Sandbox/22

Management

Characterize the symptoms: ❑ Cardiac ❑ Chest pain ❑ Cough ❑ Dyspnea at rest ❑ Exertional dyspnea ❑ Orthopnea ❑ Palpitation ❑ Paroxysmal nocturnal dyspnea ❑ Peripheral edema ❑ Extracardiac ❑ Anorexia ❑ Bloating ❑ Fatigue ❑ Nausea ❑ Oliguria ❑ Weight loss Obtain a detailed history: ❑ Medications: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs ❑ Thiazolidinedione ❑ Past medical history ❑ Arrhythmias ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Obesity ❑ Previous myocardial infarction ❑ Sleep disorders ❑ Thyroid disease ❑ Valvular heart disease ❑ Family history ❑ History of dilated cardiomyopathy ❑ Radiation to the chest

Examine the patient: ❑ General examination: ❑ Pulse rate - ↑ ❑ Blood pressure - ↑ or ↓ ❑ Respiratory rate - ↑ ❑ Weight ❑ Head/neck examination: ❑ ↑ JVP ❑ Cardiovascular examination: ❑ Wheeze (cardiac asthma) ❑ S3 or S4 or both ❑ New or changed murmur ❑ Respiratory examination ❑ Crackles ❑ Abdominal examination: ❑ Hepatomegaly ❑ Ascites ❑ Neurological examination: ❑ Altered mental status ❑ Extremity examination: ❑ Pedal edema ❑ Assess severity - NYHA or ACC/AHA scales Consider close differential diagnoses: ❑ Acute asthma ❑ Acute respiratory distress syndrome ❑ Cardiac tamponade ❑ Pneumonia ❑ Pulmonary embolism

Initial stabilization: ❑ Assess airway, pulse oximetry ❑ Nurse 45 degrees upright ❑ Give oxygen, if Sa02 ↓90% by non-rebreather face masks ❑ Continuous cardiac monitoring ❑ Intravenous access ❑ Monitor vitals - Pulse, BP ❑ Monitor urine output ❑ Order ❑chest x ray ❑ Cardiomegaly ❑ Pulmonary edema ❑ Kerley B lines ❑EKG ❑ Evidence of ischemia ❑ Infarction ❑ Arrythmia ❑ Left ventricular hypertrophy

Order laboratory tests: ❑ CBC ❑ Troponin ❑ Electrolytes - ↓Na ❑ serum calcium ❑ serum magnesium ❑ BUN, creatinine - ↑ ❑ Arterial blood gas ❑ Fasting blood sugar ❑ Liver function tests ❑ BNP or NT-pro BNP (if diagnosis is uncertain) Other additional laboratory tests: ❑ TSH ❑ Urinalysis ❑ ANA, rheumatoid factor ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑ Radionuclide ventriculography or MRI ❑ Coronary angiography ❑ Endomyocardial biopsy ❑ Pulmonary artery catheterization - in respiratory distress or shock

Consider admission: ❑ Hypotension and/or cardiogenic shock ❑ Poor end-organ perfusion - worsening renal function, cold clammy extremities, altered mental status ❑ Hypoxemia - Sa02 ↓90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Presence of an acute coronary syndrome

Acute treatment

Persistent respiratory distress ❑ Noninvasive positive pressure ventilation (NPPV) ↓ ↓ ❑ Mechanical ventilation (PEEP)

Cardiogenic shock

Treat precipitating causes/co-morbidities ❑ Acute aortic/mitral regurgitation ❑ Acute coronary syndrome ❑ Anemia ❑ Atrial dissection

Assess hemodynamic and volume status (± Congestion & Poor perfusion)

Warm & Dry

Warm & Wet

Cold & Wet

Cold & Dry

Monitoring

Discharge and follow-up