4-4
Objective: Signs
Using Basic Tools:
Vitals: Tachycardia >120, tachypnea >30, low BP or 10mm variation in systolic pressure between inspiration
and expiration (pulsus paradoxicus), fever >101 (valvular infection).
Head/Neck: Jugular venous distension (JVD) with meniscus >5cm above the sternal notch when patient
sitting at 30°; lip cyanosis.
Lungs: Fine, crepitant rales (bubbling of alveolar fluid) spreading from the bases to all lung fields; wheezing;
productive cough with pink, frothy fluid; pleural effusion.
Heart: sounds of horse galloping (all four hoofs striking the ground S4S1-S2S3); murmur throughout systole
(mitral regurgitation); murmur throughout diastole (aortic regurgitation).
Extremities: Cyanosis, pitting edema of the ankles and legs.
Using Advanced Tools: EKG: look for ST elevation or new bundle branch block;
Lab: Elevated WBC suggests infection; casts on urinalysis suggest renal failure.
Assessment:
Differential Diagnosis
Acute myocardial infarction - >1mm ST elevation in 2 or more EKG leads
Myocarditis - ST elevation in all EKG leads
Acute infective endocarditis - loud murmur of mitral regurgitation or aortic insufficiency with a fever and
WBC >14K
Hypertensive emergency - diastolic BP >110
Acute blast injury and/or smoke inhalation - sputum contains carbon particles
Multilobar pneumonia - fever, WBC>15, thick yellow/green sputum with WBCs
Mountain Sickness - history of recent arrival at >5000 feet
Plan:
Treatment
Primary:
- Oxygen at 3-5 L/min to raise oxygen saturation above 90%.
- Furosemide (Lasix) starting at 20 mg IV and doubling every 30 minutes until diuresis ensues, up to 200
mg total. There is no additional benefit above 200 mg if diuresis has not ensued. - Nitroglycerin 0.4 mg sublingual, repeating q 5 minutes for a total of 3 doses.
- Sit patient up with legs dangling to ease dyspnea.
- Monitor urine output and weight (2.2 pounds, or 1 kilogram, equals a liter of fluid loss).
Alternative: Intubation with positive pressure breathing (bag-valve-tube forced inhalation) if oxygen saturation
remains <85%.
Primitive: Phlebotomy of 500 cc and rotating tourniquets to decrease venous return.
Empiric: Antibiotics if infective endocarditis is suspected from fever, heart murmur, and red spots on the
fingers. Cephalothin 2 gm IV qid and gentamicin 1.5mg/kg IV q 8 hrs
Patient Education
General: Salt restriction is necessary and weight should not increase over 2 pounds a day.
Activity: Rest, sitting upright until diuresis ensues.
Diet: Clear liquids until oxygen sat >95% and breathing easier, then allow low sodium foods.
No Improvement/Deterioration: Evaluate immediately for evacuation.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate immediately if unable to achieve diuresis or oxygen sat >90%,
for persistent cyanosis or if HR remains over 150 (dysrhythmia). Sedation, intubation with 100% oxygen by
bag-valve-tube ventilation and EKG monitoring (if available) is required for transport. A low altitude flight
is preferable, if possible. Even a healthy 28 yr. old can not remain in CHF over 2-4 hours without risk of
developing life-threatening heart rhythms.