Flash Pulmonary Edema Morning Report Tuesday 32106 1032020

Flash Pulmonary Edema Morning Report Tuesday, 3/21/06 10/3/2020 Jose R. Jimenez M. D. 1

Captain: The bilge pump is giving out, the ship may sink !!!!! Quick!!! …. . Grab all the buckets, start bailing and let me get my rosary !!!!! 10/3/2020 Jose R. Jimenez M. D. 2

Flash Pulmonary Edema • Recognizing, stopping and reversing the downhill spiral of Acute CHF and Flash Pulmonary Edema 10/3/2020 Jose R. Jimenez M. D. 3

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Flash Pulmonary Edema • Presenting signs • Diagnostic clues • Basic Pathophysiology • Management Pearls 10/3/2020 Jose R. Jimenez M. D. 5

We will not cover • Detailed Pharmacology • Comprehensive Pathophysiology 10/3/2020 Jose R. Jimenez M. D. 6

Flash Pulmonary Edema • 4 common patient groups: • Hypertensive • Ischemic • Cardiomyopathy • Valvular Disease 10/3/2020 Jose R. Jimenez M. D. 7

Presentations • Undiagnosed patient with untreated CV disease (HTN, DM, Myopathy, Valv. Dis. ) • Poorly compliant patient • End stage treated patient responding poorly to treatment 10/3/2020 Jose R. Jimenez M. D. 8

Presentation (cont. ) • Dyspnea • Agitation • Chest Pressure/Pain • Mental Status Change 10/3/2020 Jose R. Jimenez M. D. 9

Presenting S/S • VS: BP may be elevated or low • RR: Increased • HR: Usually increased until late, may be low due to beta block. • p. Ox. : Decreased • Cough with frothy sputum, which may be pink or blood tinged 10/3/2020 Jose R. Jimenez M. D. 10

What are we dealing with? Diff. Dx • COPD with acute exacerbation? • P. E. • Fluid overload • Infection/Sepsis • ARDS, unknown trauma • Altitude Illness • Autoimmune (Goodpasture Syndr. ) • Pericardial Disease • Negative airway pressure Jose R. Jimenez M. D. • 10/3/2020 Reexpansion pulm edema 11

Narrowing the Diff. DX • Limited Hx, PE • Lab • ABG • Cxr • ECG 10/3/2020 Jose R. Jimenez M. D. 12

Pathophysiology • LV Dysfunction, failure of compensatory mechanisms • Cardiac function determined by 4 factors, they are ……. . 10/3/2020 Jose R. Jimenez M. D. 13

• Preload • Afterload • Contractility • Heart Rate 10/3/2020 Jose R. Jimenez M. D. 14

Pathophysiology • Frank-Starling Curve 10/3/2020 Jose R. Jimenez M. D. 15

Pathophysiology Increased myocardial oxygen demand: • Compensatory increase in adrenergic cardiac stimulation • Myocardial hypertrophy 10/3/2020 Jose R. Jimenez M. D. 16

Flash Pulmonary Edema: Management • Airway • Breathing • Circulation 10/3/2020 Jose R. Jimenez M. D. 17

Airway • Bag/mask leading to RSI ET tube • Verify ET placement • Ventilator support • Chemical restraint 10/3/2020 Jose R. Jimenez M. D. 18

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Monitor Circulation • Changing HR, BP, p. Ox • Urine output, foley • Invasive monitoring: CVP, central line/swan cath. 10/3/2020 Jose R. Jimenez M. D. 20

Circulatory support Remember the 4 factors affecting cardiac function 1. Preload 2. Afterload 3. Contractility 4. Heart rate 10/3/2020 Jose R. Jimenez M. D. 21

Physiology driven interventions • • Diuretics MS Sympathomimetic amines Vasodilators Inotropic agent Nesiritide (BNP) Ventilator pressure settings Bedside dialysis/ultrafiltration 10/3/2020 Jose R. Jimenez M. D. 22

Effect-driven adjustments to therapy • Oxygenation • Urine Output • Controlling and maintaining BP • VS parameters improving? • Consider invasive monitoring C. O. SVR CVP CWP 10/3/2020 Jose R. Jimenez M. D. 23

Ongoing management • Keep family informed • Adjust drips, add/change prn • Patient response…. . 10/3/2020 Jose R. Jimenez M. D. 24

References 1. 2. 3. 4. Young JB et al Clinical Management of Heart Failure, 2001, PCI Books, West Islip, NY Brawnwald, Heart Disease, 4 th Ed, W. B. Saunders, Philadelphia, USA Taylor RB, Difficult Medical Management, 1 st Ed, W. B. Saunders, Philadelphia, USA ACLS Manual, AHA 2002 10/3/2020 Jose R. Jimenez M. D. 25

Questions? 10/3/2020 Jose R. Jimenez M. D. 26