Heart Failure

EMS Professions
Temple College
 Heart Failure
Inability of heart to pump blood out as
rapidly as it enters

Often referred to as congestive heart

failure (CHF)
 Congestive Heart Failure
Congestion of pulmonary or systemic
circulation (backward failure)

Reduced output to body tissues

(forward failure)
 Causes
 Diffuse coronary artery disease
» Myocardial ischemia
 Myocardial infarction
 Arrhythmias
» Tachycardia
» Bradycardia
 Causes
 Valvular heart disease
 Acute Hypertensive Crisis
 Chronic Hypertension
 Idiopathic Causes
 CHF
May develop acutely or may be a
chronic disease

Acute Onset CHF: Suspect

»Acute MI
»Dysrhythmia
»Hypertensive Crisis
 CHF
 Chronic CHF may worsen acutely from:
» Respiratory infection
» Pulmonary embolism
» Emotional stress
» Increased salt and water intake
Congestive Heart Failure

Left sided
Right sided
Biventricular
 Left-Sided Heart Failure
 Left ventricle fails as effective pump
 Left ventricle cannot eject blood
delivered from right heart through
pulmonary circulation
 Blood backs up into pulmonary
circulation
 Left-Sided Heart Failure
 Increase pressure in pulmonary
capillaries forces blood serum out of
capillaries into interstitial spaces and
alveoli
 Increase respiratory work and
decrease gas exchange occur
 Left-Sided Heart Failure
 Common causes
» ACUTE MI
 especially if involves left ventricle
» Chronic hypertension
» Dysrhythmias
 especially tachydysrhythmias
 Left-Sided Heart Failure

Pulmonary Signs/Symptoms
 Left Heart Failure Symptoms
 Dyspnea on exertion
 Paroxysmal nocturnal dyspnea
 Orthopnea
 Fatigue, generalized weakness
 Left Heart Failure Signs
 Anxiety, confusion, restlessness
 Persistent cough
» Pink, frothy sputum
 Tachycardia
 Tachypnea
 Noisy, labored breathing
» Rales, wheezing (“cardiac asthma”)
 Cyanosis (late)
 Third heart sound (S3)
 Right-sided Heart Failure
 Right ventricle fails as effective pump
 Right ventricle cannot eject blood
returning through vena cavae
 Blood backs up into systemic
circulation
 Right Heart Failure
 Increased pressure in systemic
capillaries forces fluid out of
capillaries into interstitial spaces
 Tissue edema occurs
Right Heart Failure Causes

Most Common Cause:

Left sided Heart Failure
 Right Heart Failure Causes
 Others
» Chronic hypertension
» COPD (cor pulmonale)
» Pulmonary embolism
» Right ventricular infarction
Right-Sided Heart Failure

Systemic Signs/Symptoms
 Right Heart Failure
Signs/Symptoms
 Tachycardia
 Jugular vein distension
 Pedal, pre-tibial, sacral edema
 Hepatomegaly
 Splenomegaly

Classic Triad of Right Ventricular Failure:

JVD, Hypotension, Clear Lungs
 Right Heart Failure
Signs/Symptoms
 Anasarca (generalized edema)
 Fluid accumulation in body cavities
» Ascites
» Pleural effusion
» Pericardial effusion
Management of Heart Failure
 Goals of Management
 Improve oxygenation, ventilation
 Decrease venous return to heart
 Decrease cardiac work, O2 demand
 Improve cardiac output by
» Reducing afterload
» Increasing myocardial contractility
 Management
 Sit patient up, dangle feet
» Do not lay flat
 Oxygen by non-rebreather mask
 Consider positive pressure ventilation
 Management
 Consider intubation if:
» O2 saturation cannot be kept >90% on
100% O2
» PaO2 cannot be kept >60 torr on 100 % O2
» Patient displays signs of worsening
cerebral hypoxia
» PaCO2 progressively increases
» Patient becoming exhausted
 Management
 Monitor ECG
» Hypoxia, increased heart wall tension
leads to dysrhythmias
 IV NS TKO via microdrip or lock
» Limit Fluids
» If RVF only, fluid challenges to 
preload
 CHF First Line Drug Therapy
 Nitroglycerin
» 0.4mg SL q 5 min prn
» Systolic BP should be > 90 - 100 mm Hg
» Nitrate therapy before IV is started
» Reduces preload/afterload
» Improves coronary artery perfusion
» Caution in RVF
 NTG, Lasix or MS may worsen hypotension
 Use inotropes if fluid does not improve BP following
NTG administration
 CHF First Line Drug Therapy
 Furosemide (Lasix®) -
» 40 mg (0.5 - 1 mg/kg) slow IV
 Patients already on furosemide may have tolerance
 Increase dose to 2X daily oral dose
» Direct vasodilation leads to decreased venous return
» Diuresis leads to decreased intravascular volume
» May cause hypokalemia, dysrhythmias
 especially dangerous if patient on digitalis
» May worsen hypotension in RVF
 CHF First Line Drug Therapy
 Morphine Sulfate
» 2 mg IV push slowly q 10-15 min
» Peripheral vasodilation leads to
 Decreased preload
 Decreased afterload
» Decreased venous return leads to
 Decreased cardiac work
 Decreased O2 demand
» Decreased anxiety
 Decreased release of catecholamines
» Monitor Ventilations and BP
 Systolic BP should be > 90 - 100 mm Hg
 CHF Second Line Therapy
 Dobutamine
» 2 - 20 mcg/kg/min
» Potent 1 stimulation
 Increases contractility
 Increases level of cardiac output
» Drug of choice if systolic BP >100 and
diastolic BP <110
 CHF Second Line Therapy
 Nitroglycerin
» 10 mcg/min increased by 5-10 mcg/min q 5
min
» Vasodilation
 Decreased venous return leads to
» Decreased cardiac work
» Decreased O2 demand
 Decreased afterload leads to increased cardiac
output
 CHF Third Line Drug Therapy
 Bronchodilators (beta agonists)
» May be useful if wheezing is present
» Mild peripheral vasodilator
» Myocardial and respiratory stimulant
» May cause arrhythmias in hypoxic patients
or those with coronary artery disease
 CHF Management
 What if the BP is too low for the first and
second line drug therapies?
» BP < 70 mm Hg
 norepinephrine, 0.5 - 30 mcg/min IV infusion
» BP > 70 but < 100 mm Hg
 dopamine, 5 - 15 mcg/kg/min IV infusion
 After BP improves, treat pulmonary edema
with first and second line therapies
 CHF Management
 Long Term Management usually includes
» Fluid minimization
 Diuretics (+ Potassium if non-potassium sparing)
 Diet restrictions
» Increase contractility
 Digitalis
» Blood pressure control
 ACE Inhibitors
» Coronary artery perfusion
 Nitroglycerin
Cardiogenic Shock
 Cardiogenic Shock

Diminished cardiac output leading to

impaired tissue perfusion

Most extreme form of pump failure

 Cardiogenic Shock
 Occurs in about 15% of acute MI patients
 Usually occurs when 40% or more of the
left ventricular muscle mass infarcts
 Mortality is 85% or more with treatment
 Signs/Symptoms
 Confusion, restlessness, anxiety,
stupor, coma
 Cool, clammy skin
 Pallor
 Weak or absent extremity pulses
 Tachycardia
 Slow or absent capillary refill
 Signs/Symptoms
 BP < 90 systolic or > 30mmHg below
normal
» BP is NOT the same as perfusion
» Shock can be present with a “normal” BP
» Evaluate signs of peripheral perfusion in
addition to BP
 Cardiogenic Shock

Very difficult to assess in presence

of arrhythmias, hypovolemia,
decreased vascular tone
 Cardiogenic Shock
 Treatment Priorities:
» Rate
» Rhythm
» BP (Volume, Pump/Vascular tone)
 Correct major disorders of rate,
rhythm before directly treating BP
 Goals of Management
 Improve oxygenation and peripheral
perfusion
 Avoid increasing cardiac workload
» myocardial oxygen demand
 Management
 Primary assessment & Focused Hx
 Identify source of problem
» Acute pulmonary edema
» Volume problem
» Pump problem
» Rate problem
 Acute Pulmonary Edema
 First line interventions
» IV/O2/ECG Monitor
» If BP > 90-100 mm Hg:
 furosemide 0.5 – 1.0 mg/kg slow IV (or twice
patient’s single daily dose up to 120 mg)
 Morphine 2 – 10 mg slow IV
 Nitroglycerin 0.4 mg SL
» If BP < 90 mm Hg:
 Vasopressors based on SBP
 Volume Problem
 IV/O2/ECG Monitor
 Fluid challenge until rales or if
evidence of anterior wall AMI
 Vasopressors based on SBP
 Pump Problem
 IV/O2/ECG Monitor
 SBP <70 mmHg:
» norepinephrine 0.5 – 30 mcg/min IV inf
 SBP 70 – 100 mm Hg & shock
» dopamine 5 – 15 mcg/kg/min IV inf
 SBP > 100 mm Hg w/o shock
» dobutamine 2 – 20 mcg/kg/min IV inf
 Management
 Keep patient supine
» Difficult in presence of pulm edema
» Do not elevate lower extremities
 Oxygenate via NRB
 Consider assisting ventilations
» Decrease work of breathing may benefit
patient in shock
» Consider intubation
 Monitor ECG
 Management
 IV TKO with microdrip set or lock
» Limit fluids unless suspect RVF
 Correct major disorders of rate, rhythm
» Increase rate in bradycardias
» Terminate tachycardias with cardioversion
» Suppress frequent ectopic beats
 Management
 If rate/rhythm adequate, treat BP
» Consider fluid challenge of 250cc LR
over 10-15 minutes if relative or absolute
hypovolemia possible, including RVF
and NO pulmonary edema
» Avoid use of vasopressors until volume
deficits corrected or pulmonary edema
presents
 BP Treatment Review
 If rate, rhythm, volume adequate,
treat BP with vasopressors:
» Norepinephrine, or
» Dopamine
 Norepinephrine
 0.5 - 30 mcg/min
 Inotropic and vasoconstrictive properties
 Can be used if systolic BP < 70
 If systolic BP > 70, use dopamine instead
 DO NOT use until hypovolemia corrected
 DO NOT allow infiltration
 Dopamine
 2 - 20 mcg/kg/min
» Place 200 mg/250cc of D5W
» Begin at 5 mcg/kg/min
» In 2 - 10 mcg/kg/min range,  effects dominate
» > 20 mcg/kg/min  effects dominate
» Use lowest dose that produces good perfusion
 Use as initial vasopressor if BP 70-100 systolic
» If dopamine infusion rate is > 20 mcg/kg/min use
norepinephrine
 Dopamine
 May cause tachycardia, ectopy, nausea
 DO NOT use until hypovolemia is
corrected
 DO NOT allow to infiltrate