Managing Acute Heart Failure in the Emergency Department

Patient case study

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Initial Diagnosis Revised Diagnosis Teaching Points

Case Introduction and Care Plan and Care Plan Discussion and Conclusions

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2 4 6

Glossary

Case Details Diagnostic Disposition ? Questions

and Initial Triage Results Decision

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Salvatore Di Somma, MD PhD

Emergency Medicine Department,
Sant’ Andrea Hospital,
School of Medicine & Psychology,
University of Roma “Sapienza”
(Rome; Italy)

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Background
• This is the ER of an academic tertiary care
hospital in a large urban city
• Approximately 55,000 patients are admitted to
this ER annually, of which 2,200 cases were
AHF. This ED handles any type of emergency
• During this case, 1 attending and 1 fellow
were on duty
• You have access to (less than 30 minutes)
ECG, bedside ultrasound and comprehensive
echo, biomarkers data and chest X ray
• You have access to a cath lab

ECG=electrocardiogram; echo=echocardiogram; ER=Emergency Room

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History of Present Illness Past History, Allergy

and Review of systems History, Medications,
and Social History

Chief Complaint Physical

and Vital Signs Examination

CASE DETAILS
AND INITIAL TRIAGE

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE

Chief Complaint
“I am short of breath”

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Vital Signs (at Triage)
• BP: 220/140 mmHg
• HR: 180 bpm
• RR: 40 brpm
• Temperature: 36.4°C / 97.5°F
• O2 sat: 97% with O2 14 L/min supply

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate;
O2 sat=oxygen saturation; RR=respiration rate
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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CASE DETAILS
AND INITIAL TRIAGE
History of Present Illness
• 46-year-old female brought to the ED by
ambulance for sudden onset of acute
shortness of breath that occurred with
vomiting. Symptoms began less than
30 minutes prior to arrival. She also complains
of a productive cough for the last few days.

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ED=Emergency Department
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CASE DETAILS
AND INITIAL TRIAGE
Review of Systems
• + cough but no fever
• No abdominal pain
• No back pain
• No rash
• No fatigue
• No black or bloody stools
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CASE DETAILS
AND INITIAL TRIAGE
Past History
• April 2013: right lung lobectomy for lung
cancer treated with radiotherapy
• Recent deep vein thrombosis treated with oral
anticoagulant

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CASE DETAILS
AND INITIAL TRIAGE
Allergy History, Medications,
and Social History
Allergies Medications
• Adverse reaction • Methylprednisolone:
with Novocaine 16 mg/day (related to the
history of cancer)
Social History
• Warfarin on the basis of
• Never smoked scheduled INR values
• Very rare alcohol
• No illicit drug use

INR=international normalized ratio

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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CASE DETAILS
AND INITIAL TRIAGE
Physical Examination (Focused Exam)
• +JVD
• Severe respiratory distress (RR: 40 brpm)
• Wheezing and bilateral inspiratory rales
• Tachycardic (HR:180 bpm)
• Aortic II/VI systolic murmur and unspecified gallop
rhythm
• No peripheral edema
• Profuse warm sweating
• Rest of the exam is unremarkable

bpm=beats per minute; brpm=breaths per minute; HR=heart rate; JVD=jugular venous distension;
RR=respiratory rate
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Clinical Impression
(Initial Diagnosis)
Initial Plan of Care
and Differential
Diagnosis

INITIAL DIAGNOSIS
AND CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
• Acute cardiogenic pulmonary edema
• Pulmonary edema secondary to hypertensive
crisis
• Pulmonary edema secondary to ACS
• Pulmonary edema secondary to severe aortic
stenosis
• Aspiration pneumonia as dyspnea began after
vomiting
• Pulmonary embolism because patient has a
history of DVT on warfarin, cancer history and
sudden onset of dyspnea
ACS=acute coronary syndrome; BP=blood pressure
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN Initial Plan of Care
Diagnostic plans:
• Vein cannulation with i.v.
• Laboratory tests included BNP and Hs Troponin I
• Blood gas analysis
• ECG (12 leads and continuous cardiac monitoring)
• POCT bedside ultrasound of heart, lungs and inferior
vena cava
• Chest X ray
Therapeutic considerations:
• Diuretics (furosemide) i.v.
• Nitrates i.v.
• Nebulized -agonist (albuterol) and anti-cholinergic
(ipratropium)
• Corticosteroids i.v.
• Oxygen
• Potential rate or rhythm control depending on further
evaluation with ECG

BNP=B-type natriuretic peptide; ECG=electrocardiogram; i.v.=intravenous; More

POCT=point of care testing
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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INITIAL DIAGNOSIS
AND CARE PLAN Initial Plan of Care (cont’d)
As diagnostic work up is ongoing:
• NIV is immediately started
• i.v. nitrates are begun and titrated aggressively to
symptoms and BP

BP=blood pressure; i.v.=intravenous; NIV=non-invasive ventilation

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Lab Results Chest X ray

DIAGNOSTIC RESULTS
ECG Ancillary Imaging

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS ECG Click here for
ECG:
Interpretation
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DIAGNOSTIC
RESULTS ECG: Interpretation
• Supraventricular tachycardia, 180 bpm
• ST depression throughout the precordium, no clear
P waves

bpm=beats per minute

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DIAGNOSTIC
RESULTS Chest X ray Click here for
Chest X ray:
Interpretation

? QUESTION
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DIAGNOSTIC
RESULTS Chest X ray: Radiology Interpretation
Obtained within 1 hour from presentation

Findings
• Signs of previous right lobectomy
• Multiple bilateral areas of consolidation, mainly
in the right middle zone with pleural effusion
• Cardiac enlargement
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DIAGNOSTIC
RESULTS Ancillary Imaging Click here for
Ancillary imaging:
Bedside (2 minutes) thoracic ultrasound was
Interpretation
performed:

Chest echocardiogram Echocardiogram

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DIAGNOSTIC
RESULTS Ancillary Imaging: Interpretation
Chest echo
• Bilateral “comet-tail” signs

Echocardiogram
• Myocardial hypokinesis
• Normal left and right sections dimensions
• Absence of pericardial effusion

IVC
Appears full with no collapsibility with respiration
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DIAGNOSTIC
RESULTS Lab Results (or POCT Results)
Lab results were obtained within 1 hour from admission, while
results of point of care blood gas analysis and biomarkers were
? QUESTION

obtained within 15 minutes

(reference range) (reference range)
• Hb: 17 g/dL (12–16 g/dL) Blood Gas Analysis
• WBC: 18.480/L (4.3–18.8/L) • O2: 14 L/min
• pH: 7.05 (7.35–7.45)
• PLT: 288.000/L (140–400/L)
• pCO2: 67 mmHg (35–45 mmHg)
• BUN: 20 mg/dL (5–25 mg/dL) • pO2: 121 mmHg (80–100 mmHg)
• Creatinine: 1.21 mg/dL (0.7–1.1 mg/dL) • Lactate: 13.9 mmol/L (<2 mmol/L)
• Na+: 139 mmol/L (136–145 mmol/L) • HCO3‾: 18.5 mmol/L (22–26 mmol/L)
• K+: 3.2 mmol/L (3.5–5.1 mmol/L) • SO2: 97%
• PCT: 0.08 ng/mL (<0.05 ng/mL)
• BNP*: 52.2 pg/mL (<100 pg/mL)
• HS-TnI#: 20 pg/mL (0–15.6 pg/mL)
• INR: 2.83 (0.9–1.2)
• D-dimer 505 ng/mL (<243 ng/mL)

*Abbott Diagnostic Assay, #Abbott Diagnostic Assay.

BNP=B-type natriuretic peptide; BUN=blood urea nitrogen; Cr=creatinine; Hb=hemoglobin; HS-TnI=high-sensitivity troponin I;
INR=international normalized ratio; PCT=procalcitonin; PLTs=platelets; WBC = white blood cell count
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Revised Clinical
Impression and
Next actions
Differential Diagnoses

REVISED DIAGNOSIS AND

CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN
Revised Clinical Impression
and Differential Diagnoses
Presence of:
• Sudden onset of dyspnea
• Elevated BP levels
• Acute respiratory failure
• Bilateral “comet tails”
Our diagnostic
• Normal right side cardiac function
hypothesis:
Absence of: Flash pulmonary
REVISEDdyspnea
• Gradual worsening DIAGNOSIS AND
edema in hypertensive
• Fatigue CARE PLAN crisis with potential
• Lower limb edema aspiration pneumonia
• Fever

BP=blood pressure
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REVISED DIAGNOSIS
AND CARE PLAN
Next Actions
Patient immediately started:
• Furosemide 100 mg as i.v. bolus
• Nitroglycerin 0.9 mg/h (15 g/min) as i.v. infusion
• Morphine 5 mg as i.v. bolus

i.v.=intravenous
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DISPOSITION
DECISION
Disposition
• Patient rapidly improved during her ED course (<4
hours)
• Patient was then admitted to the Emergency Medicine
ward (hospital floor – this ED has its own inpatient
service as well) with continuous monitoring and
frequent re-evaluation for 72 hours with progressive
clinical and hemodynamic improvement
• NIV was slowly weaned
• ACS was excluded with further HS-TnI and serial
ECG evaluation

ACS=acute coronary syndromes; ED=Emergency Department; HS-TnI=highly-sensitive troponin I; NIV=non-

invasive ventilation
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Teaching Discussion and

Points Conclusions

TEACHING POINTS, DISCUSSION

AND CONCLUSIONS

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
Teaching Points
CONCLUSIONS
• Hypertensive crisis can generate pulmonary
edema due to acute vasoconstriction
(increased afterload)
• BNP may be falsely negative in flash
pulmonary edema
• Patients often improve very quickly. Prompt
regression of signs and symptoms after rapid
treatment
BNP=B-type natriuretic peptide
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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TEACHING POINTS,
DISCUSSION AND
Discussion and Conclusions
CONCLUSIONS
• Flash pulmonary edema is a general clinical term used
to describe a particularly dramatic form of acute heart
failure
• It is a medical emergency marked by the sudden
accumulation of fluid in one’s lungs. It should be noted
that despite prompt treatment, it is possible for one’s
condition to rapidly deteriorate, resulting in the need for
intubation and/or death
• Flash pulmonary edema has been difficult to study given
the severity of the patient’s symptoms and the rapid
resolution with prompt treatment, often to the point of
complete resolution of signs and symptoms in the ED
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ED=emergency department
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
Discussion and Conclusions cont’d
CONCLUSIONS
• Natriuretic peptide levels may be ‘negative’ when the onset
of AHF is very rapid, such as flash pulmonary edema
• Later measurement would demonstrate an elevated
natriuretic peptide level. However, flash pulmonary edema is
a clinical presentation
• The presentation is dramatic and prompt diagnosis and
treatment is essential to minimize morbidity and mortality
• A key element of management is prompt diagnosis of this
very distinct presentation
 Glossary of terms
Acute Medicine EHMRG
Also known as emergency medicine ward Emergency Heart Failure Mortality Risk Grade. A
tool that could be used to assess mortality risk at
CHA2DS2-VASC discharge. Note, this tool has not been
A clinical prediction rule for estimation of prospectively validated. Clinical judgement is
stroke risk in patients with atrial fibrillation important

CHEM7 GP
US terminology. A basic metabolic panel General practitioner. UK terminology.
including Na, K, Cl−, HCO3− or CO2, blood The equivalent role in the US would be family
urea nitrogen, creatinine and glucose physician

Community heart failure team R/O

UK terminology. A specialist community Ruled out
heart failure nursing service working in
partnership with Hospital Trusts Stat
statim (Latin) referring to speed
Consultant
UK terminology. The equivalent role in the Specialist
US would be an attending/staff physician UK terminology. See consultant

C/O
Complaining of