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Acute Heart Failure (AHF) – ESC 2016

 

AHF Triggers

there are many triggers for AHF, which if recognized and treated with help improve outcomes

  • Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension
  • Respiratory: PE, COPD
  • Infection: Pneumonia, Sepsis, Infective endocarditis
  • Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds
  • Increased Sympathetic Drive: Stress
  • Metabolic: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
  • Cerebrovascular Insult

Presentation & Clinical Classification

The presentation of AHF can vary but tends to fall in to the following 4 categories, which can be determined clinically and can help guide your approach to treatment; warm-dry, warm-wet, cold-dry, cold-wet.

It is worth noting that the vast majority of patients will be norm-hypertensive. However, 5-8% are Hypertensive this confers a very poor prognosis.

Investigations

  • ECG: Rarely normal (High NPV), and may identify underlying cause
  • CXR: Pulmonary congestion, Effusion, Cardiomegaly (20% will have an almost “Normal” CXR)
  • BNP: Can be helpful (we have it)
    • >845 show increased mortality
    • <100 AHF is unlikely
    • BNP is not a specific test and will elevate for many reasons
  • POCUS: This can be very useful in identifying cases but training is required [Bilat B lines in 2 zones each side]
  • Condition specific tests: Try to identify the underlying trigger dependent on history and exam (e.g. ABG, Trop, U&E, TFT, LFT, CTPA)
  • ECHO: this is important but not necessary in the ED phase (unless the patient has haemodynamic instability i.e. cardiogenic shock)

Treatment – Time Matters!!!

  • Mortality increased by 1%/hour IV treatment not started
  • Treatment after 12hrs from onset makes little difference

Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)

  • Vasodilator: has 2 effects reducing vascular resistance and thus increasing stroke volume [NOT to be used if sBP<90mmHg] 
  • Diuretic: commonly we use frurosemide 20-40mg IV, however, depending on the patient higher doses can be used. [Doses over 160mg has been shown to increase mortality!]
  • Oxygen: maintain SaO2 of 95% OR 88-92% if at risk of hypercapnic coma [Avoid hyperoxia]
  • NIV: recommended in respiratory distress (RR >25bpm, SpO2 <90%) & start ASAP, this can reduce intubations and make the patient feel more comfortable. However, doesn’t increase survival NIV Guide-HERE
  • SHOCK!!!: there is no agreement on the best treatment, ICU & Medical/Cardiology input is vital, as inotropes & vasporessors (Noradrenaline recommended) will need to be considered.

ESC Guide – 2016 Heart Failure

Urinary Catheterisation in ED

Pre-catheterisation

  • Confirm appropriate indication
    • Relief of acute or chronic urinary retention
    • Need for accurate measurements of urinary output in critically ill patients
    • Patient requires prolonged immobilisation (e.g potentially unstable traumatic injury)
    • To improve comfort for end of life care
  • Bladder scan & document result
  • Appropriate consent from patient

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MHRA: Ondansetron small increased risk of oral clefts following use in the first 12 weeks of pregnancy

MHRA (Medicines & Healthcare products Regulatory Agency)  has recently published a warning regarding the use of ondasetron in early pregnancy.leading to a small but significant risk of cleft lip. – LINK HERE

“Recent epidemiological studies report a small increased risk of orofacial malformations in babies born to women who used ondansetron in early pregnancy.1 4 Key evidence was an observational study of 1.8 million pregnancies in the USA of which 88,467 (4.9%) were exposed to oral ondansetron during the first trimester of pregnancy. The study reported that ondansetron use was associated with an additional 3 oral clefts per 10,000 births (14 cases per 10,000 births versus 11 cases per 10,000 births in the unexposed population).1 These data were recently reviewed within Europe and considered to be robust.”

Patients with vomiting in early pregnancy requiring antiemetics you can review the guidance on “Hyperemesis Gravidarum”

3. HAZMAT – CBRNe (Chemical, Biological, Radiological and Nuclear) incidents

NHS England, Public Health England and the Health Protection Agency have produced several very useful resources for us to use – BUT First.

Remove – Remove – Remove

Basics

Contacts

  • Health Protection Agency Teams – HERE
    • West Yorkshire
      • In hours: 0113 386 0300
      • Out of hours: 114 304 9843

  • ECOSA (Emergency Coordinated Scientific Advice System) – 0300 3033 493

  • UK NPIS – 0344 892 0111

Guides

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Hyponatraemia

Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior to treatment the following need to be considered and balanced.

  1. Symptoms Severity – these are not exclusive to hyponatraemia and may be due to other disease processes (esp. if the low sodium is long-term)
  2. Sodium Level – the sodium concentration doesn’t always correlate to the clinical picture, and is dependant on speed of change, and co-morbidities
  3. Rate of Drop – the faster sodium levels drop the more symptomatic the patient often is (i.e. with long term hyponatraema the patient may be profoundly hyponatraemic but asymptomatic)
  4. Co-morbidities – Increasing sodium too quickly risks osmotic demyelination. How well will the patient cope with treatment?

Emergency treatment (hypertonic saline) is generally indicated in those with Severe Symptoms ONLY

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