Managing Acute Heart Failure in the Emergency Department

Patient case study

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Initial Diagnosis Revised Diagnosis Teaching Points

Case Introduction and Care Plan and Care Plan Discussion and Conclusions

1 3 5 7

2 4 6

Glossary

Case Details Diagnostic Disposition

and Initial Triage Results Decision
? Questions

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Salvatore Di Somma, MD PhD

Emergency
Emergency Medicine
Medicine Department,
Department,
Sant’ Andrea Hospital,
Sant’ Andrea Hospital,
School
School of
of Medicine
Medicine && Psychology,
Psychology,
University
University of
of Roma
Roma “Sapienza”
“Sapienza”
(Rome;
(Rome; Italy)
Italy)

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Background
•• This
This is
is the
the ER
ER of
of an
an academic
academic tertiary
tertiary care
care
hospital
hospital in
in a
a large
large urban
urban city
city
•• Approximately
Approximately 55,000
55,000 patients
patients are
are admitted
admitted
to
to this ER annually, of which 2,200 cases
this ER annually, of which 2,200 cases
were
were AHF. This ED handles any type of
AHF. This ED handles any type of
emergency
emergency
•• During
During this
this case,
case, 11 attending
attending and
and 1 1 fellow
fellow
were
were onon duty
duty
•• You
You have
have access
access toto (less
(less than
than 3030 minutes)
minutes)
ECG,
ECG, bedside
bedside ultrasound
ultrasound andand comprehensive
comprehensive
echo,
echo, biomarkers
biomarkers data
data and
and chest
chest XX ray
ray
•• You
You have
have access
access toto a
a cath
cath lab
lab

ECG=electrocardiogram; echo=echocardiogram; ER=Emergency Room

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Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

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History of Present Illness Past History, Allergy

and Review of systems HP
I History, Medications,
and Social History

Chief Complaint Physical

and Vital Signs Examination

CASE DETAILS
AND INITIAL TRIAGE

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE

Chief Complaint
“I am short of breath”

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Vital Signs (at Triage)
•• BP:
BP: 220/140
220/140 mmHg
mmHg
•• HR:
HR: 180
180 bpm
bpm
•• RR:
RR: 40
40 brpm
brpm
•• Temperature:
Temperature: 36.4°C
36.4°C // 97.5°F
97.5°F
•• O
O22 sat:
sat: 97%
97% with
with O
O22 14
14 L/min
L/min supply
supply

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate;
O2 sat=oxygen saturation; RR=respiration rate
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

I
HP

CASE DETAILS
AND INITIAL TRIAGE
History of Present Illness
•• 46-year-old
46-year-old female
female brought
brought toto the
the ED
ED byby
ambulance for sudden onset of
ambulance for sudden onset of acute acute
shortness
shortness of
of breath
breath that
that occurred
occurred with
with
vomiting.
vomiting. Symptoms
Symptoms beganbegan less
less than
than
30
30 minutes
minutes prior
prior to
to arrival.
arrival. She
She also
also
complains
complains of a productive cough for
of a productive cough for the
the last
last
few days.
few days.

More
ED=Emergency Department
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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CASE DETAILS
AND INITIAL TRIAGE
Review of Systems
•• +
+ cough
cough but
but no
no fever
fever
•• No
No abdominal
abdominal pain
pain
•• No
No back
back pain
pain
•• No
No rash
rash
•• No
No fatigue
fatigue
•• No black
No black or
or bloody
bloody stools
stools
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Past History
•• April
April 2013:
2013: right
right lung
lung lobectomy
lobectomy for
for lung
lung
cancer treated with radiotherapy
cancer treated with radiotherapy
•• Recent
Recent deep
deep vein
vein thrombosis
thrombosis treated
treated with
with oral
oral
anticoagulant
anticoagulant

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Allergy History, Medications,
and Social History
Allergies Medications
• Adverse reaction • Methylprednisolone:
with Novocaine 16 mg/day (related to the
history of cancer)
Social History • Warfarin on the basis of
• Never smoked scheduled INR values
• Very rare alcohol
• No illicit drug use

INR=international normalized ratio

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Physical Examination (Focused
(Focused Exam)
Exam)
•• +JVD
+JVD
•• Severe
Severe respiratory
respiratory distress
distress (RR:
(RR: 40
40 brpm)
brpm)
•• Wheezing
Wheezing and and bilateral
bilateral inspiratory
inspiratory rales
rales
•• Tachycardic
Tachycardic (HR:180
(HR:180 bpm)
bpm)
•• Aortic
Aortic II/VI
II/VI systolic
systolic murmur
murmur and
and unspecified
unspecified gallop
gallop
rhythm
rhythm
•• No
No peripheral
peripheral edema
edema
•• Profuse
Profuse warm
warm sweating
sweating
•• Rest
Rest of
of the
the exam
exam isis unremarkable
unremarkable

bpm=beats per minute; brpm=breaths per minute; HR=heart rate; JVD=jugular venous distension;
RR=respiratory rate
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Clinical Impression
(Initial Diagnosis)
Initial Plan of Care
and Differential
Diagnosis

INITIAL DIAGNOSIS
AND CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
•• Acute
Acute cardiogenic
cardiogenic pulmonary
pulmonary edema
edema
•• Pulmonary
Pulmonary edema
edema secondary
secondary to
to hypertensive
hypertensive
crisis
crisis
•• Pulmonary
Pulmonary edema
edema secondary
secondary to
to ACS
ACS
•• Pulmonary
Pulmonary edema
edema secondary
secondary to
to severe
severe aortic
aortic
stenosis
stenosis
•• Aspiration
Aspiration pneumonia
pneumonia asas dyspnea
dyspnea began
began after
after
vomiting
vomiting
•• Pulmonary
Pulmonary embolism
embolism because
because patient
patient has
has aa
history
history of
of DVT
DVT on
on warfarin,
warfarin, cancer
cancer history
history and
and
sudden
sudden onset
onset of
of dyspnea
dyspnea
ACS=acute coronary syndrome; BP=blood pressure
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN Initial Plan of Care
Diagnostic
Diagnostic plans: plans:
•• Vein
Vein cannulation
cannulation with with i.v.
i.v.
•• Laboratory
Laboratory tests included BNP
tests included BNP and
and Hs
Hs Troponin
Troponin II
•• Blood gas
Blood gas analysis
analysis
•• ECG
ECG (12 leads and
(12 leads and continuous
continuous cardiac
cardiac monitoring)
monitoring)
•• POCT
POCT bedside ultrasound of heart, lungs and
bedside ultrasound of heart, lungs and inferior
inferior
vena cava
vena cava
•• Chest
Chest X X ray
ray
Therapeutic
Therapeutic considerations:
considerations:
•• Diuretics
Diuretics (furosemide)
(furosemide) i.v. i.v.
•• Nitrates i.v.
Nitrates i.v.
•• Nebulized -agonist
Nebulized -agonist (albuterol)
(albuterol) and
and anti-cholinergic
anti-cholinergic
(ipratropium)
(ipratropium)
•• Corticosteroids
Corticosteroids i.v.i.v.
•• Oxygen
Oxygen
•• Potential
Potential rate
rate or
or rhythm
rhythm control
control depending
depending on on further
further
evaluation with
evaluation with ECGECG

BNP=B-type natriuretic peptide; ECG=electrocardiogram; i.v.=intravenous; More

POCT=point of care testing
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN Initial Plan of Care (cont’d)
As
As diagnostic
diagnostic workwork up
up is
is ongoing:
ongoing:
•• NIV
NIV isis immediately
immediately started
started
•• i.v.
i.v. nitrates are begun and
nitrates are begun and titrated
titrated aggressively
aggressively to
to
symptoms and
symptoms and BP BP

BP=blood pressure; i.v.=intravenous; NIV=non-invasive ventilation

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Lab Results Chest X ray

DIAGNOSTIC RESULTS
ECG Ancillary Imaging

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS ECG Click here for
ECG:
Interpretation
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS ECG: Interpretation
•• Supraventricular
Supraventricular tachycardia,
tachycardia, 180
180 bpm
bpm
•• ST
ST depression
depression throughout
throughout the
the precordium,
precordium, no
no clear
clear
P waves
P waves

bpm=beats per minute

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DIAGNOSTIC
RESULTS Chest X ray Click here for
Chest X ray:
Interpretation

? QUESTION
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Chest X ray: Radiology Interpretation
Obtained
Obtained within
within 1
1 hour
hour from
from presentation
presentation
Findings
Findings
•• Signs
Signs of
of previous
previous right
right lobectomy
lobectomy
•• Multiple
Multiple bilateral
bilateral areas
areas of
of consolidation,
consolidation, mainly
mainly
in
in the
the right
right middle
middle zone
zone with
with pleural
pleural effusion
effusion
•• Cardiac enlargement
Cardiac enlargement
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Ancillary Imaging Click here for
Ancillary imaging:
Bedside
Bedside (2
(2 minutes)
minutes) thoracic
thoracic ultrasound
ultrasound was
was
performed:
performed: Interpretation

Chest echocardiogram Echocardiogram

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Ancillary Imaging: Interpretation
Chest
Chest echo
echo
•• Bilateral
Bilateral “comet-tail”
“comet-tail” signs
signs

Echocardiogram
Echocardiogram
•• Myocardial
Myocardial hypokinesis
hypokinesis
•• Normal
Normal left
left and
and right
right sections
sections dimensions
dimensions
•• Absence
Absence of
of pericardial
pericardial effusion
effusion   

IVC
IVC
Appears
Appears full
full with
with no
no collapsibility
collapsibility with
with respiration
respiration
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Lab Results (or POCT Results)
Lab results were obtained within 1 hour from admission, while
results of point of care blood gas analysis and biomarkers were ? QUESTION

obtained within 15 minutes

(reference range) (reference range)
• Hb: 17 g/dL (12–16 g/dL) Blood Gas Analysis
• WBC: 18.480/L (4.3–18.8/L) • O2: 14 L/min
• PLT: 288.000/L (140–400/L) • pH: 7.05 (7.35–7.45)
• pCO2: 67 mmHg (35–45 mmHg)
• BUN: 20 mg/dL (5–25 mg/dL)
• pO2: 121 mmHg (80–100 mmHg)
• Creatinine: 1.21 mg/dL (0.7–1.1 mg/dL)
• Lactate: 13.9 mmol/L (<2 mmol/L)
• Na+: 139 mmol/L (136–145 mmol/L) • HCO3‾: 18.5 mmol/L (22–26 mmol/L)
• K+: 3.2 mmol/L (3.5–5.1 mmol/L) • SO2: 97%
• PCT: 0.08 ng/mL (<0.05 ng/mL)
• BNP*: 52.2 pg/mL (<100 pg/mL)
• HS-TnI#: 20 pg/mL (0–15.6 pg/mL)
• INR: 2.83 (0.9–1.2)
• D-dimer 505 ng/mL (<243 ng/mL)

*Abbott Diagnostic Assay, #Abbott Diagnostic Assay.

BNP=B-type natriuretic peptide; BUN=blood urea nitrogen; Cr=creatinine; Hb=hemoglobin; HS-TnI=high-sensitivity troponin I;
INR=international normalized ratio; PCT=procalcitonin; PLTs=platelets; WBC = white blood cell count
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Revised Clinical
Impression and
Next actions
Differential Diagnoses

REVISED DIAGNOSIS AND

CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN
Revised Clinical Impression
and Differential Diagnoses
Presence of:
• Sudden onset of dyspnea
• Elevated BP levels
• Acute respiratory failure
• Bilateral “comet tails”
• Normal right side cardiac function Our diagnostic
hypothesis:
Absence of: Flash pulmonary
REVISEDdyspnea
• Gradual worsening DIAGNOSIS AND
edema in hypertensive
• Fatigue CARE PLAN crisis with potential
• Lower limb edema aspiration pneumonia
• Fever

BP=blood pressure
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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REVISED DIAGNOSIS
AND CARE PLAN
Next Actions
Patient
Patient immediately
immediately started:
started:
•• Furosemide 100
Furosemide 100 mg
mg asas i.v.
i.v. bolus
bolus
•• Nitroglycerin
Nitroglycerin 0.9
0.9 mg/h (15 g/min)
mg/h (15 g/min) as
as i.v.
i.v. infusion
infusion
•• Morphine 5 mg as i.v. bolus
Morphine 5 mg as i.v. bolus

i.v.=intravenous
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DISPOSITION
DECISION
Disposition
•• Patient
Patient rapidly
rapidly improved
improved during
during her
her ED
ED course
course (<4
(<4
hours)
hours)
•• Patient
Patient was
was then
then admitted
admitted toto the
the Emergency
Emergency
Medicine
Medicine ward (hospital floor – this ED
ward (hospital floor – this ED has
has its
its own
own
inpatient service as well) with continuous monitoring
inpatient service as well) with continuous monitoring
and
and frequent
frequent re-evaluation
re-evaluation forfor 72
72 hours
hours with
with
progressive
progressive clinical
clinical and
and hemodynamic
hemodynamic improvement
improvement
•• NIV was
NIV was slowly
slowly weaned
weaned
•• ACS
ACS was
was excluded
excluded with
with further
further HS-TnI
HS-TnI and
and serial
serial
ECG evaluation
ECG evaluation

ACS=acute coronary syndromes; ED=Emergency Department; HS-TnI=highly-sensitive troponin I; NIV=non-

invasive ventilation
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Teaching Discussion and

Points Conclusions

TEACHING POINTS, DISCUSSION

AND CONCLUSIONS

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
Teaching Points
CONCLUSIONS
•• Hypertensive
Hypertensive crisis
crisis can
can generate
generate pulmonary
pulmonary
edema due to acute vasoconstriction
edema due to acute vasoconstriction
(increased
(increased afterload)
afterload)
•• BNP
BNP may
may be
be falsely
falsely negative
negative in
in flash
flash
pulmonary edema
pulmonary edema
•• Patients
Patients often
often improve
improve very
very quickly.
quickly. Prompt
Prompt
regression
regression of signs and symptoms after rapid
of signs and symptoms after rapid
treatment
treatment
BNP=B-type natriuretic peptide
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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TEACHING POINTS,
DISCUSSION AND
Discussion and Conclusions
CONCLUSIONS
•• Flash
Flash pulmonary
pulmonary edema
edema is is a
a general
general clinical
clinical term
term used
used
to describe a particularly dramatic form of
to describe a particularly dramatic form of acute heart acute heart
failure
failure
•• It
It is
is a
a medical
medical emergency
emergency markedmarked by by the
the sudden
sudden
accumulation
accumulation of fluid in one’s lungs. It should
of fluid in one’s lungs. It should be be noted
noted
that despite prompt treatment, it is possible
that despite prompt treatment, it is possible for one’s for one’s
condition
condition toto rapidly
rapidly deteriorate,
deteriorate, resulting
resulting in in the
the need
need for
for
intubation and/or death
intubation and/or death
•• Flash
Flash pulmonary
pulmonary edema
edema has has been
been difficult
difficult to
to study
study given
given
the severity of the patient’s symptoms
the severity of the patient’s symptoms and the rapidand the rapid
resolution
resolution with
with prompt
prompt treatment,
treatment, often
often to to the
the point
point of
of
complete resolution of signs and symptoms
complete resolution of signs and symptoms in the ED in the ED
More
ED=emergency department
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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TEACHING POINTS,
DISCUSSION AND
Discussion and Conclusions cont’d
CONCLUSIONS
•• Natriuretic
Natriuretic peptide
peptide levels
levels may
may be
be ‘negative’
‘negative’ when
when the
the onset
onset
of AHF is very rapid, such as flash pulmonary
of AHF is very rapid, such as flash pulmonary edema edema
•• Later
Later measurement
measurement wouldwould demonstrate
demonstrate an an elevated
elevated
natriuretic
natriuretic peptide level. However, flash pulmonary edema
peptide level. However, flash pulmonary edema
is
is a
a clinical
clinical presentation
presentation
•• The presentation
The presentation isis dramatic
dramatic and
and prompt
prompt diagnosis
diagnosis and
and
treatment is essential to minimize morbidity and mortality
treatment is essential to minimize morbidity and mortality
•• A
A key
key element
element ofof management
management is is prompt
prompt diagnosis
diagnosis of
of this
this
very distinct presentation
very distinct presentation
 Glossary of terms
Acute Medicine
Also known as emergency medicine ward
CHA2DS2-VASC
A clinical prediction rule for estimation of
stroke risk in patients with atrial fibrillation
EHMRG
Emergency Heart Failure Mortality Risk Grade. A
tool that could be used to assess mortality risk at
discharge. Note, this tool has not been
prospectively validated. Clinical judgement is
important

CHEM7 GP
US terminology. A basic metabolic panel General practitioner. UK terminology.
including Na, K, Cl −, HCO3− or CO2, blood The equivalent role in the US would be family
urea nitrogen, creatinine and glucose physician

Community heart failure team R/O

UK terminology. A specialist community Ruled out
heart failure nursing service working in
partnership with Hospital Trusts Stat
statim (Latin) referring to speed
Consultant
UK terminology. The equivalent role in the Specialist
US would be an attending/staff physician UK terminology. See consultant

C/O
Complaining of