LEFT VENTRICULAR FAILURE

AND PULMONARY OEDEMA

Compiled and Presented by: Louis van Rensburg (ALS Paramedic)

Dispatch Details• On Saturday, 01 November 2014, we were

dispatched to Cedile str Kwanonqaba for SOB.

• On arrival, we found a 82-year old male; sitting upright in bed , pillows stacked behind him.

• Patient found to be anxious and tachyapnea.

Further History•S - Dyspnea/Tachyapnea/Mild

Diaphoresis •A - None•M - Pharmapress, Amtas, Simvistatin,

Furosemide, Budaflem and Asthavent(compliant)

•P – Been in Hospital 1 week before.•L – 16h00•E – Patient became progressively SOB

during last week. Patient complains of exhaustion on mild exertion.

On Examination• Vital signs: Bp, 125/73 mmHg; Pulse 124;

Respiration Rate 22

• A: Patent, Audible gargling present• B: Laboured breathing with bi-lateral crackles in

all lung fields. SpO2, 45% on RA(FiO2 of 0.21). • C: Mild Diaphoresis, Weak Bi-lateral pulses

(122bpm),ECG: sinus tachy

• CNS: GCS 15/15, patient full compesmentace.• General: Pedal oedema and General Body Oedema

Management

• A: None, just monitor to prevent sudden deterioration.

• B: Monitor Spo2(Is it reliable?), Provide additional O2 what would be effective?

• C: IV and ECG monitoring• HGT – 5.1mmol/L• Nitro-lingual spray/tablet – 1X spray/tablet• Furosemide – 40mg (0.5-1mg/kg)• Transported patient to hospital (Preferred

Position)

Pathophysiology of LVF•LEFT VENTRICULAR FAILURE when left

ventricle fails to pump blood successfully.

•Backpressure of blood causes pooling into pulmonary circulation.

•Unmanaged-Acute Pulmonary oedema

Causes of LVF•Myocardial Infarct •Valvular heart disease•Rapid AF (Why?)•Hypertensive heart disease

Management•Emergency treatment aimed at

▫Improving oxygenation and ventilation▫Decreasing the venous return▫Decreasing myocardial oxygen demand▫Improving myocardial contractility▫Off-Loading the ventricles

Management• Oxygen

▫40% Face mask▫Non-rebreather▫Bag valve mask ventilation▫Intubate and ventilate with PEEP

• Nitrates▫Spray sublingually or tablets▫Reduces preload and afterload ▫Improves myocardial oxygen delivery▫Most of the treatment benefits come from

aggressive use of nitroglycerine

Management•NitratesoOur current treatment protocol allows up

to 3 sublingual nitroglycerins as long as systolic blood pressure is greater than 90mmHg

oEvidence suggest that best combination is high dose nitrates plus low dose furosemide for acute cardiogenic pulmonary edema (“BestBETs”)

Management• Furosemide

▫Dilating effect on venous system ▫Diuretic effect reduces intravascular vol▫Has a questionable role in the prehospital

treatment of ACPE. It may help slightly in obvious cases but may be harmful to those misdiagnosed

• Morphine▫Decrease venous return▫Reduces anxiety▫Little effect on mortality and may increase the

intubation rate

CONCLUSION Diagnosis and treatment of CCF remain

important and challenging and the utilization of available sources and sound understanding of the pathophysiology and pharmacotherapy can produce rewarding results when caring for this frequently encountered and ever challenging, diverse patient group.