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Congestive HeartCongestive HeartFailureFailure

Developed by: Russell K. Miller Jr. MD, FACEPDeveloped by: Russell K. Miller Jr. MD, FACEPAssistant Professor of Surgery and Internal Medicine The University of Texas Medical Branch GalvestonAssistant Professor of Surgery and Internal Medicine The University of Texas Medical Branch Galveston

Lynn K. Wittwer, MD, MPD

Clark County EMS

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Objectives

Objectives

Overview of CHFOverview of CHF

Review cardiac physiology andReview cardiac physiology and

pathophysiologypathophysiology Early recognition of CHFEarly recognition of CHF

Early and aggressive management of CHFEarly and aggressive management of CHF

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Heart FailureHeart Failure The inability of the heart to maintain an outputThe inability of the heart to maintain an output

adequate to maintain the metabolic demands of theadequate to maintain the metabolic demands of thebody.body.

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Pulmonary EdemaPulmonary EdemaAn abnormal accumulation of fluid in the lungs.An abnormal accumulation of fluid in the lungs.

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CHFCHF Pulmonary Edema due to Heart FailurePulmonary Edema due to Heart Failure

(Cardiogenic Pulmonary Edema)(Cardiogenic Pulmonary Edema)

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EpidemiologyEpidemiology .3/1000 < 45.3/1000 < 45

3/1000 453/1000 45--6565

10/1000 >6510/1000 >65

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StatisticsStatistics US Health and Human Services.US Health and Human Services.

5 million Americans suffer from CHF.5 million Americans suffer from CHF. $17.8 billion spent annually.$17.8 billion spent annually.

400,000 new cases reported each year.400,000 new cases reported each year.

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EtiologyEtiologyArteriosclerotic Cardiovascular IschemiaArteriosclerotic Cardiovascular Ischemia

HypertensionHypertension

MiscellaneousMiscellaneous

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ArterioscleroticArteriosclerotic CardiovascularCardiovascular

IschemiaIschemia

Acute:Acute: Myocardial InfarctionMyocardial Infarction

ChronicChronic:: Ischemic CardiomyopathyIschemic Cardiomyopathy

(Dilated(DilatedCardiomyopathy)Cardiomyopathy)

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People Live with AtherosclerosisPeople Live with Atherosclerosis ButBut

Die of Thrombosis!Die of Thrombosis!

The formation,

progression

and rupture of

an

atherosclerotic

plaque

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Occlusion of Proximal Cx

RAO view - Baseline

During Rotational Ablation

Rotastenting of Proximal Cx

RAO view - Baseline

Patient with recent Non Q Wave MI

If randomized to the Invasive ArmWould have been pushed toward

Early CABG

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Patient with Non Q Wave MICath showing degenerated vein

graft anastomosis and distal LAD

High risk for intervention because

depressed EF and occluded native

coronary arteries

Angiographic results post

Rotablator assisted stenting

of the anastomosis and distal LAD.

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HypertensionHypertension Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy

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Morbidity & MortalityMorbidity & Mortality

Dramatically Affects: Quality & Length of LifeDramatically Affects: Quality & Length of Life

5 Year Mortality: Males5 Year Mortality: Males 62%62%

FemalesFemales 42%42%

6 Year Mortality: Both Sexes6 Year Mortality: Both Sexes 75%75%

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PhysiologyPhysiology FrankFrank--StarlingStarling

Length: Tension RatioLength: Tension Ratio

Ejection FractionEjection Fraction End diastolic volume/end systolic volumeEnd diastolic volume/end systolic volume

Cardiac OutputCardiac Output Stroke volume x heart rateStroke volume x heart rate

PreloadPreload

Volume of blood delivered to heart during diastoleVolume of blood delivered to heart during diastole AfterloadAfterload

Peripheral vascular resistancePeripheral vascular resistance

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PreloadPreload Primarily a venous and diastolic functionPrimarily a venous and diastolic function

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AfterloadAfterload Primarily arterial and systolic functionPrimarily arterial and systolic function

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Three Pathophysiological Causes ofThree Pathophysiological Causes of

FailureFailure

Increased work load (HTN)Increased work load (HTN)

Myocardial Dysfunction (ASCVD)Myocardial Dysfunction (ASCVD) Decreased Ventricular Filling (Misc.)Decreased Ventricular Filling (Misc.)

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DecompensationDecompensation Increased Pulmonary Venous Pressure (PAWP)Increased Pulmonary Venous Pressure (PAWP)

Interstitial EdemaInterstitial Edema

Alveolar EdemaAlveolar Edema

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Compensatory Mechanisms toCompensatory Mechanisms to

FailureFailure Increased Heart RateIncreased Heart Rate

(Sympathetic = Norepinephrine)(Sympathetic = Norepinephrine)

DilationDilation (Frank Starling = Contractility)(Frank Starling = Contractility)

NeurohormonalNeurohormonal

(Redistribution of Blood to the Brain)(Redistribution of Blood to the Brain)

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CHF Vicious CycleCHF Vicious Cycle

Low OutputLow Output

Increased PreloadIncreased Preload Increased AfterloadIncreased Afterload NorepinephrineNorepinephrine

Increased SaltIncreased Salt VasoconstrictionVasoconstriction Renal Blood FlowRenal Blood Flow

ReninRenin

Angiotension IAngiotension I

Angiotension IIAngiotension II

AldosteroneAldosterone

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SymptomsSymptoms FatigueFatigue

NocturiaNocturia

DOEDOE

PNDPND

GI SymptomsGI Symptoms

Chest PainChest Pain

OrthopneaOrthopnea

Profound DyspneaProfound Dyspnea

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Acute PulmonaryAcute PulmonaryEdema is a true LifeEdema is a true Life

ThreateningThreateningEmergency for whichEmergency for whichthe clinical picture isthe clinical picture is

hard to forget!hard to forget!

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Laboratory FindingsLaboratory Findings CXRCXR -- Single most useful clinical toolSingle most useful clinical tool

EKGEKG -- Non SpecificNon Specific

LabLab -- Non SpecificNon Specific

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Physical ExamPhysical Exam AnxiousAnxious

PalePale

ClammyClammy

DyspneaDyspnea

TachypneaTachypnea

ConfusionConfusion

EdemaEdema HypertensionHypertension

DiaphoreticDiaphoretic

RalesRales

RonchiRonchi

TachycardiaTachycardia

SS33 GallopGallop

JVDJVD

Pink Frothy SputumPink Frothy Sputum

CyanosisCyanosis Displaced PMIDisplaced PMI

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Precipitating CausesPrecipitating Causes Non Compliance with Meds and DietNon Compliance with Meds and Diet

Acute MIAcute MI

ArrhythmiaArrhythmia

PneumoniaPneumonia

Increased Sodium Diet (Holiday Failure)Increased Sodium Diet (Holiday Failure)

AnxietyAnxiety

PregnancyPregnancy

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EMS ManagementEMS Management Sit uprightSit upright

High Flow OHigh Flow O22 NTG (If SBP > 100)NTG (If SBP > 100)

Diuretics (Lasix)Diuretics (Lasix)

Rotating Tourniquets (Controversial)Rotating Tourniquets (Controversial)

Ventilatory SupportVentilatory Support

CPAPCPAP intubation/ventilationintubation/ventilation

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Emergency Dept.Emergency Dept.ManagementManagement

EMS Therapy Plus:EMS Therapy Plus:

MorphineMorphine

DopamineDopamine

DobutrexDobutrex

AntihypertensivesAntihypertensives DigitalisDigitalis

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AntihypertensivesAntihypertensives NitroprussideNitroprusside

ACE Inhibitors (Enalapril)ACE Inhibitors (Enalapril)

Calcium Channel Blockers (Nefedipine)Calcium Channel Blockers (Nefedipine) Beta Blockers (With Caution)Beta Blockers (With Caution)

HydralazineHydralazine

Phosphodiesterase Inhibitors (Amrinone)Phosphodiesterase Inhibitors (Amrinone)

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Chronic CHF TreatmentChronic CHF TreatmentAdjunctive Treatment:Adjunctive Treatment:

Lifestyle changesLifestyle changes

Weight lossWeight loss

Decrease dietary saltDecrease dietary salt

Increase OIncrease O22

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DrugsDrugs Treat causeTreat cause

DiureticsDiuretics

DigitalisDigitalis NTGNTG

AntihypertensivesAntihypertensives

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IntroductionIntroduction

CPAP is a nonCPAP is a non--invasive procedure that is easily appliedinvasive procedure that is easily appliedand can be easily discontinued without untowardand can be easily discontinued without untowardpatient discomfort.patient discomfort.

CPAP is an established therapeutic modality, recentlyCPAP is an established therapeutic modality, recentlyintroduced into the prehospital setting.introduced into the prehospital setting.

In the primary phase CPAP application in cardiogenicIn the primary phase CPAP application in cardiogenicpulmonary edema, thus far, appears to be beneficial topulmonary edema, thus far, appears to be beneficial to

patient outcome.patient outcome.

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Key Points of CPAPKey Points of CPAP

CPAP has been successfully demonstrated asCPAP has been successfully demonstrated asan effective adjunct in the management ofan effective adjunct in the management ofpulmonary edema secondary to congestivepulmonary edema secondary to congestiveheart failure.heart failure.

CPAP may prove to be a viable alternative inCPAP may prove to be a viable alternative inmany patients previously requiring endotrachealmany patients previously requiring endotracheal

intubation by prehospital personnel.intubation by prehospital personnel.

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CPAP MechanismCPAP Mechanism

Increases pressure withinIncreases pressure withinairway.airway.

Airways at risk for collapseAirways at risk for collapse

from excess fluid are stentedfrom excess fluid are stentedopen.open.

Gas exchange is maintainedGas exchange is maintained

Increased work of breathingIncreased work of breathingis minimizedis minimized

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Prehospital IndicationsPrehospital Indications

Congestive Heart FailureCongestive Heart Failure

Pulmonary Edema associated with volumePulmonary Edema associated with volume

overload ( renal insufficiency, iatrogenic volumeoverload ( renal insufficiency, iatrogenic volumeoverload, liver disease , etc)overload, liver disease , etc)

Near DrowningNear Drowning

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Absolute ContraindicationsAbsolute Contraindications

Respiratory ArrestRespiratory Arrest

Agonal RespirationsAgonal Respirations

UnconsciousUnconscious

Shock associated with cardiac insufficiencyShock associated with cardiac insufficiency

PneumothoraxPneumothorax

Facial Anomalies e.g. burns, fractures, etc.Facial Anomalies e.g. burns, fractures, etc.

Facial traumaFacial trauma

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Relative ContraindicationsRelative Contraindications

Decreased L.O.C.Decreased L.O.C.

COPDCOPD

AsthmaAsthma ClaustrophobiaClaustrophobia

Patient Intolerance to equipment (e.g. mask)Patient Intolerance to equipment (e.g. mask)

Tracheostomy (If lacking the adaptor)Tracheostomy (If lacking the adaptor)

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HazardsHazards

Gastric Distention (19 cm HGastric Distention (19 cm H22O pressure)O pressure)

Corneal DryingCorneal Drying

HypotensionHypotension PneumothoraxPneumothorax

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Important PointsImportant Points

Pulmonary edema patients, properly selected,Pulmonary edema patients, properly selected,quickly improve with CPAP in a matter ofquickly improve with CPAP in a matter ofminutes.minutes.

CPAP is to CHF like D50 is to insulin shock.CPAP is to CHF like D50 is to insulin shock.

Visual inspection of chestwall movement revealsVisual inspection of chestwall movement revealsimproved respiratory excursion.improved respiratory excursion.

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Important Points (Continued)Important Points (Continued)

COPD and AsthmaticCOPD and Asthmaticpatientspatients do notdo not respondrespondpredictably to CPAP.predictably to CPAP. They have a higher risk ofThey have a higher risk of

complications such ascomplications such aspneumothorax, and thus shouldpneumothorax, and thus shouldnot be treated in the field withnot be treated in the field withCPAPCPAP

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Study IntroductionStudy Introduction

IRB approval through UTMB.IRB approval through UTMB.

6 hours didactic instruction6 hours didactic instruction Recognize CHFRecognize CHF

Differentiate CHF, COPD, Asthma & Bronchitis.Differentiate CHF, COPD, Asthma & Bronchitis.

2 hours clinical training.2 hours clinical training.

Instruction on assessment most importantInstruction on assessment most important

reason for success.reason for success.

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Data SummaryData Summary19961996 19971997SeptemberSeptember MayMay

Total IntubationsTotal Intubations 2222Hospital StayHospital Stay 14.8 Days14.8 DaysICU AdmissionICU Admission 100%100%

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Data SummaryData Summary19971997 19981998SeptemberSeptember MayMay

CPAPCPAP 5050Total IntubationsTotal Intubations 8 (15%)8 (15%)

-- Primary IntubationsPrimary Intubations 44 (8%)(8%)

-- CPAP FailuresCPAP Failures 44 (8%)(8%)Hospital StayHospital Stay 8 days8 daysICU AdmissionICU Admission 48%48%

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Data ComparisonData Comparison19961996 19971997 19971997 19981998

IntubatedIntubated 2222 88

CPAPCPAP 00 5050

Hospital StayHospital Stay 14.814.8 88

ICU AdmissionICU Admission 100%100% 48%48%

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CPAP vs. IntubationCPAP vs. Intubation

CPAPCPAP

NonNon--invasiveinvasive

Easily discontinuedEasily discontinued

Easily adjustedEasily adjusted Use by EMTUse by EMT--BB

Does not require sedationDoes not require sedation

ComfortableComfortable

IntubationIntubation InvasiveInvasive

Usually dont extubate inUsually dont extubate infieldfield

Potential for infectionPotential for infection

Requires highly trainedRequires highly trainedpersonnelpersonnel

Can require sedationCan require sedation

TraumaticTraumatic

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SummarySummary

CPAP provides an adjunct between oxygen byCPAP provides an adjunct between oxygen byNRB and endotracheal intubation.NRB and endotracheal intubation.

Reduces length of hospital admission.Reduces length of hospital admission. Reduces trauma of intubationReduces trauma of intubation

Reduces costsReduces costs