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‘Need to knows’
• Review of pump physiology (two pumps)
• Review of pump flow (backwards & forwards)
• Review causes that effect C.H.F. (valves, M.I.,
clogged pipes/hard pipes, high b/p, C.A.D.,
C.O.P.D.)
• Natural progression of C.H.F.
• Signs and symptoms
• What we can do about it
No J.V.D.
Clear lungs
with
great alveolar
diffusion
Great cardiac output
~ 5 L / Min
Clear lungs
with
great alveolar
diffusion
No ascites
No venous pooling
Great Coronary,
brain & kidney
perfusion
Presence of J.V.D.
Poor cardiac output
Congested
lungs with
poor O2/C02
diffusion
Ascites &
build-up of
fluid in other areas
build-up of interstitial fluid in legs
Congested
lungs with
poor 02/C02
diffusion
Compromised
perfusion of coronaries,
brain & kidneys
When a lock on the Trent-Severn waterway
doesn’t work, and water continues to flow
from the feeder rivers and lakes...
Flooding! up-stream
Cities & Towns downstream lack water
When the right ventricle fails to pump, and
blood continues to flow in from capillaries,
venules and veins...
Flooding!
...flow towards the lungs & left ventricle are compromised
When the left ventricle fails to pump, and
the right ventricle continues to function
well...
Flooding!
...flow towards the coronaries, brain & kidney’s is reduced
Ascites
Right Ventricular Failure (RVF)
• Occurs when the right ventricle fails as an
effective forward pump, causing back-pressure of
blood into the systemic venous circulation
• Can result from:
– Chronic hypertension (in which LVF usually precedes
RVF)
– COPD
– Pulmonary embolism
– Valvular heart disease
– Right ventricular infarction
• RVF most commonly results from LVF
Left Ventricular Failure (LVF)
and Pulmonary Edema
• LVF occurs when the left ventricle fails to
function as an effective forward pump, causing a
back-pressure of blood into the pulmonary
circulation
• May be caused by a variety of forms of heart
disease including ischemic, valvular, and
hypertensive heart disease
• Untreated, significant LVF culminates in
pulmonary edema
• Heart failure is not a
specific disease
• HF describes the signs
and symptoms that result
when the heart can’t keep
up
Not quite a ‘Cinderella’ story...
Grandma
Faccino
11:30 AM
Needs a
rest, mildly
s.o.b. due
to work in
the garden.
8:30 AM,
She woke-up
this morning
feeling well.
9:00 AM,
Takes her water
pills, 7 other
meds & puffers.
8:30 PM
11:00 PM
5:00 PM
Mild c/p relieved In bed, legs up, Complaint of
with 2 sprays ntg. head elevated sore feet and legs,
with her ntg on they seem more
2:15 AM
Severe s.o.b. with bedside table. swollen.
audible crackles
10:00 PM
7:00 PM
Gets ready for
Dinner
&
a
water
3:30 PM
bed with her
pill
with
3
meds
Needs a rest,
4 pillows.
&
2
puffers.
due to s.o.b.
1:00 PM
walking up stairs. 2:00 AM
Chest pain resolved First onset Lunch & a water
pill
with
4
other
with 2 ntg sprays. of s.o.b. with
meds and puffers.
Mild J.V.D. visible. c/p
2:30 EMS arrives,
Grandma Faccino presents:
• In severe respiratory distress (sitting forward and
upright, with use of supraclavicular muscles and
having 2 word dyspnea).
• She is extremely diaphoretic, appears in severe
distress and is becoming lethargic and cyanotic.
•There is obvious external jugular venous distension,
gross pitting edema and ascites.
2:30 EMS arrives, Grandma Faccino’s vitals are:
• Respirations: 48b/m, shallow and decreasing from
exhaustion.
• Pulse of 156 weak and irregular.
• Skin – diaphoretic x 3, warm core with cool
extremities. She appears pale with cyanotic nail-beds.
• O2 sat reads ‘84’
• Auscilltation: Course crackles in all air fields
bilaterally. Audible adventitious sounds orally.
• G.C.S. – Eyes open to loud verbal (2), spontaneous
verbal with 3 word dyspnea (5), spontaneous motor
(6).
2:45 AM EMS is still in Grandma Faccino’s
residence new vitals are:
• Respirations: 10b/m very shallow.
• Pulse of 170 hardly palpable at radial.
• Skin – diaphoretic x 3, warm core with cool
extremities. She appears pale with cyanotic nailbeds.
• O2 sat reads in 60’s
• Auscilltation: Course crackles in upper air fields
with decreased b/s in bases bilaterally. Froth in
airway.
• G.C.S. – Eyes closed (1), occasional moaning
(3), withdraws from pain (4).
History
•
•
•
•
Why did you call? What has changed?
How long has the dyspnea been present?
Was the onset gradual or abrupt?
Is the dyspnea better or worse with position? Is
there associated orthopnea?
• Has the patient been coughing?
- If so, was the cough productive?
- What was the character and colour?
- Is there any hemoptysis?
History (continued)
• Is there pain associated with the dyspnea?
- OPQRST for the pain
• Pt’s past history?
• Allergies
• Current Medications (pay close attention to
O2 therapy, oral bronchodilators,
corticosteriods,Beta Blockers, Digitalis, ACE
Inhibitors, Diuretics)
Quick differentiation of Shortness of Breath
Asthma
Pulmonary
edema (CHF)
Pneumonia
gradual
& fast
onset
Quick onset
& deterioration
Slow onset
Crackles that go
from fine to course
quickly, wheezes.
B/p norm
fine and course
crackles. Congestion
‘one sided’ or two
if both lungs effected.
b/p elevated
b/p norm
No productive
sputum
Late – frothy
red sputum
Chronic cloudy
yellow/green
Wheezes
History of
Asthma
History of c.h.f., History/signs-symptoms
fluid retention, new
of infection
infarct, etc.
Many
Others
Standard Assessment
for all SOB calls
•
•
•
•
•
•
ABC’s and Critical interventions
Chief Complaint
Incident History (OPQRST)
Med History (SAMPLE)
Vitals
Physical Assessment
Management of Respiratory Distress due to
Pulmonary Edema
•
•
•
•
•
ABC’s (including O2 or BVM), Monitor, and
Baseline Vital Signs
Consider positive pressure ventilations
Thorough History and Assessment of respiratory
status (chest assessment)
Carefully screen patient for indications and
contraindications for Nitroglycerine™
Transport in the most appropriate position as per
patient condition without delay
Nitroglyerin for Pulmonary Edema
1.
Indications:
See new standing order!.