CHF pt's

[firedoc5]

Right sided heart failure presents as body edema. This is not an emergent threat to life or limb. While these patients need drying out, it is best for them to do it slowly. Hospital care and home medications is what these folks get. So my answer to your question is - in the absence of ACS, no - no nitrates. (PS - the main cause of right sided heart failure is left sided heart failure. One of the few times you see isolated right heart failure is in cor pulmonale - the emphysema patient that gets pulmonary hypertension from blown blebs.... )

Darlin', you nailed it, in all your posts here.

If worried of giving NTG, go ahead with MS. Treat pain appropriately. If need be, especially if COPD hx. be prepared to tube.

[fiznat]

I've attended a few lectures on this subject and it seems to me that MS in CHF is becoming more and more controversial. On the surface there are a lot of docs out there who shy away from giving a potential respiratory depressant to patients in respiratory distress. In addition though, MS causes a release of histamine which is thought to play a role in antagonizing the inflammatory aspect of acute CHF. NTG (and CPAP if there is pulm. edema) remains the gold standard treatment for this condition, although I agree that I would hold off on it if the only sign/symptom was peripheral edema.

[CTXMEDIC]

Left sided CHF pt's treatment is aimed at moving the fluid in the lungs and the Pulmonary edema.

Right sided CHF tx is aimed at the full body edema.

So for left sided CHF you give nitrates and CPAP, and lasix.

Right sided tx: do u give Nitrates.

and nitro reduces preload correct?.

so i guess my question is we dont give nitrates to pt's with right sided heart failure? correct?

Ok bro. heres the deal. i know im just a 'noob' here but lemee give you a hand. i decided to jump on this because a few of these 'answers' are scaring the heck out of me. we even have one poster that is telling you that a right sided failure needs 'drying out'. another poster is telling you that MS in CHF is 'for the pain'.

This is a pump problem guys. The pulmonary/peripheral edema is a side effect of the pump problem. So what is our goal????? fix the pump problem.

Medic 112. To answer your question, not everyone in CHF needs to be 'saved'. I understand youre posting about treatments in CHF with distress so we'll run with that.

In left ventricular failure secondary to CHF, the ventricle has lost its ability to adequatley contract due to its enlargement (hypertrophy). This results in a backup of fluid in pulmonary circulation because the heart is unable to pump fluid forward. So how do we alleviate this problem? Nitrates (Nitro and MS) dilate the vasculature creating more space for the fluid. a bigger tank means less pressure, right? CPAP is another great tool. CPAP doesnt 'push fluid out of the lungs' it holds the alveoli open longer allowing for improved oxygenation which is why our patient called in the first place. Lasix, EVIL. Forget it exists. Dopamine. At lower concentrations it improves myocardial contractility. It makes the pump, pump harder, not faster.

so to our original problem.

Pt in RR distress w/ hx of CHF. First thing we're gonna do is improve that respiratory effort, right? if she aint breathin nothing else matters. So she gets put on CPAP. So you have a patient in distress with a cardiac history, how about a 12 lead? Oh snap, looky here, LVH! So now we know she has a fat, floppy left ventricle which isnt pushing blood into circulation. lets fix that. whats her pressure lookin like? is she hypotensive? ok, but its relative, she has fluid it just isnt being circulated so we giver her a little dopamine to increase contractile force. heart is now contracting with more force, fluid is being pushed forward, lungs are clearing, pressure is comming up, family wants to name the next grand kid after you.

So say shes hypertensive. Remember this is probally a chronic state for this patient so we dont wanna tank the BP, just 'take the edge off'. assuming everything above is the same except for the pressure we would introduce MS and nitro. Again, CPAP, 12 lead, dopamine to improve contractility but wait you say! i thought her pressure was high, wont this make it worse? yes. so we throw a nitro drip and some MS into the mix. Nitro drip because we dont want to be spraying nitro forever and on a 60gtt set, its easily controlled. So we dilate the vasculature creating a lower pressure, give dopamine for increased contractility which will help clear the lungs and get that oxygenated blood circulating, CPAP to improve oxygenation and off we go.

so now we have right sided failure. Ever hear of that Frank Starling guy? these patients CAN be given nitro if they are having 'the big one' just keep an eye on that pressure. The patient in right sided failure requires LARGE amounts of fluid to improve their condition. if the right side of the heart is in failure and cant adequatley push blood to the lungs resulting in a lower volume of blood being pushed to the left heart creating a hypotensive state and a back up of blood in the periphery. so how to fix?

FLUID and alot of it. we're using the fluid to increase the stretch of the right right heart. the greater the stretch, the greater the contractile force, remember hearing that before? the greater the force, the higher the pressure, the higher the pressure the greater the filling of the left heart which as we now know improves oxygenation.

as far as diagnosing this prehospital. first off is the patient themselves. they usually know whats wrong with them. second is their med list. HCTZ, Lasix(not so much anymore), digoxin(a-fib is usually from CHF) are the most popular. Third is vitals, pressure, lung sounds etc. fourth is a 12 lead or even a 3 lead. 3 lead will show a-fib, a 12 lead will show the LVH.

we'll get into reasons for CHF some other time. Hope this kinda answers your question. have a good one.

[CBEMT]

I had to stop somebody from shoving 240mg of Lasix into a peripheral edema patient once.

Why? Because that's what the CHF protocol said to do. :roll:

[reaper]

Just had this discussion with the cardiologist in the cath lab the other day. We were talking about NTG in RHF. He stated that you can use NTG in a inferior MI, with fluids.

If you prove that Right side involvment is there, push lots of fluids. He stated that they will push any where from 4-20L of NS on these pt's, over a 24 hr period. Then they will be taken to the cath lab.

He was telling me about a study that Emory had done. They found that if you have and inferior MI with elevation in leads II,III and AVF, look for elevation in V-4. If elevation is present in II,III,AVF and V-4, it almost always points to right side involvement. If you have the time, run a right side 12 lead. This will confirm the involvement.

I have always pushed fluids on a right side MI, but I was surprised at the amounts they push, prior to cath lab!

[p3medic]

He's refering to V4 Right, as in the V4 electrode on the R side of the chest, in same position as it would be on the Left.

[reaper]

No he was actually talking about V-4. He stated that they found in 98 out of 100 cases they studied that elevation in V-4 along with II,III and AVF, indicated right side involvement.

He said that the Dr. at Emory has been studying this for a while. I thought it was pretty interesting.

[p3medic]

It would seem unlikely to have isolated st elevation in V4 associated w/II, III and F. I can't say I have seen it. I have on the other hand seen plenty of elevation in V4R associated w/IMI, which is diagnostic of RV infarct, in fact, I saw one three days ago. V4 looks at the anterior wall of the Left ventrical, V4R looks at the Right ventrical. You might want to ask him just for clarification, I think you may have misunderstood perhaps.

[CTXMEDIC]

It would seem unlikely to have isolated st elevation in V4 associated w/II, III and F. I can't say I have seen it. I have on the other hand seen plenty of elevation in V4R associated w/IMI, which is diagnostic of RV infarct, in fact, I saw one three days ago. V4 looks at the anterior wall of the Left ventrical, V4R looks at the Right ventrical. You might want to ask him just for clarification, I think you may have misunderstood perhaps.

Oops!

http://www.emsvillage.com/articles/article.cfm?id=84

While you are talking with the patient and monitoring her vital signs you begin to ponder why her blood pressure dropped so much from one Nitroglycerin tablet. You remember a conversation with one of the Emergency physicians about right-sided Inferior Wall Myocardial Infarctions (IWMI) making the patient’s blood pressure sensitive to nitrates and similar acting medications. The physician explained that this was because the patient’s preload is low because of a right-ventricular infarction (RVI). Clinically, the patient with RVI may present with low-normal or hypotensive blood pressure, JVD and dry lungs because the right-side of the heart is not allowing enough blood to get through to the left side of the heart. This simple explanation of the physiology involved explains why there is JVD, and why the blood pressure is low and the lungs are dry. RVI can accompany left-sided inferior wall MI in as much as 40% of IWMI cases. If the patient is extremely hypotensive, the appropriate treatment includes small fluid boluses to increase preload and improve cardiac output.

[Mateo_1387]

Oops!

http://www.emsvillage.com/articles/article.cfm?id=84

RVI can accompany left-sided inferior wall MI in as much as 40% of IWMI cases.

And which leads look at the inferior wall? II, III, and aVF. V4 view the anterior heart, and closer to the lateral left ventricular wall more so than the inferior wall.

Now, with someone who is Right Coronary Artery Dominant, and having an active Right sided MI could show ST segment elevation in the low lateral leads, V5 and V6, and ST depression in the Septal/Anterior leads.