0071643192.pdf

■ Medication: Effect or noncompliance

■ Sodium load (diet)

■ Volume overload, often iatrogenic

Decompensation may be acute or gradual in onset, depending on the under-

lying trigger. Cardiogenic pulmonary edema occurs when a rapid elevation of

pulmonary capillary hydrostatic pressure forces fluid from the intravascular

space into the alveolar space.

SYMPTOMS

■ Fatigue, weakness, memory problems

■ Mild dyspnea to marked respiratory distress (depending on severity)

■ Left heart failure

■ Dyspnea

■ Orthopnea

■ Paroxysmal nocturnal dyspnea

■ Right heart failure

■ Dyspnea

■ Abdominal distention or pain

■ Leg swelling

EXAM

■ Diaphoresis, tachycardia, HTN: From sympathetic activation

■ Tachypnea, rales, and/or “cardiac” wheezes

■ S3 and S4 gallop

■ Underlying or associated right heart failure

■ Hepatic enlargement

■ Peripheral edema

■ Jugular venous distention

■ Hepatojugular reflex

■ End stage =severe hypoxia and ventilatory failure with mental status change

and terminal dysrhythmias

■ Look for evidence of underlying cause/event: infection, PE, valvular disease.

DIFFERENTIAL

■ Noncardiogenic pulmonary edema in which capillary membrane perme-

abilityis compromised (infection, ARDS, drug reaction)

■ Pneumonia, asthma, COPD, PE

DIAGNOSIS

■ ECG

■ Look for LVH, ischemia, dysrhythmias.

■ Upright chest radiograph (CXR)

■ CXR findings may lag clinical findings!

■ Progression of CXR changes

■ Vascular congestion (cephalization of vessels) →

■ Interstitial edema (Kerley B lines, haziness) →

■ Alveolar infiltrates (butterfly pattern, effusions)

■ Normal heart size? Suspect noncardiogenic pulmonary edema or acute

valve failure.

■ Labs

■ To identify underlying causes: renal failure, anemia, MI, hyperkalemia

■ B-type natriuretic peptide (BNP)

■ Released in response to ventricular myocyte stretch

■ Level →with severity of CHF

CARDIOVASCULAR EMERGENCIES

BNP < 100 pg/mL makes heart

failure unlikely.