!!!pulmonary edema!!! Flashcards
A 72 year old lady has been referred to the medical team with worsening shortness of breath.
It has been getting worse over the last two weeks and is associated with worsening lower limb oedema.
Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrilation and a previous Deep vein Thrombosis.
Her medication includes Amlodipine 10mg OD, Furosemide 40mg BD, Ramipril 10mg OD, Atorvastatin 80mg OD, Bisoprolol 5mg OD.
She is a known smoker.
The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.
what did you miss out on AE
in C - JVP elevation
E =any signs of peripheral edema
differentials ?
congestive heart failure
PE
infection
pneumothorax
pulmonary hypertension
ANAPHYLAXIS
COPD
investigations you missed out on ?
ECHO when patient is more stable
CXR signs of pulmonary edema ?
prominent hila
more interstitial shadowing
pleural effusion
kerley b lines
cardiomegaly may or may not be present
patient has pulmonary oedema secondary to decompensated heart failure. How will you manage this patient?
make sure the patient is sitting upright and start high flow oxygen
I would secure venous access and give a stat dose of IV furosemide. This is for symptomatic relief.
I would insert a urinary catheter to monitor urine output and
start the patient on a fluid restriction.
If there is little or no response to the initial dose, the dose should be doubled at two-hour intervals as needed up to the maximum recommended doses.
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Vasodilator therapy is recommended for patients with urgent need for afterload reduction (eg, severe hypertension). It is also recommended as an adjunct to diuretic therapy for patients without adequate response to diuretics. Therefore, based on the response to the above and if the SBP is >90 mmHg and the patient does not have aortic stenosis, then I could start an IV infusion of GTN and titrate the dose against the BP.
What could be the cause for this patient’s decompensation?
Chronic stable heart failure may easily decompensate.
This most commonly results from an intercurrent illness (such as pneumonia),
myocardial infarction (a heart attack),
cardiac arrhythmias (such as AF),
uncontrolled hypertension,
or the person’s failure to maintain an adequate fluid restriction, diet, or a lack of compliance with medication.
classifications of heart failure?
The New York Heart Association (NYHA) functional classification
NYHA Class Symptoms
I Cardiac disease, but no symptoms and no limitation in ordinary physical activity,
II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.
IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
Because functional capacity is such a powerful determinant of outcome it remains arguably the most important prognostic marker in routine clinical use in heart failure today.
What medications improve morbidity and mortality in patients with heart failure?
Angiotensin converting enzyme (ACE) inhibitor and single-agent angiotensin receptor blockers (ARB),
In addition, beta-blockers and mineralocorticoid receptor antagonists (such as Spironolactone) have also been shown to reduce morbidity and mortality in these patients with heart failure with reduced ejection fraction.
They should be up titrated to the highest tolerated dose.
