Pulmonary oedema and acute heart failure

Question 1

Which A-E does this affect?

Answer 1

Breathing

Question 2

Airway

Answer 2

Is the patient vocalising? Look for any obstruction of airway, any sputum

Question 3

Breathing

Answer 3

Look for signs of respiratory distress, use of accessory muscles, cyanosis

Auscultate lungs paying attention to bases – crackles and wheeze à pulmonary oedema

Feel for symmetrical chest expansion, tracheal deviation and percuss lung fields

O2 sats, RR – if hypoxic – sit the patient up and put on 15L O2 via NRB

ABG and CXR (signs of heart failure and specifically pulmonary oedema)
- CXR: ABCDEF
- Alveolar oedema, Kerley B lines, Cardiomegaly, Upper lobe diversion, bilateral pleural effusions, fluid in horizontal fissure

Management

1. Sit the patient up
2. Oxygen 15 L via NRB mask - aim 94%
3. Furosemide 40-80 mg
   -If already on diuretic, consider giving higher dose than what they are already on, Further doses as required
   - If very unstable may use a low dose on cardio advice, then increase once BP improves
4. IV 1.25-5 mg Morphine (venodilator so will increase pre load and help with breathing)
5. GTN - if SBP > 90

Escalate

1. Nitrates infusion (with senior opinion)
2. CPAP (be wary of hypotention, only in Type 1 RF)
3. Intra-aortic ballon pump (if cardiogenic shock)
4. Intubation and ventilation

Question 4

Management of AHF

Answer 4

Question 5

Management of PO

Answer 5

Question 6

Circulation

Answer 6

Look for scars on chest, raised JVP
- ↑ JVP , Pitting ankle or sacral oedema, Tender smooth hepatomegaly, ascites

Auscultate heart sounds, any murmus?
S3 gallop rhythm - filling against a stiffened ventricle

Feel for CRT, character of pulse, sacral and pedal oedema

HR, BP

IV access and bloods – FBC, LFTs, U&Es, CRP, troponin, BNP, cholesterol, HbA1c

ECG and bedside echo if possible

If BP not low consider GTN infusion

USE NEY YORK HEART ASSOCIATION CLASSIFICATION

Question 7

Disability

Answer 7

GCS, PEARL, BM

Question 8

Exposure

Answer 8

Temperature, lines, scars, calves, urine output – put catheter – strict input output chart, fluid restrict patient and reassess

Long-term:
ACEi, Beta Blockers, mineralocorticoid antagonist (ARB), SGLT-2 inhibitor

Question 9

Management overall HF

Answer 9

Question 10

Management overall PO

Answer 10