Management of Congestive Heart Failure: An Approach for the New Millenium 1997 12 08 Ppt Powerpoint Presentation slides Joann Aaron Medical Slideshow Congestive Heart Failure CHF Congestive heart failure CHF is caused by:

Management of Congestive Heart Failure: An Approach for the New Millenium 1997 12 08

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Notes

Show Notes

Slide 1 :

Congestive Heart Failure, Pulmonary Edema, and CPAP James Pointer, MD, FACEP Medical Director Alameda County EMS

Slide 2 :

Objectives Review cardiac physiology and pathophysiology of CHF Early recognition of CHF Management of CHF Use of CPAP

Slide 3 :

Terminology Heart Failure: The inability of the heart to maintain an output adequate to maintain the metabolic demands of the body. Pulmonary Edema: An abnormal accumulation of fluid in the lungs. CHF with Acute Pulmonary Edema: Pulmonary Edema due to Heart Failure (Cardiogenic Pulmonary Edema)

Slide 4 :

Etiology Arteriosclerotic Cardiovascular Ischemia Acute MI Ischemic Cardiomyopathy (Dilated Cardiomyopathy) Hypertension Miscellaneous

Slide 5 :

People Live With Atherosclerosis – But Die of Thrombosis! Arteriosclerotic plaques gradually narrow the coronary arteries, but it is a rupture of the plaque and subsequent platelet aggregation and thrombosis that occludes the artery. Acute Myocardial Infarction

Slide 6 :

Hypertension Hypertrophic Cardiomyopathy

Slide 7 :

Heart Failure - Concepts Frank-Starling Length: Tension Ratio Ejection Fraction Cardiac Output Preload Primarily a venous and diastolic function Afterload Primarily arterial and systolic function

Slide 8 :

Three Pathophysiological Causes of Failure Increased work load (HTN) Myocardial Dysfunction (ASCVD) Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)

Slide 9 :

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

Slide 10 :

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

Slide 11 :

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

Slide 12 :

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

Slide 13 :

Acute Pulmonary Edema a true life- threatening emergency

Slide 14 :

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

Slide 15 :

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

Slide 16 :

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

Slide 17 :

Slide 18 :

EMS Management Sit upright High Flow O2 NTG (If SBP > 100) Diuretics (furosemide) – use care Morphine (base consult) Ventilatory Support BVM CPAP intubation/ventilation

Slide 19 :

CPAP - 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.

Slide 20 :

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.

Slide 21 :

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

Slide 22 :

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

Slide 23 :

Patient, age > 8, in severe respiratory distress who meets one of the following criteria: Medical history and presenting complaints consistent with cardiogenic pulmonary edema Near drowning Prehospital Indications - Patient Assessment

Slide 24 :

Absolute Contraindications Age < 8 Respiratory or Cardiac Arrest Agonal Respirations Severely depressed LOC Systolic Blood Pressure < 90 Pneumothorax Major Trauma, esp. head injury with increased ICP or significant chest trauma Facial Anomalies (e.g. burns, fractures) Vomiting

Slide 25 :

Relative Contraindications History of Asthma/COPD History of Pulmonary Fibrosis Decreased LOC Claustrophobia or unable to tolerate mask (after initial 1-2 minutes)

Slide 26 :

Complications Hypotension Pneumothorax Corneal Drying

Slide 27 :

Using the Machine Turn all three control knobs fully clockwise to the OFF position Turn the ON/OFF valve counter-clockwise to the ON position Turn the Flow Adjustment Valve about 5 complete turns counter-clockwise to the completely open position to provide full flow. Turn the Oxygen Control Valve 5 complete turns counterclockwise (50-60% 02). on/off Flow O2 You may deliver higher oxygen concentrations (up to 100%) by turning the valve farther counterclockwise. In the closed position (completely clockwise) the unit will deliver a minimum 28-29% oxygen to the patient. Verify that air is flowing to the mask. Leave the oxygen and flow controls as you have just set them, then turn the ON/OFF valve fully off (clockwise).

Slide 28 :

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 chest wall movement demonstrates improved respiratory excursion.

Slide 29 :

Important Points (cont.) 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

Slide 30 :

CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Does not require sedation Comfortable Intubation Invasive Usually don’t extubate in field Potential for infection Traumatic

Slide 31 :

CPAP Study 1996 – 1997 1997 – 1998 September – May September – May Intubated 22 8 CPAP 0 50 Hospital Stay(d) 14.8 8 ICU Admission 100% 48%

Slide 32 :

Alameda County Data 22 Patients 19 lived / 3 died / 2 patients to ICU Respiratory Rate: Range: 42 - 16 / Mean Change: 7.25 (n=16) SPO2: Range: 30 - 100 / Mean Change: 19.5 (n=18) RDS: Range: 10 - 3 / Mean Change: 4 (n=15) Unable to obtain RDS in 2 patients 2 pts intubated / 1 intubated pt died

Slide 33 :

Alameda County CPAP Policy

Slide 34 :

Summary CPAP provides an adjunct between oxygen by NRB mask and endotracheal intubation Eliminates trauma of intubation Reduces length of hospital stay Reduces costs of care

Slide 35 :

	SlidesOnline 1 Years ago. Category: Cardiology

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