CHF
 
Inability of heart to pump blood. This could  be 2ry to :

  1. L  ventricular  failure: ­BP, valve failure, endocarditis, MI, arrhythmia.
     
  2. R  ventricular  failure:  RVMI, valve failure, ­ pulmonary BP, PE.
     
  3. High Output  failure : Anemia, T1 deficiency ( Beri-Beri ), Thyrotoxicosis, AV fistula, Paget's.
     
  4. L ventricular can be further classified into Systolic Dysfunction 2ry to ¯ EF ( p.eg. sp MI ) or Diastolic  Dysfunction 2ry to­EF (e.g.  restrictive myopathy).

S & S:

    Dyspnea, Ortopnea, PND, Diaphoresis, JVD, HJR, Gallop S3 ( the latter is the most specific bed-side sign ),S4 if diastolic dysfunction, rales on lung auscultation, pedal edema. Symptoms are variably present if it is predominantly L, R or bi-ventricular failure.

DX:

Symptoms, history and CXray are more sensitive for diagnosis of CHF than physical findings.

  1. Physical exam, CBC, SMA, PT/PTT, CPK, dig level (as needed)
     
  2. CXray - Kerly line, pleural effusion, cephalization.
     
  3. Swan-Ganz - ­ PCWP and ­ PADP.
     
  4. Differential is with COPD, Peric. Effusion, RWMI, PE, PNA, PNTX, Renal failure.

Treatment:

  1. Oxygenation. The spectrum is from O2 NC to Intubation.
     
  2. Furosemide (Lasix) 40-100mg IVP. Helps diuresis and ¯ venous return.
     
  3. Nitroglycerin ( if SBP > 100 ): decreases venous return,¯ BP.
     
  4. Nitroprusside if CHF is 2ry to HTN. Also ACEi are indicated for same situation, yet it is harder to titrate this class of medications.
     
  5. Morphine 2-6mg:  ¯ anxiety. Also decreases venous return by causing  venodilation. Has as well ¯  of subjective dyspnea.
  6. Control tachyarrhythmia.
     
  7. Dopamine 5-20mcg/kg/min or Dobutamine 5-20mcg/kg/min. They have inotropic effect and also useful vasopressor.
     
  8. Digitalis 0.5mg IV. Mainly useful  to control tachyarrhythmias.
     
  9. Amrinone (Inocor) 0.75mg/kg initially.
     
  10. Do not forget that CHF is a symptom and the cause must be searched. Thus MI, arrhythmia, infection must be ruled out.


    NOTE!!! The medications are listed in order of FirstThird  Line treatment, the latter are Digitalis and Amrinone.

 

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