Slides chf jsw
Transcript of Slides chf jsw
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65 y/o SOB Hypotensive
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CHF
J. Scott Wieters MD FAAEM Assistant Professor Emergency Medicine
Texas A&M University Health Science CenterScott and White Hospital, Temple, TX
Anything but a dry topic…
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Objectives
“Learn you fools bout CHF”
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Epidemiology
•5 million Americans •2.3% of general public •35% die in 2 yrs 80% at 6 yrs •1 million admits each year •Costs $27.9 billion •Chance to hear a CHF lecture.....
•Priceless....
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How’d you get it?
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Classifications?
•Left v. Right sided? •High v. Low output? •Ischemic v. Nonischemic? •Systolic v. Diastolic? •NY class I-IV?
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CHF The Big Picture
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Big Picture
•Preload •Afterload •Renin Angiotensin •Pulmonary edema •Cardiogenic Shock
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Systolic?
or
Diastolic?
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Low vs High?
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ACE-Inhibitors
•Afterload Reduction •First Dose Hypotesion?
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•Hypertensive HF 48% •Rapidly SOB •Minimal weight gain/edema
•Normotensive HF 48% •Progressive Weight gain, edema,
•Hypotensive HF 3% •Cardiogenic shock
Initial Presentation
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specifisc
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I Wanagetta BNP
• <100- prob not CHF •100-500 not sure what to do? •>500- probably CHF
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False High BNP?
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False LOW BNP?
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False Positive (falsely high) BNP False Negative (falsely low) BNP
Left ventricular hypertrophy Obesity
Ischaemia Treatment with heart failure drugs
Tachycardia
Hypoxaemia including pulmonary
embolismRenal impairment (GFR<60 ml/
min)Sepsis
COPD
Diabetes
Age>70 years
Liver cirrhosis
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Treatment Options
•BIPAP/CPAP •Nitrates •Lasix •ACE-I
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L MN OP
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Lasix MorphineNitratesOxygen Pressure
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P O N D
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Pressure Oxygen Nitrates Diuresis
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NIPPV
•Reduces: •Preload/Afterload •BP •Work Of Breathing •Intubation rate •Mortality*
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Nitrates
•Stop dicking around! •Reduce preload •Afterload red. at higher doses •Nitrates better than Lasix
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What Dose?
• One tablet = 80mcg/min
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ACE-Inhibitors
•Afterload Reduction •First Dose Hypotesion?
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Nesiritide
•VMAC trial •No reduction in mortality •Just Say No...
AusNn MarNn Vanquish. $279,999
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Lasix
•Mod/Severe helpful •Nitrates better than Lasix •Monotherapy? Really?
•Renal Failure •NO Mortality benefit
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Beta Blockers
•Really no role in ADCHF
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CRASHING CHF
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Crashing ADCHF
•Airway? •Rhythm? •Circulation
•Perfusion of vital organs
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Crashing ADCHF
•Hypotensive <100? •Dopamine 2-20mcg/kg/min •Dobutamine 2.5-20mcg/kg/min
•Still <70? •Norepi 4 -12 mcg/min •CATH lab for IABP?
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Post test CHF
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