ACUTE LEFT VENTRICULAR FAILURE Acute LVF Oxygen (Target SaO2: 94-98%)
Patient in HDU / Resus Normal BP Reconsider Diagnosis:
- Give iv Furosemide (20-40 mg)
- Consider: GTN inf if SBP > 110 mmHg - Consider Morphine (2-5 mg IV) only if in pain or restless - Give Clexane 1 mg/ttkg sc if not anticoagulated and/or containdicated Senior help Involve ITU Metabolic acidosis Resp or mixed acidosis REFER TO MEDICS REFER to MEDICS
Involve Outreach Team / ITU See explanation and key points below:
Version 1.0 (Feb 2013) Review date: Feb 2015
Clinical presentation:
- Dyspnoea - Tachycardia (sinus tachycardia)
o If arrhythmia (broad or narrow complex tachycardia or bradycardia
or new onset AF is present, treat that first!)
- Blood pressure is usually high (increased afterload is often the trigger);
o if patient is hypotensive then treat it as Cardiogenic shock - or
consider alternative diagnosis (e.g. COPD, chest infection, septic shock, etc.)!
- Patient is in a distress: skin is cold and clammy - Wheezing and crackles
Investigations:
- If MEWS score > 4, the patient must be seen / treated in Resus - Monitoring (SaO2, ECG, NIBP) - 12 lead ECG. Consider right sided and posterior leads if necessary. - Bloods (U&E, FBC, CRP, Creat, LFT, INR (if on warfarin or AF), Troponin
(if chest pain within the past 7 days or diabetic), Se Mg.
- ABG (to assess tissue hypoxia by checking metabolic acidosis) - Chest X-Ray (portable) - Temperature - Consider to arrange emergency bedside echocardiography if:
o Myocardial infarction within the past 7 days (assess acute MR) o (Presumably) new heart murmur o Clinical suspicion of pericardial tamponade o If BP drops
MANAGEMENT:
- Keep the patient in a comfortable sitting position - Give high flow (10-15 l/min) oxygen via non-rebreathing face mask - If LVF is the result of an arrhythmia apply electrical DC cardioversion (see
- If ACS is the likely casue of the LVF early and aggressive
revascularisation (PCI) strategy should be pursued. Contact senior cardiology team.
- Increased afterload is one of the most common cause of acute LVF. When
diastolic blood pressure is high (DBP > 90 mmHg) GTN would be the best choice to reduce afterload. Give Nitroglicerin (GTN) IV infusion 10-20 mcg/min to start, could then be increased up to 200 microgramm/min.
o Reduces afterload and preload o Could be titrated against BP and clinical signs (short halflife)
Version 1.0 (Feb 2013) Review date: Feb 2015
o Don’t give if BP < 110 mmHg or HR < 50/min
- Furosemide 20-40 mg IV
o Reduces afterload (vasodilation) and preload o Diuretic effect is slower and cannot be titrated o Don’t give if BP < 90 mmHg
- Consider Morphine (very careful, 2-5 mg IV) in case of pain
o Reduces sympathetic tone, heart rate and afterload
- Patients in acute LVF need anticoagulation. Give LMWH (enoxaparin / Clexane 1 mg/kg sc.) unless contraindicated (e.g. active bleeding) or already on warfarin. - Digoxin could only be useful in AF with fast ventricular rhythm. Its effect is slow and weak in a case of acute LVF but patient might benefit from digitalization in the longer term. - DO NOT USE POSITIVE INOTROPES (Dopamin, Dobutamin, etc.) in LVF unless in cardiogenic shock and under the supervision of senior ITU doctor (central line and arterial line is mandatory such as the introduction of invasive haemodynamic monitoring in the ITU as early as possible.)
- CPAP is very effective and non-invasive treatment for acute LVF. It
reduces the afterload and increases tissue oxygenation. There is no evidence that long term mortality would be affected.
o Metabolic acidosis (BE < -2) confirms tissue hypoxia o Patient is conscious and co-operative with CPAP
If GCS reduced or patient deteriorates:
- early intubation and IPPV (PEEP) is recommended
Cardiogenic shock:
- Acute left ventricular failure with SBP < 90 mmHg due to reduced
- Most common cause is ACS - Treatment:
o If GCS reduced: intubation and ventilation with PEEP o Intra Aortic Balloon Pump (IABP) and revascularisation (PCI) o Inotropic / inodilator drug treatment should be initiated if IABP is not
available with the discussion of ED senior + ITU / Cardiology senior. (Need CV line and arterial line and haemodynamic monitoring)
This policy lays out guidance in relation to Acute Left Ventricular Failure
Version 1.0 (Feb 2013) Review date: Feb 2015
All staff working in the ED at East Surrey Hospital
Dr J Webb, Lead Consultant in Emergency Medicine
Dr C Dioszeghy Consultant in EM / Guideline
Medical Division Management Board for Quality and Risk (submission 11th February2013)
ESC Guidelines for the diagnosis and treatment of acute and
chronic heart failure 2012 – European Heart Journal, doi: 10.1093 /eurheartj/ehs104
Version 1.0 (Feb 2013) Review date: Feb 2015
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ACUTE LEFT VENTRICULAR FAILURE