Adult Medical Emergency Handbook - Scottish Intensive Care Society

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MILD-MODERATE LEFT VENTRICULAR FAILURE/PULMONARY OEDEMA
The following features either together or in isolation should raise clinical
suspicion of heart failure:
• Mild breathlessness at rest or on minimal exertion.
• Persistent tachycardia.
• Elevated JVP.
• Basal crepitations.
• Upper lobe diversion on CXR.
• Pulmonary oedema on CXR.
After a myocardial infarction an elevated JVP as an isolated
feature may reflect right ventricular infarction particularly in the
setting of an inferior or posterior infarction. Diuretic therapy
may worsen the situation.
Management
• Oxygen (high concentration >60%).
• Blood gases are not always required but should be performed if
shock or COPD also present.
• Monitor O 2 saturation and ECG.
• Consider reducing or stopping beta blocker temporarily.
• Ensure the patient is on an ACE inhibitor such as lisinopril or
ramipril unless contra-indicated.
• Consider oral diuretics such as furosemide or bumetanide.
Assess the need for diuretics daily. Be careful not to over-treat.
• Assess cardiac structure and function by echocardiography prior to
hospital discharge.
• Use intravenous glyceryl trinitrate if systolic blood pressure
>90mmHg.
• Once the patient is stable with no signs of pulmonary oedema or
salt and water excess consider starting a low dose beta-blocker
such as bisoprolol 1.25mg od or Carvedilol 3.125mg bd.
SEVERE LEFT VENTRICULAR FAILURE (LVF)
Patient breathless at rest. Sinus tachycardia is usual, or possibly rapid atrial
fibrillation (BP often high). A gallop rhythm and widespread crepitations
are often present. CXR shows features of pulmonary oedema.
If a patient looks “shocked”: tachypnoeic and tachycardic
but with a high BP LVF is the likely problem.
110 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11