Emergency - Severe pulmonary oedema Flashcards
What are the features of pulmonary oedema on a CXR?
- Bat’s wing appearance (bilateral shadowing indicating oedema)
- Kerley B lines (fluid in the septal lines)
- Fluid in interlobar fissures
- Small effusions at costophrenic angles
- Upper lobe diversion (increased blood flow to the superior parts of the lung)
- Cardiomegaly
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Do patients have to have an existing diagnosis of heart failure to be diagnosed with acute heart failure?
Acute heart failure (AHF) is life-threatening emergency. AHF is a term used to describe the sudden onset or worsening of the symptoms of heart failure, particularly acute left ventricular failure.
It may present with or without a background history of pre-existing heart failure. AHF without a past history of heart failure is called de-novo AHF. Decompensated AHF is more common (66-75%) and presents with a background history of HF.
Name some common triggers for acute heart failure.
- Iatrogenic (e.g. aggressive IV fluids in frail elderly patient with impaired left ventricular function)
- Sepsis
- Myocardial Infarction
- Arrhythmias
What are the symptoms of acute heart failure?
- Acute SOB worse on lying flat
- Cough with frothy pink sputum
- Distressed, sweaty and feeling very unwell
Symptoms related to underlying cause:
- Chest pain in ACS
- Fever in sepsis
- Palpitations in arrhythmias
What are the signs of acute heart failure?
General exam - usually sitting up and leaning forward
- B - tachypnoea, reduced oxygen sats, bibasal fine lung crackles +/- wheeze
- C - tachycardia, hypotension in severe cases (cardiogenic shock), S3 heart sound
- In right sided HF - raised JVP, peripheral oedema
Which investigations would you request if you are suspecting acute heart failure? What are you looking for?
- B
- ABG - type 1 resp failure?
- CXR - pulmonary oedema?
- C
- ECG - ischaemia? arrhythmia?
- Bloods
- FBC - infection?
- U&Es - diuretics
- CRP - infection?
- Troponin - MI?
- BNP - raised in HF
- Further investigations - ECHO
Would you wait for BNP/ECHO to confirm acute left ventricular failure before treating?
NO
What does a high BNP tell you?
- Testing for BNP is sensitive but not specific
- BNP can be raised in:
- Heart failure
- Sepsis
- Pulmonary embolism
- Renal impairment
- COPD
What is BNP?
BNP is a hormone that is released from the heart ventricles when the myocardium is stretched beyond the normal range
The action of BNP is to relax smooth muscle in blood vessels to reduce the systemic vascular resistance
How should acute heart failure be immediately managed according to A-E?
- B - sit patient upright, 15L high-flow oxygen via non-rebreather
- C - check BLOOD PRESSURE and manage accordingly
- Alert senior
If normotensive/hypertensive:
- Stop any IV fluids
- IV furosemide 40mg STAT + monitor fluid balance with daily weight, urine output and U&Es
- GTN spray 2 puffs
If hypotensive - this is cardiogenic shock!
- ITU referral - CPAP/NIV/intubation and inotropes may be required
What further management steps should be considered if IV furosemide and 2 GTN puffs does not help symptoms?
- IV nitrates
- IV morphine + anti-emetics
- CPAP
Symptoms/Signs of acute heart failure + Hypotension
What are you worried about?
CARDIOGENIC SHOCK