Rosen & Barkin's 5-Minute Emergency Medicine Consult (171 page)

• Left-sided CHF:
  
  • Acute exacerbation of COPD
    
  • Asthma exacerbation
    
  • Acute respiratory distress syndrome
    
  • Pneumonia, bronchitis
    
  • Constrictive pericarditis
    
  • Anemia, malnutrition
    
  • Pericardial tamponade
    
  • Coarctation of aorta
    
• Right-sided HF:
  
  • Nephrotic syndrome, chronic renal failure
    
  • Cirrhosis
    
  • Left-side heart failure
    
  • Pulmonary embolism
    
  • Sleep disordered breathing
    
  • Venous stasis
    

TREATMENT

• IV access
  
• Supplemental oxygen
  
• Cardiac monitor and pulse oximetry
  
• EKG
  
• Sublingual nitrates for active chest pain without hypotension
  
• Furosemide
  
• Endotracheal intubation may be required.
  

• IV access
  
• Supplemental oxygen
  
• Cardiac monitor and pulse oximetry
  
• EKG
  
• Elevate head of bed to reduce venous return.
  
• Control airway as needed:
  
  • Noninvasive positive pressure ventilation
    
    • CPAP vs. BiPAP
      
    • Reduce work of breathing, improve oxygenation, decrease need for intubation, possible mortality benefit
      
    • Some studies report higher incidence of MI with BiPAP over CPAP in acute CHF; studies not conclusive
      
  • Intubation for impending respiratory failure
    

• General: Oxygenate, ventilate, treat underlying condition when possible
  
• Congestion with adequate perfusion: Reduce preload, consider fluid restriction
  
  • Rapidly reduce preload in acute pulmonary edema:
    
    • Sublingual or IV nitroglycerin
      
    • Nitro paste
      
    • IV diuretics (less rapid/effective in patients with poor renal perfusion)
      
  • Avoid preload reduction in ADHF when suspected etiology is aortic stenosis, HOCM, or pulmonary hypertension.
    
  • Cautious afterload reduction in ADHF: Avoid ACEi and ARBs in cases of hypotension, acute renal failure, and hyperkalemia.
    
    • Nesiritide
      
  • Limited benefit, may cause hypotension
    
• Poor perfusion with hypotension:
  
  • Agents that increase contractility:
    
    • Dobutamine
      
    • Dopamine
      
    • Milrinone
      
  • Avoid vasodilators (nitrates, morphine)
    
  • Initiate diuretics after inotropes.
    
• Initiate venous thromboembolism prophylaxis in those with ADHF without contraindications
  

• Neonates (1st weeks of life):
  
  • Suspect ductal-dependent cardiac lesions if clinical CHF and no improvement with O
    ₂
    :
    
    • PGE1 to maintain patent ductus
      
• Children:
  
  • IV furosemide, and dopamine or milrinone
    
  • IV nitroglycerin for pulmonary edema
    

• Aspirin: 325 mg PO/PR if AMI is suspected
  
• Bumetanide (Bumex): 1–3 mg IV, max. 10 mg/day
  
• Dobutamine: 2–10 μg/kg/min IV, max. of 40 μg/kg/min
  
• Dopamine: 2–20 μg/kg/min IV, max. of 50 μg/kg/min
  
• Enalapril: 0.625–1.25 mg IV; 2.5–20 mg/d PO
  
• Furosemide (Lasix): No prior use: 40 mg IVP; prior use: Double 24-hr dose (80–180 mg IV); no effect in 30 min: Redouble dose
  
• Milrinone: 50 μg/kg IV load; 0.375–0.75 μg/kg/min IV
  
• Nesiritide: 2 μg/kg bolus, then infusion of 0.01 μg/kg/min
  
• Nitroglycerin: 0.4 mg sublingual; 1–2 in of nitro paste; 5–20 μg/min IV, max. of 100–200 μg/min IV. USE NON-PVC tubing.
  
• Nitroprusside: 0.3–10 μg/kg/min IV (starting dose), max. of 10 μg/kg/min
  

ACEi and ARBs are associated with multiple fetal abnormalities and should be held

• Oxygen
  
• Nitroglycerin
  
• Furosemide
  

FOLLOW-UP

• ICU:
  
  • Pulmonary edema
    
  • Cardiogenic shock
    
  • Concomitant MI or ischemia
    
• Medical wards:
  
  • New-onset CHF
    
  • Symptoms not relieved by ED therapy
    

• Mild exacerbation of chronic CHF:
  
  • Responds to ED treatment
    
  • No other cardiac and pulmonary findings
    
• Close follow-up should be arranged with continuation of diuretic, vasodilator, or ACE inhibitor therapy and patient lifestyle education.
  

Consider ICD and/or BV pacer in advanced HF

• Shown to decrease mortality and hospitalization rates in select patient groups
  

• Close follow-up within 1 wk of discharge
  
• Medication and dietary compliance
  
• Frequent home monitoring of body weight
  
• Monitor electrolytes and renal function during chronic diuretic therapy
  

• BNP may be useful if CHF diagnosis uncertain.
  
• In severe CHF, NIPPV can improve impending respiratory compromise.
  
• Be vigilant in searching for and treating the underlying cause of the heart failure exacerbation (e.g., MI, PE, valvular pathology).
  

• Heart Failure Society of America. Executive summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline.
  J Card Fail
  . 2010;16(6):475–535.
  
• Singer AJ, Birkhahn RH, Guss D, et al. Rapid Emergency Department Heart Failure Outpatients Trial (REDHOTII): A randomized controlled trial of the effect of serial B-type natriuretic peptide testing on patient management.
  Circ Heart Failure.
  2009;2:287–293.
  
• Silvers SM, Howell JM, Kosowsky JM, et al. ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes.
  Ann Emerg Med
  . 2007;49(5):627–669.
  

CODES

• 428.0 Congestive heart failure, unspecified
  
• 428.20 Systolic heart failure, unspecified
  
• 428.30 Diastolic heart failure, unspecified
  

BASICS

Inflammation of the conjunctiva arising from a broad group of etiologies. Commonly referred to as “pink eye.”

• Bacterial:
  
  • Staphylococcus aureus
    
  • Streptococcus pneumoniae
    
  • Haemophilus influenzae
    
  • Gonococcal:
    
    • Ophthalmic emergency
      
  • Chlamydia:
    
    • Transmission occurs via autoinoculation from genital secretions.
      
    • Often occurs in newborns
      
• Viral:
  
  • Adenovirus most common
    
  • Epidemic keratoconjunctivitis (EKC) is caused by adenovirus subtypes.
    
  • Frequently associated with upper respiratory infections or exposure to someone with a red eye
    
  • Most commonly referred to as “pink eye”
    
  • Herpes simplex virus (HSV)
    
  • Recurrent ocular infection occurs in 25% patients within 2 yr.
    
  • Use of steroids is contraindicated:
    
    • Allergic
      
  • Frequent history of allergy, atopy, nasal symptoms
    
  • Contact related
    
  • May be due to chemical irritation, hypersensitivity from preservatives, medications, shampoo, chlorine, dust, smoke
    
  • Pseudomonas commonly implicated organism:
    
    • May be found in patients using saliva to clean contact lenses
      

DIAGNOSIS