Slides chf jsw
Transcript of Slides chf jsw
65 y/o SOB Hypotensive
CHF
J. Scott Wieters MD FAAEM Assistant Professor Emergency Medicine
Texas A&M University Health Science CenterScott and White Hospital, Temple, TX
Anything but a dry topic…
Objectives
“Learn you fools bout CHF”
Epidemiology
•5 million Americans •2.3% of general public •35% die in 2 yrs 80% at 6 yrs •1 million admits each year •Costs $27.9 billion •Chance to hear a CHF lecture.....
•Priceless....
How’d you get it?
Classifications?
•Left v. Right sided? •High v. Low output? •Ischemic v. Nonischemic? •Systolic v. Diastolic? •NY class I-IV?
CHF The Big Picture
Big Picture
•Preload •Afterload •Renin Angiotensin •Pulmonary edema •Cardiogenic Shock
Systolic?
or
Diastolic?
Low vs High?
ACE-Inhibitors
•Afterload Reduction •First Dose Hypotesion?
•Hypertensive HF 48% •Rapidly SOB •Minimal weight gain/edema
•Normotensive HF 48% •Progressive Weight gain, edema,
•Hypotensive HF 3% •Cardiogenic shock
Initial Presentation
specifisc
27
28
29
30
31
I Wanagetta BNP
• <100- prob not CHF •100-500 not sure what to do? •>500- probably CHF
False High BNP?
False LOW BNP?
False Positive (falsely high) BNP False Negative (falsely low) BNP
Left ventricular hypertrophy Obesity
Ischaemia Treatment with heart failure drugs
Tachycardia
Hypoxaemia including pulmonary
embolismRenal impairment (GFR<60 ml/
min)Sepsis
COPD
Diabetes
Age>70 years
Liver cirrhosis
Treatment Options
•BIPAP/CPAP •Nitrates •Lasix •ACE-I
L MN OP
Lasix MorphineNitratesOxygen Pressure
P O N D
Pressure Oxygen Nitrates Diuresis
NIPPV
•Reduces: •Preload/Afterload •BP •Work Of Breathing •Intubation rate •Mortality*
Nitrates
•Stop dicking around! •Reduce preload •Afterload red. at higher doses •Nitrates better than Lasix
What Dose?
• One tablet = 80mcg/min
ACE-Inhibitors
•Afterload Reduction •First Dose Hypotesion?
Nesiritide
•VMAC trial •No reduction in mortality •Just Say No...
AusNn MarNn Vanquish. $279,999
Lasix
•Mod/Severe helpful •Nitrates better than Lasix •Monotherapy? Really?
•Renal Failure •NO Mortality benefit
Beta Blockers
•Really no role in ADCHF
CRASHING CHF
Crashing ADCHF
•Airway? •Rhythm? •Circulation
•Perfusion of vital organs
Crashing ADCHF
•Hypotensive <100? •Dopamine 2-20mcg/kg/min •Dobutamine 2.5-20mcg/kg/min
•Still <70? •Norepi 4 -12 mcg/min •CATH lab for IABP?
Post test CHF
Twitter Email@jscottwieters [email protected]