Buffl verwendet Cookies, um dir ein besseres Erlebnis zu bieten. Weitere Infmorationen findest du in unserer Datenschutzerklärung.
Describe the initial management.
Perform a rapid ABCDE survey to assess hemodynamic stability.
Identify and treat any acute underlying cause of AHF for all patients.
Describe the management of hemodynamically stable patients.
Clinical presentation: SBP > 90 mm Hg AND no signs of end-organ hypoperfusion; respiratory distress can be present.
Management: depends on the classification of AHF
No evidence of congestion (dry and warm): Optimize oral therapy.
Evidence of congestion (wet and warm)
Start initial measures for respiratory support in AHF (e.g., positioning, supplemental O2) as needed.
Start diuretic therapy for AHF if there is volume overload.
Consider vasodilators for AHF, e.g., nitrates.
Morphine is no longer routinely recommended.
To remember the management of ADHF, think of “LMNOP”: Loop diuretics (furosemide), Modify medications, Nitrates, Oxygen if hypoxic, Position (with elevated upper body).
Describe the management of hemodynamically unstable patients.
Clinical presentation: can vary
Cardiogenic shock: SBP < 90 mm Hg OR signs of end-organ hypoperfusion
Hypertensive emergency: hypertension (e.g., SBP > 180 mm Hg) PLUS flash pulmonary edema and hypoxemic respiratory failure
Management: depends on the classification of AHF (See also “Management of cardiogenic shock.”)
Evidence of congestion with shock (wet and cold)
Prioritize respiratory support for AHF.
Consider inotropic support (e.g., dobutamine, norepinephrine).
Shock without evidence of congestion (dry and cold): Consider fluid challenge; add vasopressors and inotropes for shock refractory to fluids.
Hypertensive emergency with flash pulmonary edema (wet and warm)
Begin NIPPV and vasodilators for AHF. [35][37][38]
Identify and treat the underlying trigger.
Describe the supportive care in ongoing hospital management.
Fluid restriction
Sodium restriction
Identify and treat comorbidities (e.g., atrial fibrillation, pneumonia, COPD) and underlying triggers.
Describe the optimization of chronic therapy for CHF in ongoing hospital management.
Administer beta blockers cautiously in beta-blocker-naive patients.
Start at a low dose.
Administer only after stabilization (e.g., after volume status has been optimized and IV diuretics, vasodilators, and inotropic agents have been discontinued) [7][35]
Initiate, adjust, or continue medical treatment of heart failure as needed.
Optimize blood pressure control (
Administer only after stabilization (e.g., after volume status has been optimized and IV diuretics, vasodilators, and inotropic agents have been discontinued)
Optimize blood pressure control
For patients not previously on beta blockers, use cautiously and only once the patient has been stabilized.
Describe the treatment for refractory acute heart failure.
Consider the following if AHF persists despite maximal respiratory and hemodynamic support.
Ultrafiltration (e.g., hemodialysis): indicated in congestion with no response to medical therapy
Mechanical circulatory support: indicated in reversible refractory acute heart failure
Management of effusions: Consider therapeutic thoracentesis or pericardiocentesis as needed.
Describe initial measures for respiratory support.
Positioning: Ensure the patient is sitting upright. [47]
Supplemental oxygen: indicated for patients with an SpO2 < 90% or PaO2 < 60 mm Hg
Describe the treatment of respiratory failure.
NIPPV: for patients with respiratory distress despite supplemental oxygen
Invasive mechanical ventilation
Indications
Hypoxemic respiratory failure unresponsive to NIPPV
Refractory hypoxemia (PaO2 < 60 mm Hg)
Hypercapnia (PaCO2 > 50 mm Hg)
Acidosis (pH < 7.35)
EPAP and/or PEEP should be used with caution in patients with hemodynamic compromise.
Describe the diuretic therapy in acute heart failure.
Initial treatment
Administer diuretics intravenously, if possible.
Diuretic-naive patients: IV furosemide OR bumetanide
Continuing treatment
Dosage adjustment: Assess the effect of diuretics (e.g., urine output, symptoms) every 6 hours.
Refractory AHF (despite high doses of loop diuretics): Consider any of the following.
Combination therapy with a thiazide diuretic, e.g., metolazone, hydrochlorothiazide, chlorothiazide [5][54]
Addition of a vasodilator for AHF [5]
Monitoring
Monitor and replete serum electrolytes.
Monitor renal function (creatinine levels).
Describe the vasodilator therapy in acute heart failure.
Acute heart failure caused by hypertensive emergency (see “Treatment of hypertensive crises”)
Flash pulmonary edema
Adjuvant to diuretics for symptomatic relief of dyspnea
Treatment options
IV nitroglycerin
Sodium nitroprusside
If there are contraindications to nitroglycerin, consider nesiritide.
Avoid the use of vasodilators in patients with acute heart failure and hypotension.
Zuletzt geändertvor 2 Jahren