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Vincent N. Mosesso, Jr., MD, James Dunford, MD, Thomas Blackwell, MD, John K. Griswell, MD vices (EMS) personnel in the future.
accurate diagnosis of CHF. Key words:
left ventricular (LV) filling pressures.
Congestive heart failure (CHF) is
Received May 13, 2002, from the University Pennsylvania; the University of California,San Diego Medical Center (JD), San Diego, (JKG), Fort Worth, Texas. Revision receivedAugust 21, 2002; accepted for publication Presented at the Turtle Creek Conference IV, Dallas, Texas, February 27–March 1, 2002.
requests to: Vincent N. Mosesso, Jr., MD, Pittsburgh, PA 15213. e-mail: <mosessovn@ *Reproduced with permission from: Marx J, Hockberger R, Walls R. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed.
prompt relief of respiratory distress.
Field Assessment
another.11 The correct identificationof the precipitating events andthe immediate administration ofappropriate treatment are criticalfor a positive outcome in CHFpatients, because inappropriatetherapy initiated as a result of mis-diagnosis may result in deleteriouseffects. Hoffman and Reynolds10reported that adverse effects weremore common in misdiagnosedpatients. Untoward effects includ-ed 1) respiratory depression (withor without lethargy) in patientswho received morphine; 2)hypotension and bradycardia inpatients who received both mor-phine and nitroglycerin; and 3)arrhythmia associated with hypo-kalemia and hypotension in pa-tients who received furosemide.
ditions, including myocardialischemia, hypertensive crisis, fluidexcess, medication noncompliance,diet, and overexertion, may trigger FIGURE 1. Processes involved in pulmonary edema. Cycle may begin at any point but oncebegun is self-perpetuating. Reprinted with permission from: Sacchetti AD, Harris RH. Acute cardiogenic pulmonary edema. What’s the latest in emergency treatment? Postgrad Med.
1998;103:145-66. The McGraw-Hill Companies.
• Hypertension or cardiovascular disease • Ischemic heart disease• Valvular disease • Diet or exercise indiscretions• Signs of pulmonary edema such as • Signs of chronic obstructive pulmonary • End-tidal carbon dioxide trends• Electrocardiogram rhythm and 12-lead if Reduction of LV Preload
• Identify and treat specific etiology • Provide inotropic support when needed • Provide oxygen and ventilatory support • Match receiving facility with needed output to more closely matchinflow from the pulmonary sys- MANAGEMENT OF APE
reduction of LV preload in the field.
It is fast acting, efficient, and easy to Furosemide
Combined Drug Therapies
with Nitroglycerin, Furosemide,
and Morphine
Reduction of LV Afterload
Nitrates at Higher Doses
Natriuretic Peptides
ACE Inhibitors
Ventilatory Support
Noninvasive Positive
Pressure Ventilation
to increase intra-alveolar pressure.
Brett Kaplan, and Janice Liesch for their edi-torial assistance.
Inotropic Support
MIs) with high-dose nitrate thera-py (10% MIs) (p = 0.006).63 Very dif- CONSENSUS
The consensus of the group
I Asymptomatic
II Mild Symptoms
III Moderate
IV Severe
*Treatment at each level should consider the lowest dose applicable; SL = sublingual; MDI = metered-dose inhaler; SBP = systolic blood pressure; IV = intravenous;ECG = electrocardiogram; ETI = endotracheal intubation; NIPPV = noninvasive passive pressure ventilation.
lines for the Evaluation and Manage-ment of Heart Failure). J Am Coll ONCLUSION
ment. Eur J Heart Fail. 2002; 4:227-34.
Herlitz J. Has an intensified treatment in severe left heart failure improved the out- come? Eur J Emerg Med. 2000;7:15-24.
6. Bertini G, Giglioli C, Biggeri A, et al.
edema. Ann Emerg Med. 1997;30:493-9.
edema. Cardiol Clin. 1984;2:183-200.
8. Marx J, Hockberger R, Walls R. Rosen’s Clinical Practice, 5th ed. St. Louis, MO: 9. Cecil RL, Bennett JC, Goldman L. Cecil phia, PA: W. B. Saunders Company, 1999.
10. Hoffman JR, Reynolds S. Comparison of 12. Sacchetti AD, Harris RH. Acute cardio- Pulmonary edema: new insight onpathogenesis and treatment. Curr Opin References
1. Croft JB, Giles WH, Pollard RA, Keenan patient with dyspnea. J Gen Intern Med.
16. Little B, Ho KJ, Scott L. Electrocardio- gram and rhythm strip interpretation byfinal year medical students. Ulster Med population. Arch Intern Med. 1999;159:505-10.
3. Hunt SA, Baker DW, Chin MH, et al.
diagnosis of heart failure. N Engl J Med.
ACC/AHA guidelines for the evalua-tion and management of chronic heart 18. Maisel A. B-type natriuretic peptide in failure in the adult: executive summary.
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33. Hamilton RJ, Carter WA, Gallagher EJ.
itive pressure ventilation in status asth- et al. Utility of B-type natriuretic pep- tide in the diagnosis of congestive heart pril. Acad Emerg Med. 1996;3:205-12.
49. Pennock BE, Crashaw L, Kaplan PD.
Maisel A. Utility of a rapid B-natriuretic acute respiratory failure: institution of a 35. Langes K, Siebels J, Kuck KH. Efficacy congestive heart failure. Curr Ther Res.
21. Tabbibizar R, Maisel A. The impact of B- 36. Annane D, Bellissant E, Pussard E, et al.
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support in the emergency department.
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and tolerance. Eur J Clin Pharmacol.
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56. Takeda S, Nejima J, Takano T, et al.
for acute heart failure? Lancet. 1996;347: ventilation in acute respiratory failure.
60. Mehta S, Jay GD, Woolard RH, et al.
trial of BiPAP in severe acute congestive 61. Antonelli M, Conti G, Rocco M, et al. A 63. Sharon A, Shpirer I, Kaluski E, et al.
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Heart failure: Part II. West J Med. 1999; 62. Masip J, Betbese AJ, Paez J, et al. Non-


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