary to give immediately… it is not part of the Mantra!

3)   Maintain a high level of concern for acute coronary syndrome/ischemia as the precipitant for the current exacerbation.  Obtain ECG early and monitor serial ECGs and cardiac enzymes.

 

From 2nd/3rd year Group:

1)   “Nitro, Nitro, Nitro.” {funny how that happened}  Dial up the dose on the nitro quickly.  Remember that the routine sub-lingual dose per protocol (3 doses over 15 minutes) can be estimated at around 80mcg/min… so don’t start your IV drip at 10mcg/min and slowly titrate.  You can start higher and titrate faster for effect.

2)   The patient presenting with a CHF exacerbation and hypotension is a very difficult patient to manage.  Nitro may worsen BP.  ACEI may worsen BP.  Seems like pressors would be a good idea… but recall that they may lead to increased HR (lower diastolic filling time), increase myocardial oxygen consumption, increase ischemia, and increase arrhythmias (all sub-optimal in a patient whose cardiac output is tenuous).  Moral of the story, be judicious and careful all around.

3) Do not forget to use CPAP/BiPAP early in the course in a patient with CHF exacerbation and increased work of breathing.  This will not only help improve oxygenation and work of breathing (by opening collapsed airways and increasing FRC, Tidal Volume, and lung compliance), but it will also decrease Pre-load and Afterload (all beneficial).  While intubating patients is often what occurs, it is always better for the patient to avoid a large piece of plastic in their airway from being necessary.

4)   “STAT Echo!” – particularly for the patient with florid pulm edema or hypotension.  Helps to determine any surgically correctable etiologies (tamponade, valvular insufficiency, etc).

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  1. Severe COPD entails an inflammation of the lungs caused by an enzyme called phosphodiesterase 4. Treatments of COPD are targeted to inhibit this enzyme. The best available on the marked is Daxas which is a new oral therapy which should be taken once a day by patients. This treatment reduces the risk of exacerbations and improves the patient’s general lung function. The inhibitor and active ingredient of Daxas is called roflumilast. This inhibitor reduces the inflammation of the lungs like no other available COPD drug is capable of, benefitting patients with severe COPD greatly. Research has shown that lung function improves within 4-8 weeks after starting the Daxas treatment with the benefits sustaining for a 12 month period. Therefore, patients should be patient as the drug does not give immediate relief. One of the very unfortunate elements about this disease is the fact that it is not curable; however, it is preventable. It affects mostly people above 40 years of age. The incidents of people being diagnosed with COPD continue to rise despite a general decline in smoking. However, the disease is still rather under-diagnosed and many people are unaware that they have it despite its life threatening nature. They may interpret the symptoms as symptoms of getting older such as coughing and breathlessness when in fact they are not.

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