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Microsoft word - lvf.doc

Acute LVF
Oxygen (Target SaO2: 94-98%)
Patient in HDU / Resus
Normal BP
- Give iv Furosemide (20-40 mg)
- Consider: GTN inf if SBP > 110 mmHg
- Consider Morphine (2-5 mg IV) only
if in pain or restless
- Give Clexane 1 mg/ttkg sc if not
anticoagulated and/or containdicated
Senior help
Involve ITU
Resp or mixed
Involve Outreach Team / ITU

See explanation and key points below:

Version 1.0 (Feb 2013) Review date: Feb 2015 Clinical presentation:
- Dyspnoea - Tachycardia (sinus tachycardia) o If arrhythmia (broad or narrow complex tachycardia or bradycardia or new onset AF is present, treat that first!) - Blood pressure is usually high (increased afterload is often the trigger); o if patient is hypotensive then treat it as Cardiogenic shock - or consider alternative diagnosis (e.g. COPD, chest infection, septic shock, etc.)! - Patient is in a distress: skin is cold and clammy - Wheezing and crackles Investigations:
- If MEWS score > 4, the patient must be seen / treated in Resus - Monitoring (SaO2, ECG, NIBP) - 12 lead ECG. Consider right sided and posterior leads if necessary. - Bloods (U&E, FBC, CRP, Creat, LFT, INR (if on warfarin or AF), Troponin (if chest pain within the past 7 days or diabetic), Se Mg. - ABG (to assess tissue hypoxia by checking metabolic acidosis) - Chest X-Ray (portable) - Temperature - Consider to arrange emergency bedside echocardiography if: o Myocardial infarction within the past 7 days (assess acute MR) o (Presumably) new heart murmur o Clinical suspicion of pericardial tamponade o If BP drops MANAGEMENT:
- Keep the patient in a comfortable sitting position - Give high flow (10-15 l/min) oxygen via non-rebreathing face mask - If LVF is the result of an arrhythmia apply electrical DC cardioversion (see - If ACS is the likely casue of the LVF early and aggressive revascularisation (PCI) strategy should be pursued. Contact senior cardiology team. - Increased afterload is one of the most common cause of acute LVF. When diastolic blood pressure is high (DBP > 90 mmHg) GTN would be the best
choice to reduce afterload. Give Nitroglicerin (GTN) IV infusion 10-20
mcg/min to start, could then be increased up to 200 microgramm/min.
o Reduces afterload and preload o Could be titrated against BP and clinical signs (short halflife) Version 1.0 (Feb 2013) Review date: Feb 2015 o Don’t give if BP < 110 mmHg or HR < 50/min - Furosemide 20-40 mg IV
o Reduces afterload (vasodilation) and preload o Diuretic effect is slower and cannot be titrated o Don’t give if BP < 90 mmHg - Consider Morphine (very careful, 2-5 mg IV) in case of pain
o Reduces sympathetic tone, heart rate and afterload - Patients in acute LVF need anticoagulation. Give LMWH (enoxaparin /
Clexane 1 mg/kg sc.) unless contraindicated (e.g. active bleeding) or already
on warfarin.
- Digoxin could only be useful in AF with fast ventricular rhythm. Its effect is
slow and weak in a case of acute LVF but patient might benefit from
digitalization in the longer term.
- DO NOT USE POSITIVE INOTROPES (Dopamin, Dobutamin, etc.) in LVF
unless in cardiogenic shock and under the supervision of senior ITU doctor
(central line and arterial line is mandatory such as the introduction of invasive
haemodynamic monitoring in the ITU as early as possible.)
- CPAP is very effective and non-invasive treatment for acute LVF. It reduces the afterload and increases tissue oxygenation. There is no evidence that long term mortality would be affected. o Metabolic acidosis (BE < -2) confirms tissue hypoxia o Patient is conscious and co-operative with CPAP If GCS reduced or patient deteriorates:
- early intubation and IPPV (PEEP) is recommended Cardiogenic shock:
- Acute left ventricular failure with SBP < 90 mmHg due to reduced - Most common cause is ACS
- Treatment:
o If GCS reduced: intubation and ventilation with PEEP o Intra Aortic Balloon Pump (IABP) and revascularisation (PCI) o Inotropic / inodilator drug treatment should be initiated if IABP is not available with the discussion of ED senior + ITU / Cardiology senior. (Need CV line and arterial line and haemodynamic monitoring) This policy lays out guidance in relation to Acute Left Ventricular Failure Version 1.0 (Feb 2013) Review date: Feb 2015 All staff working in the ED at East Surrey Hospital Dr J Webb, Lead Consultant in Emergency Medicine Dr C Dioszeghy Consultant in EM / Guideline Medical Division Management Board for Quality and Risk (submission 11th February2013) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 – European Heart Journal, doi: 10.1093 /eurheartj/ehs104 Version 1.0 (Feb 2013) Review date: Feb 2015

Source: http://emergencymedicinegroup.co.uk/Left%20Ventricular%20Failure%20(LVF)%20-%202013.pdf

Microsoft word - 31000004.doc

DELIBERAZIONE DEL CONSIGLIO COMUNALE OGGETTO : MODIFICA ART. 9 DEL REGOLAMENTO COMUNALE PER L'APPLICAZIONE DELLA TASSA PER LO SMALTIMENTO DEI RIFIUTI SOLIDI URBANI. L’anno duemiladieci , addì uno , del mese di marzo, alle ore 15 e minuti 15, nella sala delle adunanze consiliari , convocato dal Sindaco mediante avvisi scritti e recapitati a norma di legge, si è riunit


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