CHF pt's

[medic112]

Left sided CHF pt's treatment is aimed at moving the fluid in the lungs and the Pulmonary edema.

Right sided CHF tx is aimed at the full body edema.

So for left sided CHF you give nitrates and CPAP, and lasix.

Right sided tx: do u give Nitrates.

and nitro reduces preload correct?.

so i guess my question is we dont give nitrates to pt's with right sided heart failure? correct?

[Kaisu]

Right sided heart failure presents as body edema. This is not an emergent threat to life or limb. While these patients need drying out, it is best for them to do it slowly. Hospital care and home medications is what these folks get. So my answer to your question is - in the absence of ACS, no - no nitrates. (PS - the main cause of right sided heart failure is left sided heart failure. One of the few times you see isolated right heart failure is in cor pulmonale - the emphysema patient that gets pulmonary hypertension from blown blebs.... )

[medic112]

okay. so for pt's with Left sided Heart failure, NTG - assuming SBP remains stable. IV - conservative of fluids. CPAP - if you have it, and its indicated, and Lasix?

on a side note, pt's with Right sided MI's. you dont want to give NTG to, due to its effect on reducing preload. - correct?

[Kaisu]

CHFer with full lungs gets O2, IV, monitor, CPAP (if you have it), NTG, lasix, morphine, methylprednisolone, RSI, intubation

CHFer with peripheral edema gets O2, IV, monitor

ACS symptoms gets O2, IV, monitor, ASA, NTG, Morphine (possibly), Metoprolol (possibly), etc.

All of these treatments are dependent on the presentation of the patient and your local protocols. For example, your right heart ACS patient often presents with hypotension and bradycardia. This patient would NOT get NTG. You will need to be VERY cautious fixing this patient's rate because you don't want to increase the work load of the heart. If they are stable, I don't play with fire. If they are unstable, then I need to go to work. If they have an adequate rate and they are non-perfusing hyptotensive, then you need to think about vasoconstrictors, and nitro is the opposite.

My general strategy for dealing with symptomatic cardiac is fix the rate, then fix the tank, finally the pump.

I dont know if I am helping you. Maybe some of the others with more experience can chime in here.

[crotchitymedic1986]

The problem with left sided CHF is that it usually presents without edema to the lungs (unless the patient has waited too long). So it can be difficult to differentiate, Left CHF, COPD, or MI (depending on patient complaint). Most ER docs used to have to wait on the CXR to definitively know a diagnosis, now they have a lab test for it (BNP).

[HellsBells]

...And to add to that, don't worry so much about whether it is right or left sided, treat the symptoms. Does the patient have pulmonary edema related to CHF? DO they have a decent BP? If so treat with nitrates, and so on...

[chbare]

Also remember, CHF is usually caused by some other problem such as CAD. In addition, it is not uncommon for people to experience both left and right sided failure. Given enough time left sided failure can cause right sided failure. Other conditions that can cause heart failure include; chronic lung disease, heart valve problems, HTN, infection, and many other problems. I find CHF is rarely an isolated condition.

Take care,

chbare.

[Doczilla]

CHF is still principally diagnosed by chest xray, though BNP can help in a patient with a normal xray or abnormal xray and you can't tell what that perihilar infiltrate is exactly... (oh, and there is such a thing as unilateral pulmonary edema too.

Remember that the most common cause of right sided heart failure is LEFT sided heart failure.

Isolated right sided heart failure from acute MI is rare, representing only about 40% of inferior MIs. It's not that you CAN'T give nitro to these patients, you just have to be very careful about it.

'zilla

[AZCEP]

I'd like to add that the patient with pulmonary edema due to heart failure can usually tolerate a moderate amount of fluid replacement. It isn't because of a loss of volume, rather their volume is in the wrong place--a relative hypovolemia. This is especially useful when using nitrates, or for the right sided failure situation.

The typical prehospital dosing of NTG makes it difficult to control, however with the symptoms being present NTG is still indicated. It is not uncommon to use the nitrates with a pressor to improve the hemodynamics. Again not something that is often considered by EMS.

[fiznat]

medic112, I assume you are a student? Good for you coming here to check up on things you aren't sure about. Be sure to check the books and your instructors, as well.

The only bit I can add to what has already been said is that it is dangerous to divide pathology so sharply along clinical signs like that. Patients in failure won't always have edema in one place or the other. There is a saying out there that the patient never "reads the book on how to present." If you hear rales in the absence of distal edema it is good to have that knowledge in your mind, but don't have any strong expectation that your patient will follow the rules.