Quick and Dirty Guide to CHF and Pulmonary Edema

HEART FAILURE means the heart is not pumping enough blood to keep the organs alive. Since its unable to pump the blood fast enough, the blood ON THE WAY TO THE HEART gets backed up in the veins. Reduced blood flow to the kidneys results in water retention. You end up with fluid in the lungs and edema on the body. This is a very serious condition. You need to handle both the "pump" problem and the fluid problem in a quick way. Look for signs of hypoventilation and be ready to BVM or intubate these patients immediately. Use CPAP to keep alveoli open and O2 going in. Reduce the workload on the heart by using drugs like Nitroclycerin, and getting the fluid off by using drugs like Furosemide (Lasix.)

Diagnosing CHF

When you're called out for a CHF emergency, its mostly likely going to be toned out as a shortness of breath or respiratory distress. Go through your normal ABCs, look for signs of cardiogenic shock such as cyanosis, clammy, and  diaphoretic skin. CHF'ers will have coughing, labored breathing, and wheezing. Listen for rales in lower lung lobes, tachypnea and pitting edema in legs. Look at the neck tilted in a 45 degree angle and look for jugular veinous distention (JVD) that is common with CHF.  So, basically, even if your patient is in mild respiratory distress, this condition can build upon itself and become life threatening in a hurry. Be ready to intubate if the patient's respiratory distress worsens.

Physical exam

  • Inspect face and neck:  for pursed lip breathing (an effort to pressurize the lungs) and accessory muscle use (muscles will exhaust soon.) Check jugular vein distention, it is a sign of right sided heart failure resulting from severe pulmonary congestion.
  • Sputum production:
    • Thick, green, or brown sputum may indicate pneumonia
    • Yellow or pale gray sputum may be related to allergic or inflammatory causes
    • Pink, frothy sputum is associated with severe and late stages of pulmonary edema
  • Chest Wall – inspect chest wall for signs of trauma, barrel chest from COPD or accessory muscle use. Listen for breath sounds. Equal? Adventitious?
  • Extremities : Check for peripheral cyanosis – its caused when a lot of the hemoglobin in the blood isn’t carrying oxygen. Clubbing of the fingers is caused by chronic hypoxemia. Carpopedal spasms are spasms of the hands, thumbs, feet or toes, and are associated with hypocapnia. They come from long periods of rapid, deep respiration.

Cardiac monitor and 12 Lead - You will typically see signs of Left Ventricular Hypertrophy on a 12 lead, but CHF can result in a myriad of dysrhythmias you may need to manage as well.

Auscultate heart tones - Normal heart beats consists of 2 sounds: (s1 and s2) Lub, dub... lub, dub.... lub, dub: If you hear extra heart tones, we use the sound "ta" or (S3)

The “Lub” sound (S1) is created by the closing of the bicuspid and tricuspid valves at the beginning of ventricular systole.
The “Dub” sound (S2) is creatd by the closing of the aortic and pulmonic semilunar valves at the end of ventricular systole.

If you hear an extra sound, it means the bicuspid and tricuspid valves are closing at different times, making 2 noises...
SO : S1-S2-S3 (Lub-dub-ta) = CHF

(S4-S1-S2-S3) (Ta-lub-dub-ta) indicates core pulmonare (right heart failure secondary to chf)

Sample CHF Protocol:

Place pt in position of comfort (Generally, CHF pts will not be able to lie flat.)
Apply O2, Establish IV , get CPAP ready and keep intubation kit close
Make sure its CHF - Look for signs of poor perfusion, edema, rales in lower lung lobes, tachypnea, JVD and difficulty speaking. Pneumonia can look like CHF, and pneumonia pts are frequently dehydrated. Giving diuretics to a dehydrated pneumonia patient with congestion will result in very bad things.

Administer Nitroglycerin 0.4mg SL up to 3 times, of course making sure that you have an IV, Pt BP >100, and pt is not on enhancement drugs.
Initiate CPAP or assist ventilations with PEEP valve
Administer LASIX 40mg IVP SLOWLY over 2 minutes. If your pt takes Lasix regularly, use 80mg instead. Maintain BP>100.
CONSIDER Morphine 4mg IVP SLOWLY over 2 minutes.


Nuts and bolts

Left Ventricular Failure (LVF) and Pulmonary Edema - possibly due to chronic hypertension, electrolyte imbalance: results in reduced ejection fraction (percentage in decimal of the amount of blood that left ventricle puts out with each contraction.) 85 to 90% is normal ejection fraction expressed as .85 to .90. As ventricle fails, contraction is not as strong, it wont squeeze with same amount of intensity, so ejection fraction falls. If EF falls below .6 then you need to figure out whats wrong. When you get down to .45, its called CHF.
- Left ventricle fails to function as an effective forward pump
- Causes back-pressure of blood into pulmonary circulation - causes pulmonary vascular distention. Pulmonary capillaries - as they distend, the area inside the capillary distends and the internal pressure increases, and it pushes serum and fluid out. Blood cells stay inside capillaries, but fluid goes out because the walls are only 1 cell wall thick. You end up with fluid buildup between the capillary walls and the alveolus by almost 10 times. Its normally 1 micron distance in order to pass oxygen. If the space is increased 10x, oxygen can no longer pass freely in the built up interstitial fluid. Crackels (rales) is the sound you hear when air is "bubbling" through the fluid at the alveolar level.


Links and Tools

Cardiogenic Shock/ CHF Flash Cards

Wikipedia Entry for CHF