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Heart Failure

Acute/severe shortness of breath follow acute pulmonary oedema

Suspected Heart Failure (HF) causing Acute Pulmonary Oedema/Congestion

History/examination
inc. baseline observations (HR, BP, Temp, Resp Rate, Spo2, EWS, AVPU)
Investigations:

  • ECG - CXR - Urinalysis
Bloods:

  • FBC, Glucose, Arterial/Venous Blood Gases

Immediate management of colon and side if acute pulmonary oedema seen on ECG/CXR

Intravenous bolus of loop diuretic

Hypoxaemia

- Titrate oxygen to O2 Sats on air
- Check ABC if O2 sats <90%

Are O2 Sats <90% on 60% O2?

YES
- Consider NIV and referral to critical care
- Indications for NIV: pH <7.35 with PcO2 >6.0

NO

Consider i.v. opiate if severe anxiety/distress

SBP <85 mmHg or shock

- Senior Review for decision to treat
- Consider referral to CCU or HDU

Add non-vasodilating inotropes

SBP 85–110 mmHg

No additional therapy until response assessed

SBP >150 mmHg

Consider vasodilator (e.g. GTN)

Adequate response to treatment?

- EWS < 3
- Reduction in dyspnoea
- Adequate diuresis (>100 mL/h urine production in first 2 h)
- Accompanied by an increase in oxygen saturation (if hypoxaemic)
- Reduction in heart and respiratory rate (which should occur in 1–2 h).

- Improved capillary refill time. Peripheral blood flow may also increase as indicated by a reduction in skin vasoconstriction, an increase in skin temperature, and improvement in skin colour.

Adequate Response

- Full set of physiological observations (at least 4 hrly)
- Fluid balance (at least 4 hrly)
- Daily weight chart initiated (within 24 hrs)

HF team will review patients with BNP >400 within 24 hours of BNP result

Continue present treatment
Once the patient is comfortable and a stable diuresis has been established, withdrawal of i.v. therapy can be considered (with substitution of oral diuretic treatment).

Ensure Management of:
- Fluid overload (diuretics prescribed)
- Renal dysfunction

Repeat U&Es within 48 hours

ECHO performed within 48 hours of BNP

Ensure daily body weight is monitored for duration of admission

Inadequate Response

- ECHO/Cardiology review (within 2 hours)
- Ceiling of Care
- BNP/Troponin Result

Seek urgent Cardiology review if:
SBP not maintained >85mmHg
OR
SpO2 <90%
OR

Urine output <20 mL/h at 2 hours