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12. Other conditions
Heart failure in adults
H e a r t fa ilu r e is d e fin e d a s t h e in a bilit y of t h e m yoc a r d iu m t o p r ov id e
n or m a l
ha e m od yna m ic fu nc tion.
L e ft-s id e d he a r t fa ilu r e (ofte n s e c ond a r y to c or ona r y or v a lv u la r he a r t
d is e a s e , a nd / or
a r te r ia l hyp e r te ns ion) is the m os t c om m on for m .
T he r e a r e tw o typ e s :
– c hr onic he a r t fa ilu r e w ith ins id iou s ons e t
– a c u te h e a r t fa ilu r e , w h ic h is life th r e a t e n in g, p r e s e n t s e it h e r a s a c u t e
p u lm on a r y
oe d e m a or a s c a r d ioge nic s hoc k.
Clinical features
– Left-sided heart failure s e c ond a r y to le ft v e ntr ic u la r fa ilu r e :
•fa t igu e a n d / or p r ogr e s s iv e d ys p n oe a , oc c u r s on e xe r t ion a n d t h e n a t
re st
(a c c e ntu a te d by the d e c u bitu s p os ition, p r e v e nting the p a tie nt fr om lying
d ow n )
•a c u t e p u lm on a r y oe d e m a : a c u t e d ys p n oe a , la r yn ge a l c r a c kle s , c ou gh ,
fr ot h y
s p u tu m , a nxie ty, p a llor , v a r ie d d e gr e e s of c ya nos is , fe e ble r a p id p u ls e ,
w e t r a le s in
both lu ng fie ld s , m u ffle d he a r t s ou nd s , ofte n w ith c a r d ia c ga llop
– Right-sided heart failure s e c ond a r y to r ight v e ntr ic u la r fa ilu r e :
•oe d e m a of t h e low e r lim bs , ju g u la r v e n ou s d is t e n t ion ,
h e p a t om e g a ly,
he p a toju gu la r r e flu x
•a s c ite s in a d v a nc e d s ta ge s
R a r e ly is ola te d , this is ofte n a c ons e q u e nc e of le ft v e ntr ic u la r fa ilu r e .
– Global heart failure s e c ond a r y to fa ilu r e of both v e ntr ic le s :
•le ft a n d r igh t - s id e d s ign s . Sign s of r igh t v e n tr ic u la r fa ilu r e a r e ofte n t h e
m os t
p r om ine nt.
TreafutmroseenmtidoefI aVcu(otensheetaorftafacitluiornein(a5cumteinpuutlemsonaanrdy poeedaekmeaffeacntdin 3 0 m inu te s ) : 4 0
cardiogenic shock)
– First case: blood pressure is maintained
•P la c e the p a tie nt in the s e m i-r e c line d p os ition w ith le gs low e r e d .
•G iv e high-flow oxyge n
•R e d u c e p u lm ona r y p r e s s u r e w ith c om bina tion fu r os e m id e + m or p hine
+ r a p id ly-
a c ting nitr a te d e r iv a tiv e s :
8 0 m g/ in je c tion , t o be r e p e a t e d e v e r y 2 h ou r s a c c or d in g t o c lin ic a l
e v olu t ion .
M onitor blood p r e s s u r e a nd u r ine ou tp u t.
+ morphine: a c c or d ing to s e v e r ity 3 to 5 m g by s low IV inje c tion or 5 to 1 0 m g
by SC
inje c tion
+ glyceryl trinitrate s u blingu a l: 0 .2 5 to 0 .5 m g. M onitor blood p r e s s u r e .
Heart failure in adults
H e a r t fa ilu r e is d e fin e d a s t h e in a bilit y of t h e m yoc a r d iu m t o p r ov id e
n or m a l
ha e m od yna m ic fu nc tion.
L e ft-s id e d he a r t fa ilu r e (ofte n s e c ond a r y to c or ona r y or v a lv u la r he a r t
d is e a s e , a nd / or
a r te r ia l hyp e r te ns ion) is the m os t c om m on for m .
T he r e a r e tw o typ e s :
– c hr onic he a r t fa ilu r e w ith ins id iou s ons e t
– a c u te h e a r t fa ilu r e , w h ic h is life th r e a t e n in g, p r e s e n t s e it h e r a s a c u t e
p u lm on a r y
oe d e m a or a s c a r d ioge nic s hoc k.
Clinical features
– Left-sided heart failure s e c ond a r y to le ft v e ntr ic u la r fa ilu r e :
•fa t igu e a n d / or p r ogr e s s iv e d ys p n oe a , oc c u r s on e xe r t ion a n d t h e n a t
re st
(a c c e ntu a te d by the d e c u bitu s p os ition, p r e v e nting the p a tie nt fr om lying
d ow n )
•a c u t e p u lm on a r y oe d e m a : a c u t e d ys p n oe a , la r yn ge a l c r a c kle s , c ou gh ,
fr ot h y
s p u tu m , a nxie ty, p a llor , v a r ie d d e gr e e s of c ya nos is , fe e ble r a p id p u ls e ,
w e t r a le s in
both lu ng fie ld s , m u ffle d he a r t s ou nd s , ofte n w ith c a r d ia c ga llop
– Right-sided heart failure s e c ond a r y to r ight v e ntr ic u la r fa ilu r e :
•oe d e m a of t h e low e r lim bs , ju g u la r v e n ou s d is t e n t ion ,
h e p a t om e g a ly,
he p a toju gu la r r e flu x
•a s c ite s in a d v a nc e d s ta ge s
R a r e ly is ola te d , this is ofte n a c ons e q u e nc e of le ft v e ntr ic u la r fa ilu r e .
– Global heart failure s e c ond a r y to fa ilu r e of both v e ntr ic le s :
•le ft a n d r igh t - s id e d s ign s . Sign s of r igh t v e n tr ic u la r fa ilu r e a r e ofte n t h e
m os t
p r om ine nt.
TreafutmroseenmtidoefI aVcu(otensheetaorftafacitluiornein(a5cumteinpuutlemsonaanrdy poeedaekmeaffeacntdin 3 0 m inu te s ) : 4 0
cardiogenic shock)
– First case: blood pressure is maintained
•P la c e the p a tie nt in the s e m i-r e c line d p os ition w ith le gs low e r e d .
•G iv e high-flow oxyge n
•R e d u c e p u lm ona r y p r e s s u r e w ith c om bina tion fu r os e m id e + m or p hine
+ r a p id ly-
a c ting nitr a te d e r iv a tiv e s :
8 0 m g/ in je c tion , t o be r e p e a t e d e v e r y 2 h ou r s a c c or d in g t o c lin ic a l
e v olu t ion .
M onitor blood p r e s s u r e a nd u r ine ou tp u t.
+ morphine: a c c or d ing to s e v e r ity 3 to 5 m g by s low IV inje c tion or 5 to 1 0 m g
by SC
inje c tion
+ glyceryl trinitrate s u blingu a l: 0 .2 5 to 0 .5 m g. M onitor blood p r e s s u r e .
