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13mosesso article

PREHOSPITAL THERAPY FOR ACUTE CONGESTIVE HEART FAILURE:
STATE OF THE ART
Vincent N. Mosesso, Jr., MD, James Dunford, MD, Thomas Blackwell, MD, John K. Griswell, MD vices (EMS) personnel in the future.
accurate diagnosis of CHF. Key words:
left ventricular (LV) filling pressures.
Congestive heart failure (CHF) is
ATHOGENESIS OF APE
Received May 13, 2002, from the University Pennsylvania; the University of California,San Diego Medical Center (JD), San Diego, (JKG), Fort Worth, Texas. Revision receivedAugust 21, 2002; accepted for publication Presented at the Turtle Creek Conference IV, Dallas, Texas, February 27–March 1, 2002.
requests to: Vincent N. Mosesso, Jr., MD, Pittsburgh, PA 15213. e-mail: <mosessovn@ *Reproduced with permission from: Marx J, Hockberger R, Walls R. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed.
prompt relief of respiratory distress.
Field Assessment
another.11 The correct identificationof the precipitating events andthe immediate administration ofappropriate treatment are criticalfor a positive outcome in CHFpatients, because inappropriatetherapy initiated as a result of mis-diagnosis may result in deleteriouseffects. Hoffman and Reynolds10reported that adverse effects weremore common in misdiagnosedpatients. Untoward effects includ-ed 1) respiratory depression (withor without lethargy) in patientswho received morphine; 2)hypotension and bradycardia inpatients who received both mor-phine and nitroglycerin; and 3)arrhythmia associated with hypo-kalemia and hypotension in pa-tients who received furosemide.
ditions, including myocardialischemia, hypertensive crisis, fluidexcess, medication noncompliance,diet, and overexertion, may trigger FIGURE 1. Processes involved in pulmonary edema. Cycle may begin at any point but oncebegun is self-perpetuating. Reprinted with permission from: Sacchetti AD, Harris RH. Acute cardiogenic pulmonary edema. What’s the latest in emergency treatment? Postgrad Med.
1998;103:145-66. The McGraw-Hill Companies.
• Hypertension or cardiovascular disease • Ischemic heart disease• Valvular disease • Diet or exercise indiscretions• Signs of pulmonary edema such as • Signs of chronic obstructive pulmonary • End-tidal carbon dioxide trends• Electrocardiogram rhythm and 12-lead if Reduction of LV Preload
• Identify and treat specific etiology • Provide inotropic support when needed • Provide oxygen and ventilatory support • Match receiving facility with needed output to more closely matchinflow from the pulmonary sys- MANAGEMENT OF APE
Nitrates
reduction of LV preload in the field.
It is fast acting, efficient, and easy to Furosemide
Morphine
Combined Drug Therapies
with Nitroglycerin, Furosemide,
and Morphine
Nitroprusside
Reduction of LV Afterload
Nitrates at Higher Doses
Natriuretic Peptides
ACE Inhibitors
Ventilatory Support
Noninvasive Positive
Pressure Ventilation
to increase intra-alveolar pressure.
Brett Kaplan, and Janice Liesch for their edi-torial assistance.
Inotropic Support
MIs) with high-dose nitrate thera-py (10% MIs) (p = 0.006).63 Very dif- CONSENSUS
PRESENTATION
The consensus of the group
I Asymptomatic
II Mild Symptoms
III Moderate
Symptoms
IV Severe
Symptoms
*Treatment at each level should consider the lowest dose applicable; SL = sublingual; MDI = metered-dose inhaler; SBP = systolic blood pressure; IV = intravenous;ECG = electrocardiogram; ETI = endotracheal intubation; NIPPV = noninvasive passive pressure ventilation.
REATMENT OPTIONS
lines for the Evaluation and Manage-ment of Heart Failure). J Am Coll ONCLUSION
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8. Marx J, Hockberger R, Walls R. Rosen’s Clinical Practice, 5th ed. St. Louis, MO: 9. Cecil RL, Bennett JC, Goldman L. Cecil phia, PA: W. B. Saunders Company, 1999.
10. Hoffman JR, Reynolds S. Comparison of 12. Sacchetti AD, Harris RH. Acute cardio- Pulmonary edema: new insight onpathogenesis and treatment. Curr Opin References
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