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Download Acute pulmonary oedema
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File 18 cardiovascular emergencies Acute pulmonary oedema (Left ventricular failure / heart failure) Recommend See immediate management below Related topics: Breathlessness, page 76 Chest pain, page 79 1. May present with: Breathlessness (may start suddenly waking up at night, worse when lying down) Increased heart rate Cough, with or without wheezes Pink frothy sputum (in severe cases) Wet crackles especially in lung bases Lethargy, confusion Oedema of the ankles or sacrum and an enlarged liver may co-exist as a sign of right heart failure These patients can look preterminal Seen in conjunction with renal failure Cyanosis Ischaemic chest pain File 18 cardiovascular emergencies Nearly all patients with breathlessness require oxygen in high concentrations. For the few patients with Chronic Obstructive Pulmonary Disease (COPD), an oxygen saturation of 85-90% may be normal for them and oxygen in high concentration may put them at risk by decreasing their breathing effort. However it may be necessary to use high flow oxygen when they are acutely distressed for a short time only, MO will advise. 2. Immediate management: DRABC Resuscitation / the collapsed patient Sit the patient up for all patients except known COPD: Give oxygen at 15 L/minute via re-breather mask (see O2 Delivery systems) to maintain O2 saturation >94%. If >94% not maintained Consult MO for patients with known COPD give oxygen 28% by Venturi mask or nasal cannula (see O2 Delivery systems) to maintain O2 saturation >90%. If >90% not maintained, consult MO. If no Venturi mask give O2 by Hudson mask at 5 litres/min only, or by nasal prongs at 2 litres/min only Perform BP / heart rate / respiration rate / O2 saturation Check conscious state – Glasgow coma scale/ AVPU If hypotension / shock or irregular heart beat (fast or slow) consult MO urgently Consult MO as soon as possible 3. Clinical assessment: Obtain patient history - include in history this episode and previous heart trouble angina, heart attack, heart failure? have they had heart palpitations? Current medications Perform standard clinical observations – note pulse rate, rhythm – is it irregular, respiratory rate – is it fast? and O2 saturation Monitor their conscious state – AVPU / Glasgow coma scale Perform physical examination inspect and palpate the skin - what is the colour? – is it ashen? cyanosed? sweaty? do they have cool peripheries? check the capillary return? is it reduced? auscultate the chest for air entry and added sounds – are there crackles or wheezes palpate the abdomen for enlarged liver inspect and palpate the ankles, front of legs, sacrum - is oedema present? 4. Management: Give GTN provided not hypotensive (systolic BP greater than 100 mmHg). Note: do not give GTN if has taken Viagra® in the last 24 hours Schedule 3 DTP IHW / NP Glyceryl Trinitrate Authorised Indigenous Health Workers may proceed Nurse Practitioners may proceed Route of Form Strength Administration Tablet 0.6 mg provided not Sublingual hypotensive ie. Systolic BP greater than 100 mmHg Spray 400 microgram/dose: in Sublingual 14.7 mL. Recommended Dosage Duration Stat If pain persists can repeat after 5 min again provided not hypotensive Adults only: If pain persists can repeat One to two sprays after 5 min again provided not hypotensive Provide Consumer Medicine Information if available: do not give GTN if has taken Viagra® in the last 24 hours Management of Associated Emergency: Consult MO Adults only: 0.6 mg Connect to ECG monitor / defibrillator Insert IV cannula – take bloods for electrolytes, troponin level and renal function Do 12 lead ECG and fax to MO Consult MO who may advise topical (patch) GTN is very beneficial in severe pulmonary oedema even if no chest pain because it reduces blood pressure which is often raised and reduces the work of the heart and vasodilates vessels Frusemide IVI or IM stat GTN infusion CPAP / BiPap can be lifesaving if available intubation and ventilation may be needed if above not available or successful File 18 cardiovascular emergencies Continue rest in bed, sitting up with legs hanging down, until patient settles or evacuated / hospitalised Schedule 4 Frusemide Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Nurse Practitioners may proceed Form Strength Route of Administration Recommended Dosage Ampoule 20 mg/ IV or Adults only: 40 mg maximum – 2 mL IMI one dose only Provide Consumer Medicine Information if available: Management of Associated Emergency: Consult MO DTP IHW / RIN / NP Duration Stat 5. Follow up: Keep patient under close supervision until evacuated/hospitalised As per MO instructions 6. Referral / Consultation: Consult MO on all occasions of pulmonary oedema (left ventricular failure /heart failure)
