.A Figure 1 5-2. A. Bilateral infiltrates, cardiomegaly and cephalization can be seen in this patient with pulmonary

edema. B. Kerley B Lines in patient with pulmonary edema (white arrowheads). (B: Reprinted with permission

from Schwa rtz DT. Chapter 1 -7. Congestive Heart Failure-Interstitial Lung Markings. In: Schwartz DT, ed. Emergency

Radiology: Case Studies. New York: McGraw-Hill, 2008.)

pneumothorax, or malignancy. Importantly, a normal

CXR does not exclude CHF, as radiographic findings can

lag the onset of clinical symptoms by up to 6 hours.

Echocardiography is often performed on an inpatient

basis to assess ventricular size and function and rule out

underlying valvular disease. Emergency practitioners

skilled in ultrasonography may use bedside e chocardiography to assess global cardiac function in the critically ill or

clinically indeterminate cases.

MEDICAL DECISION MAKING

Rapidly address any signs of respiratory distress. Mildly symp ­

tomatic patients require supplemental oxygen, whereas

patients in moderate to severe respiratory distress often

require some form of ventilatory assistance. After respiratory

stabilization, address the patient's hemodynamic status. A

hypotensive patient with signs of shock requires vasopressor/

inotropic support, whereas a hypertensive patient will benefit

from vasodilator and diuretic therapy. The differential diag ­

nosis of CHF is broad and includes many of its precipitants

such as ACS, cardiac dysrhythmias, pulmonary embolus, and

valvular disease. Bronchospastic disease and chronic pulmonary conditions (eg, COPD) may be difficult to distinguish

from acute CHF. A good history combined with ancillary

studies, including a BNP or CXR, may help with diagnosis

(Figure 15-3).

TREATMENT

The goals of treatment include symptom management,

hemodynamic stabilization, and reversal of precipitating

factors. Place all dyspneic and hypoxic patients on

supplemental oxygen via a nonrebreather mask and rap ­

idly escalate to noninvasive positive pressure ventilation

(NIPPV) (eg, bilevel positive airway pressure) in patients

who fail to respond. When initiated early, NIPPV will

reduce the need for endotracheal tube placement and

mechanical ventilation in patients with decompensated

CHF. The higher intrathoracic pressure improves oxygen ­

ation by recruiting additional alveoli and decreasing cardiac preload, thereby curtailing further pulmonary edema.

Contraindications to NIPPV include patients who are at

risk for aspiration, unable or too confused to cooperate, or

those with significant facial trauma. Endotracheally intubate and initiate mechanical ventilation in patients who do

not qualify for or fail NIPPV.

Patients with hypotension and/or signs of systemic

hypoperfusion are by definition in cardiogenic shock and

require immediate hemodynamic support. Initiate a dobutamine infusion for inotropic (cardiac pump) support, but

beware of worsening hypotension because of its vasodilatory properties. Most patients will require concurrent

dopamine or norepinephrine infusions to maintain an

adequate blood pressure. Aggressively seek the precipitating factor, keeping in mind that acute myocardial infarction

is the most likely culprit. Obtain early cardiology consultation to facilitate emergent bedside echocardiography and

admission to an intensive care unit/critical care unit setting

for further management.

The majority of patients in acute CHF present with

marked hypertension. In these patients, vasodilators are

the initial therapy of choice. Nitroglycerin is the preferred

agent as it rapidly decreases the ventricular preload and at

higher doses reduces the cardiac afterload, thereby improving overall cardiac output. Start with sublingual doses of

CHAPTER 15

Decompensated CHF (dyspnea,

orthopnea/PND, LE edema,

inspiratory crackles)

Preload reduction

• Nitroglycerin

• Nitroprusside

· Morphine

loop diuretics

Figure 1 5-3. CHF diagnostic a lgorithm. BiPAP, bilevel positive airway pressure; BP, blood pressure; CHF, congestive

hea rt failure; CXR, chest x-ray;