You get your pateint on the cot and get her outside fast. Your partner gets an IV and you start working on getting another set of vitals. As the oscillometric BP cuff whines to life, you squeeze out 1 inch of nitroglycerin paste onto a piece of wax paper and place it on the left chest. Your partner leans in and delivers 5 sprays of nitroglycerin sublingually.
The Advanced EMT set up the CPAP and the patient applies the mask to herself, with a little assistance to maintain pressure on her face. You secure the mask using the provided straps and make a bee line for the nearest hospital.
The patient reports relief after 5 minutes of CPAP and nitrate therapy, but is still working to breathe. At the hospital, the patient is left on CPAP by the physician and is placed on a NTG drip, along with 40 mg of Lasix to start. When you leave, she is looking much more relieved.
Respiratory emergencies in patients in advanced disease states can be tough calls to handle. They require quick thinking and accurate diagnoses, and definitive action. The differential included many different things: asthma attack, pneumonia, and ADHF (acute decompensated heart failure). Based on her recent and present history as well as the current vitals, ACHF was agreed upon as the most likely culprit, and the treatment reflected it.
Congestive heart failure, basically, is where the heart fails to pump blood out, resulting in a back up of blood into other places of the body. It has many causes primarily resulting from some underlying cardiovascular disease like a previous MI or hypertension with resulting ventricular hypertrophy, to name a few common ones. It is usually divided into four types:
- Left sided heart failure is the most common heart failure. Fluids may be backing up into the lungs.
- Right sided heart failure is where the right ventricle can no longer push enough blood to the left. Fluid backs up into the abdomen and extremites
- Systolic is where the left ventricle is unable to contract forcibly enough to push blood out
- Diastolic is where the left chamber does not fill completely. These patients usually have a normal ejection fraction
This inability to perform results in a fluid back up leading from the heart to other places, most notable the extremities and the abdomen. Pedal edema and ascites is common for chronic heart failure and is not an emergency. Undiagnosed heart failure patients may present with pitting edema and a hard, distended abdomen. They may also present with complaints of exertional dyspnea, inability to lie down, decreased appetite but weight gain, or rapid heartbeats. There are usually well controlled with medications.
Acute decompensated heart failure can have many causes including MI, uncontrolled hypertension, inability for the patient to maintain diet or activity restrictions, dysrhythmias, or illnesses such as pneumonia. Severe decompensation is an immediate life threat and you should work quickly to reverse the respiratory and cardiovascular problems.
You should start with an assessment of the patient including time since onset and past medical history. If the patient is alone, send an extra hand to search out the patient’s medications. Medications such as hypertension medications, diuretics, nitroglycerin, and other cardiac medications can indicate the possibility for ADHF. Physical signs will include JVD, edema, wheezing or rales on auscultation of the lungs, and sometimes a pink frothy sputum will be present when the patient coughs. Of these signs, JVD is considered the most sensitive but should not be the only thing you look for when ADHF is suspected.
So now that we’ve created a differential and our assessment makes us suspect ADHF, immediate treatment should begin to correct immediate life threats. Our quickest and most effective treatment of ADHF with hypertension is nitrates. A patient in severe decompensation should receive both sublingual and transdermal nitroglycerin. The sublingual dose will act much faster and some will recommend that you use 3 or more doses of NTG immediately, this is done to reach a therapeutic level so the paste can take over. Constant BP and ECG monitoring as well as a 12 lead ECG should be done.
This will have a positive effect, but the patient will still need ventilatory support, and for that we fall back upon basic airway skills. CPAP will provide airway pressure, and force the fluid out of the lungs enabling the patient to breathe. If the patient is too tired to breathe anymore, you can provide airway pressure using a BVM. Endotracheal intubation may be required if the patient is unresponsive, CPAP is ineffective, and advanced care is available.
“Assess, decide, act, reassess” are the keys to maintaining a critical patient through to definitive care and a safe discharge home.