Day 2 - Congestive Heart Failure

Acute Congestive Heart Failure

History:

  • Shortness of Breath

  • Orthopnea

  • Paroxysmal nocturnal dyspnea

  • Peripheral Edema

  • Assess for Etiologies of CHF: ACS, PE, Tamponade, Excess Salt Intake, Medication non-adherence, Infection (including IE), Arrhythmia

Clinical Exam:

  • Vitals: Tachycardia, hypoxia, tachypnea

  • Cardiovascular Exam: Presence of S3, Elevated JVP

  • Respiratory Exam: Bibasilar crackles, cardiac wheeze

  • Abdominal Exam: Positive abdominojugular reflex

  • Peripheral Edema

Work Up:

  • ECG

  • Troponin

  • Electrolytes, Creatinine

  • BNP - >250 + LR of 4.6

  • Echocardiogram

CHFexac.jpg

Chest X-Ray Findings of Congestive Heart Failure

Figure 1: Chest X-Ray findings of Congestive Heart Failure (source: Relias Media: Volume Overload: Acute Decompensated Heart Failure in the Emergency Department)

Figure 1: Chest X-Ray findings of Congestive Heart Failure
(source: Relias Media: Volume Overload: Acute Decompensated Heart Failure in the Emergency Department)

  1. Vascular Redistribution/Cephalization

  2. Pleural Effusions

  3. Pulmonary Edema

  4. Curly B Lines

  5. Increased Cardiac Silhouette >50% of thoracic width

  6. Bronchial Cuffing

Treatment:

  1. Diuresis - Lasix 2.5x home dose - IV administration (DOSE trial)

    • Home dose: Lasix 40mg PO BID, administer Lasix 40-60mg IV BID

    • Renal failure necessitates higher IV Lasix dosing

  2. Hypertensive? - Add nitro patch for increased renal perfusion

  3. Monitor Urine Output

  4. Oxygen support

    • BiPAP for increasing work of breathing

The Intern at Work -