see also:

• cardiology
• congestive cardiac failure
• Mx of the wheezy elderly patient - acute pulmonary oedema versus asthma
• AFTB lectures - APO
• non-invasive positive pressure ventilation (NIPPV)

• improve cardiac function:
  • correct hypoxaemia
    • supplemental oxygen
    • correct acute respiratory failure
  • promote coronary blood flow
  • reduce LV diastolic pressure via:
    • decreasing systemic vascular resistance
    • improve systolic and diastolic functional reserve

• supplemental oxygen
• sit patient up to ensure optimised lung function
• continuous cardiac monitor
• iv access and send bloods for usual FBE, U&E, cardiac enzymes, glucose
• 12 lead ECG to help exclude acute myocardial infarction (AMI/STEMI/NSTEMI)
• consider nitrates including GTN (eg. GTN) if systolic BP > 110mmHg
  • results in rapid venodilatation and reduces LV afterload as well as promotes coronary blood flow
  • BUT watch for excessive drop in BP!
• most ED physicians now avoid iv frusemide / furosemide / Lasix:
  • most patients are euvolaemic or hypovolaemic and thus a diuretic is probably not in their best interest
  • efficacy not proven and may in fact decrease cardiac output, but is still often given judiciously (eg bd bolus dosing)
  • no clear benefit of continuous infusion vs bolus vs high dose vs low dose strategies
  • high dose bolus strategy is associated with greater diuresis and more rapid relief of dyspnoea, but with transent worsening of renal function, and may be the preferred option¹⁾
• do not give morphine as tends to worsen outcomes
• avoid ACEI's in acute setting as may cause dramatic fall in BP
• commence noninvasive positive pressure ventilation (NPPV or NIPPV) early as this reduces need for intubation and apears to reduce mortality by ~40%
• patients in extremis or not able to tolerate NIPPV generally require intubation.
• consider inotropic support if hypotensive but inotropes increase myocardial oxygen demand and may cause further deterioration, particularly if there is underlying myocardial ischaemia or acute infarct.