Lecture

• Pathogenic mechanisms of left sided heart failure: CAD, hypertension, arrhythmias, anemia, hyperthyroidism, alcoholism, aortic stenosis and CRF
• Pathogenic mechanisms that cause right sided heart failure: COPD(emphysema/Cor Pulmonale), pulmonary embolism, pulmonic stenosis, valve disease and pericardial constriction
• top 3 pertinent questions of the OPQRST: can you point to where it hurts, does your pain get worse with exertion and does your pain get better with rest
• ask questions about smoking and family hx of MIs if you don't have any PMHx
• Clinical features of CHF: dyspnea/orthopnea, tachypnea/RR >25, increased WOB, hypoxia, JVD and bilateral crackles on auscultation
• Acute causes of LHF are acute hypertension/flash pulmonary embolism, non compliance of med orders and excessive salt and fluid intake
• Primarily listening for these 3 things on auscultation: crackles, wheezing and congestion
• To differentiate between pneumonia and pulmonary edema, auscultate and determine if its dependent or isolated
• For ACPE always inquire about how the PT is sleeping at night or if they have paroxysmal nocturnal dyspnea
• if a PT has a heart rate over 160, their coronary arteries aren't being perfused; why NTG is contraindicated in those cases
• The crackles sound is caused by fluid disrupting the surface tension and crushing alveoli
• Fine crackles are in the bases while coarse is near major airways
• The congestion sound is caused by mucus and it's thick and sticky
• Isolated crackles are indications of infections
• Dependent crackles is influenced by gravity or positioning of the patient
• Chronic Renal Failure(CRH): PT can't piss so there's fluid overload or they piss too much and nothing's filtered
• Bilateral crackles differentiate heart failure from pneumonia
• Ascites can cause fluid to press against the diaphragm to increase SOB
• For onset ask if it started suddenly or over a long period of time
• Levels of severity won't help narrow down your diagnosis but will give you insight
• Patients with heart failure rarely have pain on inspiration
• If PT is coughing or has had a cough, ask if its productive or not
• Pink/Frothy sputum indicates heart failure or alveolar issues
• For COPD ask: speed of onset, history of recent illnesses, if they have a productive cough or worsening symptoms
• Blood tinged sputum is indicative of pneumonia or a pulmonary embolism
• Cardiac asthma presents with a CC of SOB. It is the spazzing of vessels which causes wheezing to be present on inspiration; must also decide whether to use NTG or Ventolin in these cases as it can be hard to differentiate this from asthma
• Asthma is louder and a lot more central than cardiac asthma
• Pneumonia is an isolated infection of one side of the lungs. It usually entails a hx of fevers and chills, productive cough of yellow/green/brown sputum and sometimes pleuritic chest pain.
• Congestion is heard on auscultation for pneumonia
• Sputum can be brown if PT has COPD and Pneumonia at the same time
• Infections can cause vasodilation which drops BP. This a good differential for respiratory infections vs other things
• In acute pulmonary embolism: there's rapid onset, PT is normovolemic and there's no changes to the heart structure
• Managing HF involves: oxygenation(To standard), positioning(sitting them up), preload reduction(Give NTG) and reduce stress and promote rest(Do not ambulate/these are CTAS 1-2 patients)
• In the ACPE directive the PT can be altered due to hypoxia that comes from moderate to severe SOB
• In the ACPE directive, dosing is dependent on history, blood pressure and IV access
• Cardiac ischemia and ACPE directives are not to be combined
• AMI could be the cause of ACPE but ASA will likely be contraindicated bcuz of altered LOAs
• Indications of ACPE is moderate to severe respiratory distress and suspected acute cardiogenic pulmonary edema
• Conditions for NTG for ACPE is that they must be 18 or older, HR must be 60 to 159 BPM and their SBP must be 100 or greater
• Contraindications for NTG for ACPE: allergy or sensitivity to nitrates, Phosphodiesterase inhibitor use within the previous 48 hours and SBP drops by 1/3 of its initial value after NTG is given. Unlike cardiac ischemia, there is no contraindication of right ventricular MI