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.
ongestive 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.
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
reduction of LV preload in the field.
It is fast acting, efficient, and easy to
Combined Drug Therapies
with Nitroglycerin, Furosemide,
Reduction of LV Afterload
Nitrates at Higher Doses
to increase intra-alveolar pressure.
Brett Kaplan, and Janice Liesch for their edi-torial assistance.
MIs) with high-dose nitrate thera-py (10% MIs) (p = 0.006).63 Very dif-
he consensus of the group
II Mild 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.
lines for the Evaluation and Manage-ment of Heart Failure). J Am Coll
ment. Eur J Heart Fail. 2002; 4:227-34.
Herlitz J. Has an intensified treatment in
severe left heart failure improved the out-
come? Eur J Emerg Med. 2000;7:15-24.
6. Bertini G, Giglioli C, Biggeri A, et al.
edema. Ann Emerg Med. 1997;30:493-9.
edema. Cardiol Clin. 1984;2:183-200.
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
1. Croft JB, Giles WH, Pollard RA, Keenan
patient with dyspnea. J Gen Intern Med.
16. Little B, Ho KJ, Scott L. Electrocardio-
gram and rhythm strip interpretation byfinal year medical students. Ulster Med
population. Arch Intern Med. 1999;159:505-10.
3. Hunt SA, Baker DW, Chin MH, et al.
diagnosis of heart failure. N Engl J Med.
ACC/AHA guidelines for the evalua-tion and management of chronic heart
18. Maisel A. B-type natriuretic peptide in
failure in the adult: executive summary.
gestive heart failure. Cardiol Clin.
source present logistical obstacles.
33. Hamilton RJ, Carter WA, Gallagher EJ.
itive pressure ventilation in status asth-
et al. Utility of B-type natriuretic pep-
tide in the diagnosis of congestive heart
pril. Acad Emerg Med. 1996;3:205-12.
49. Pennock BE, Crashaw L, Kaplan PD.
Maisel A. Utility of a rapid B-natriuretic
acute respiratory failure: institution of a
35. Langes K, Siebels J, Kuck KH. Efficacy
congestive heart failure. Curr Ther Res.
21. Tabbibizar R, Maisel A. The impact of B-
36. Annane D, Bellissant E, Pussard E, et al.
tive heart failure. Curr Opin Cardiol.
with congestive heart failure. Chest.
22. Lee SC, Stevens TL, Sandberg SM, et al.
37. Podbregar M, Voga G, Horvat M, et al.
treatment of heart failure. J Card Fail.
with acute refractory decompensation.
52. Pollack C Jr, Torres MT, Alexander L.
38. Colucci WS. Nesiritide for the treatment
practice in the treatment of heart failure.
support in the emergency department.
respiratory failure. Am Rev Respir Dis.
53. Kosowsky JM, Storrow AB, Carleton SC.
and tolerance. Eur J Clin Pharmacol.
40. Colice GL, Stukel TA, Dain B. Laryngeal
complications of prolonged intubation.
41. Craven DE, Steger KA. Epidemiology of
54. Rasanen J, Heikkila J, Downs J, Nikki P,
and adaptations in congestive heart fail-
55. Lin M, Chiang HT. The efficacy of early
27. Cotter G, Metzkor E, Kaluski E, et al.
43. Meduri GU, Turner RE, Abou-Shala N.
56. Takeda S, Nejima J, Takano T, et al.
for acute heart failure? Lancet. 1996;347:
ventilation in acute respiratory failure.
60. Mehta S, Jay GD, Woolard RH, et al.
trial of BiPAP in severe acute congestive
61. Antonelli M, Conti G, Rocco M, et al. A
63. Sharon A, Shpirer I, Kaluski E, et al.
of-hospital patients. Acad Emerg Med.
trate is safer and better than Bi-PAP ven-
66. Wilkes MS, Middlekauff H, Hoffman JR.
acute respiratory failure. N Engl J Med.
treatment for severe pulmonary edema.
Heart failure: Part II. West J Med. 1999;
62. Masip J, Betbese AJ, Paez J, et al. Non-
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