CHF Talk - Beckman Laser · PDF file4- Cyanosis 5- Murmur 6- Crackles ... 1- Flow-by oxygen 2- Oxygen cage 3- Oxygen hood 4- Nasal oxygen

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David Liss, BA, RVT, VTS (ECC, SAIM) Los Angeles, CA

[email protected]

  We will follow this case from admitting to discharge

  Learning principles along the way

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  6y MN Doberman   Presents on emergency

for trouble breathing   On PE:

  HR: 160/ weak pulses   RR: 70   Cyanotic MM’s   Orthopneic posture   Collapsed in the lobby   5/6 Systolic murmur   Crackles heard on

auscultation

  Congestive Heart Failure (CHF) is a syndrome resulting from cardiac disease   Valvular disease

  MVD, Tricuspid dysplasia

  Myocardial disease   DCM, HCM

  Left/Right Side Failure (LEFT = LUNGS)

  Progressive and chronic   Incremental changes occur until they lead to

volume overload

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  Cardiac Output = WORK of the heart   Amount of blood (L) ejected in one minute

  L/min   HR = MIN   Stroke Volume (L)

  Preload   Afterload   Contractility

CARDIAC OUTPUT (L/min)

Heart Rate (min) Stroke Volume (L) components:

Preload: Volume in LV at end diastole

Problems associated: •  Tachycardia •  Bradycardia

Afterload: force heart must pump against

Contractility: Instrinsic strength of the heart

Low blood volume

Weak/ stretched heart

Ventricle wall

stretches No compensatory

increase in contractility

Release of Renin in kidneys

Converts Angiotensinogen to AgI

Aldosterone retains Na+

ADH retains free water

•  Potent Vasoconstrictor •  ADH Release •  Aldosterone Release

Vasoconstriction

Blood pools SV CO

Angio I Angio II

Angiotensin-Converting Enzyme (ACE)

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  Massive fluid retention   Capillary blood vessels swell   Hydrostatic pressure increases- water leaks   Water leaks into interstitium

and eventually alveoli

  Heart failure can occur bi-ventricularly   RIGHT = BODY   LEFT = LUNGS

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1- Doberman 2- Dyspnea/Orthopnea 3- Tachycardia 4- Cyanosis 5- Murmur 6- Crackles

  1- Ensure adequate oxygenation   2- Assess cardiac function   3- Provide sedation (if needed)   4- Increase forward flow   5- Assess for arrhythmias

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  Initial assessment + airway   Airway is clear

  Breathing:   Tachypneic   Orthopneic   Dyspneic

  Options?

  1- Flow-by oxygen   2- Oxygen cage   3- Oxygen hood   4- Nasal oxygen   5- Tracheal catheter   6- Intubation/PPV

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  1- Oxygen provided via face mask

  2- Large bore IV Catheter placed   16 ga R Cephalic

  3- Blood pressure obtained   42 mmHg systolic

  4- Stat Thoracic Ultrasound   5- Furosemide bolus

administered

  Physical Exam

  Radiographs   ECG

  Echocardiogram

  Weak thready pulses   Hypoxic   Murmur   Crackles

  Classic findings (LEFT):   Perihilar interstitial/alveolar pattern   Cardiomegaly   Left atrial enlargement

  Cats may have pleural effusion (rare in dogs with L sided failure)

  Classic findings (RIGHT):   Right atrial enlargement   Ascites   Pleural effusion

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  Validated to assess cardiac size   Step 1: Measure long axis of heart   Step 2: Transfer to cranial edge of T4

  Count how many vertebrae fall within lines

  Step 3: Measure short axis of the heart   Step 4: Transfer to cranial edge of T4

  Count how many vertebrae fall within lines

  VHS = S + L   Canine normal: 8.7-10.7

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Cranial edge T4

Long axis

Short axis

L = 6.1 S = 5.1

S + L = 11.2

  Arrhythmias of all sorts   Sinus

  Tachycardia   Supraventricular

  Atrial Fibrillation   SVT   Atrial Tachycardia

  Ventricular   Ventricular Tachycardia

ATRIAL FIBRILLATION

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  Visual inspection of the heart/lungs   Cardiac function can be assessed

  Atrial/ventricular chamber size   Valve function (doppler flow)   Abnormal pathology

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  1- Diuretics   2- Vasodilators

  3- Positive inotropes

  4- Anti-arrhythmics

  Furosemide is most commonly used/recommended   Inhibits Na reabsorption in Loop of Henle   If tubular fluid contains more Na+ water will follow

  Mobilizes fluid from alveoli/ interstitium and excretes it via urination

  Bolus dose: 2-4 mg/kg   CRI dose: 0.6-1 mg/kg/hr

  Concerns:   1- Additional fluid

may worsen edema   2- Rate could increase

edema   Tips: Use D5W and set

rate equal to 1 ml/hr

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  1- Sodium Nitroprusside   2- Nitroglycerin   Sodium Nitroprusside = VERY short-acting   Given as a CRI- only for limited time   Both reduce ventricular volume (preload) by

increasing venous capacity

  Dobutamine   Increases intrinsic contraction of heart   Improves forward flow   Not long term

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  Inodilator (Positive inotrope and vasodilator)   Good oral bioavailability   Peak effects in one hour   Only give if able to

give PO meds

  Oral vasodilator (arteriodilator)   1 hour onset of action after PO administration   Can be used for refractory heart failure

  Digoxin   Calcium Channel Blockers   Beta blockers

  Careful with DCM   Don’t want to reduce

rate TOO quickly

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  After initial interventions:   Started Lasix CRI   Dobutamine CRI   Weaned off anesthetic

machine- placed in O2 cage

  Started Sodium Nitroprusside CRI

  Continuous BP monitoring

  Patient was noticeably less dyspneic   Added Pimobendan and Hydralazine   Weaned off Sodium Nitroprusside

  Continued in oxygen

  Weaned off Lasix CRI   Started intermittent injections

  Weaned off Dobutamine CRI

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  Off of O2   Oral medications + food/water   Transferred to Cardiology

  Discharged by Cardio   Returned with acute forelimb weakness

  Sudden acute cardiac arrest in hospital

  Questions? [email protected]   Join my Facebook group: ER Vet Tech Rounds