1. Approach to Congestive Heart Failure and Vascular Emergencies Dan O’Donnell 9/12/06

2. What Are we Going to Talk About A little bit of everything Discuss some of the causes and treatment of pulmonary edema Explain why those D&@m ER docs want us to keep using nitrates all of the time D&@m What to do when the big vessels get into trouble How bad Michigan is going to beat on ND

3. Case #1 Called to respond to “Difficulty Breathing” Find a 68 y/o male with known hx of CAD and other “water problems” diaphoretic speaking in one-two word sentences PMHx: CAD, HTN Meds: Doesn’t know and hasn’t been taking them

4. PE Gen: Patient in distress Gen: Patient in distress P 125, BP 255/135, SaO2 82% on NRB Lungs: Crackles up to mid lung LE: 3+ Edema

5. Diagnosis Congestive Hear Failure –Secondary to hypertensive emergency

6. Congestive Heart Failure Vascular congestion in either the pulmonary bed, systemic bed, or both. Caused by dysfunction of the heart Resulting in edema in the lungs and or periphery A fluid problem –Either too much or what is there is not being pushed around enough

7. Cardiac Physiology Preload- blood volume available to pump After load- resistance against which pump operates Contractility- intrinsic ability of pump to function If one of these is affected you will have CHF

8. Causes of Increased Pre-Load Medication non-compliance Inability to get rid of fluid –I.E. Renal failure Fluid retention from dietary non- compliance Goal: Get rid of the pre-load

9. Causes of Increased Afterload Remember afterload=resistance Hypertension Some obstruction (I.e. Aortic Stenosis) Goal: Decrease the resistance

10. Causes of Decrease Contractility Causes an inability to respond to increased pre-load and afterload Systolic vs. Diastolic dysfunction Systolic Dysfunction-Not able to push enough forward Diastolic Dysfunction-Not able to relax and fill up

11. Systolic vs. Diastolic Dysfunction SystolicIschemia Infection (myocarditis) Toxic (iron, CO) TraumaDiastolicTamponadeLVHTachycardia –A-fib with RVR Always ask WHY THEY WENT INTO FAILURE???????????

12. Left vs. Right Heart Failure Left Heart Failure SOBCracklesWheezesOrthopnea Coughing up pink frothy sputum Right Heart Failure EdemaJVD Hepatic Congestion

13. Enough O’Donnell Back to our Case Treatment If SBP is 110 mm Hg or Greater administer 0.4mg dose of NTG and repeat every 3-5 minutes as long as the SBP is at or above 110 mm Hg Cardiac Monitor (ischemia?) IV Lasix 40mg slow IVP if SBP 110 or greater

14. Why Do the Docs Love Nitro? Causes relaxation of smooth muscle in vascular beds Decreases preload and afterload Quick and easy fix Dose dependent results Proven to have better results in the long term

15. Always Nitro??? Do Not administer NTG to any patient who has taken Viagra or other ED drugs in the past week

16. Lasix Does increase urine output and can help decrease fluid Theoretical dilation of pulmonary vasculature Takes time to work Not effective if the kidneys don’t work

17. Definitive Treatment Positive Pressure Ventilation Will greatly improve pulmonary edema Oxygen doesn’t really hurt anybody

18. Summary of CHF There are many causes Always ask yourself why they are in CHF –Are they having a big MI Nitro, Nitro, Nitro (except in Viagra, Levitra, Cialis, etc…) Lasix is okay but no need to redose

19. New Case Called for “Abdominal and Back Pain” Upon arrival you find a 62 y/o male with long history of hypertension and “Something wrong with my “Horta” Describe sudden onset of ripping pain in lower back and abdomen for 2 hours

20. PE Patient is diaphoretic and extremely uncomfortable P 132, BP 70/P, Sa02 98% on NRB Abdomen is rigid and you might feel a pulsitile mass Diagnosis?

21. Abdominal Aortic Aneurysm Dilation of the Aorta that can occur anywhere along the Aorta Most commonly below the renal arteries Most commonly found in elderly Risk factors are hypertension, vascular disease, connective tissue problems

23. Presentation of Ruptured AAA Syncope –Occurs from sudden loss of blood flow to the brain Severe back or abdominal pain –Typically sudden onset Sudden death –Usually occurs due to intraperitoneal rupture of the aneurysm

24. Physical Exam Findings A pulsating abdominal mass Abdominal tenderness to palpation Ecchymosis around the umbilicus or on the flanks May have normal distal pulses Hypotension is common

25. Diagnosis History + Physical Exam + Strong Suspicion= Diagnosis

26. Treatment Most important role of EMS and Emergency Physician is rapid diagnosis and transfer to a surgeon for operative repair.

27. What Can We Do Prehospital? Two large-bore IVs Cardiac monitor Oxygen Fluid resuscitation Drive Fast and Safe

28. Summary of AAA High Mortality Combination of history and high suspicion will lead in diagnosis Need surgical repair This person is essentially dying from hemorrhagic shock

29. Case # 3 Dispatched for “Chest Pain” 59 y/o male c/o sudden onset of “tearing” chest pain that began in left chest and radiated to his back Pain is unlike his previous MI PMHx: Hypertension, CAD s/p Stent Meds: Clonidine, Metoprolol, Norvasc, NTG to name a few

30. Case #3 Cont… P 115, BP 200/110, SaO2 94% on RA Sinus tachy on monitor ECG unremarkable CV: Tachy no M/R Lungs: CTA B Abd: Soft, NT, ND

31. En Route Pain suddenly worsens and he feels it moving down his back You note

32. En Route Cont… Patient becomes unconscious and goes into PEA What besides AMI happened?

33. Aortic Dissection May occur anywhere along the aorta Most common site is in the chest just past the origin of the left subclavian artery Occurs when a tear in the lining of the aorta allows blood to get in between layers of the vessel

35. Predisposing Factors for Dissection HypertensionHypertension Hypertension (notice a trend here?) Connective tissue disease (i.e. Marfan’s) Pregnancy Congenital heart disease Trauma

36. Presentation 90% of patients present with sudden onset of severe, tearing chest pain radiating to the back. May have stroke symptoms –Occurs when dissection includes origin of carotid arteries May have paraplegia –Occurs when dissection includes origin of spinal arteries

38. Physical Exam May have a normal exam Findings are related to ischemia from disruption at the origin of aortic branches. Diagnosis requires imaging –Angiography or CT scan

39. Prehospital Treatment Two large bore IVs Oxygen Cardiac Monitoring Rapid transport Aggressive blood pressure control May require surgery

40. Summary Aortic Dissection can present in many ways Diagnosis often lies in the history Treat similar to ruptured AAA prehospital

41. Questions?