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What classification would include a patient that is not limited with normal physical activity by symptoms?
What classification would include a patient that can do normal activities but results in fatigue, dyspnea, or other symptoms?
What classification would include a patient that has marked limitations while performing normal activities?
What classification would include a patient that shows symptoms at rest?
What is a signature finding on a CXR of a patient suffering systolic dysfunction?
A boot shaped heart.
At what age is there no genger preference for CHF?
75 and older
In whom and at what age is CHF more prevelant?
What race is more likey to die from CHF and by how much?
African Americans are 1.5 times more likely to die than white.
CHF is an imbalance in what?
Pump function in which the heart fails to maintain the circulation of blood adequately.
What is the most severe manifestation of CHF?
When does pulmonary edema develop when a patient has CHF?
When the imbalance of blood circulation causes an increase in lung fluid. The lung fluid comes from a leakage from the pulmonary capillaries into the interstitium and alveoli.
What are the two categories of CHF?
Forward and Backward CHF
What type of CHF is secondary to a decrease of flow into the aorta and systemic circulation?
What type of CHF is secondary to an elevated SVR?
Mitral valve stenosis and aortic stenosis is seen in what type of CHF?
What are the two subdivisions of CHF?
Systolic and diastolic dysfunction
What subdivision of CHF includes a dilated left ventricle with impaired contractility?
What type of subdivision occurs in normal or intact left ventricle with impaired ability to relax and receive as well as eject blood?
What is a common finding of a diastolic dysfunction?
The heart becomes stiff and the ventricles will not relax.
What is a very common symptom that most patient's with CHF complain of?
Name eight of the most common physical findings in a patient with CHF.
- 1. peripheral edema
- 2. JVD
- 3. tachycardia
- 4. tachypnea
- 5. hypertension
- 6. pulsus alternans
- 7. wheezes
- 8. crackles
What happens to the plasma oncotic and pulmonary capillary pressures in CHF?
The plasma oncotic pressures are higher than the pulmonary capillary pressures.
In CHF, the connective tissue and cellular barriers are relatively impermeable to what?
What happens when the lymph drainage is exceeded?
Liquid accumulates in the interstitial spaces surrounding the bronchioles and lung vasculature.
What happens when there is an increase of fluid and pressure causes leakage into the interstitial space around the alveoli causing a disruption of the av membrane and the fluid eventually floods the alveoli?
You now have pulmonary edema.
What is characterized as a malfunction between mechanisms that keep the interstitium and alveoli dry and the opposing forces that are responsible for fluid transfer to the interstitium?
An imblance in Starling's forces.
What is Starling's forces?
The degree of end-diastolic fiber stretch proportional to the systolic mechanical work expended in an ensuing contraction.
What are common findings in the history of a patient with CHF?
Anxiety, dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea, and a productive cough
What is a common finding of the secretions from a CHF patient's productive cough?
Pink and frothy
What are the common responses when asking a CHF patient about their history?
cardiomyopahty, valve disease, alcohol use, hypertension, angina, MI, family history
What are some non-specific symptoms of a patient with CHF?
weakness, light-headed, abdominal pain, malaise, wheezing, nausea
What can cause pulmonary edema secondary to altered capillary permeability?
ARDS, infections, inhaled toxins, DIC, aspiration, near drowning
Note: DIC is when you bleed out of everything. For example, your eyes, ears, etc...
What causes a decrease in oncotic pressure?
Hypoalbuminemia (low nutrition/low protein)
How can CHF be caused by the lymph system?
Lymphatic insufficiency. The inability to carry fluids out and away.
When is CHF secondary to increased pulmonary capillary pressure?
Pulmonary venous thrombosis, stenosis or veno-occlusive diseases, volume over-load
What are some mixed or unknown causes of CHF?
HAPE, heroin OD, neurogenic PE, pulmonary emboli, eclampsia, post cardioversion, post anesthia, post extubation, and post CAB
Note: HAPE is high altitude pulmonary edema
On a chest x-ray, how do you distinguish if a patient's pulmonary edema is coming from CHF or another cause?
Look to see if the patient has a boot shaped heart. If they do, then the pulmonary edema is being caused by a cardiac issue. If they do not, the pulmonary edema is being caused by something other than the heart.
What are some differential diagnosis that could cause pulmonary edema?
ARDS, Altitude illness, anaphylaxis, acute anemia, bronchitis, COPD, pneumonia, pneumothorax, pulmonary emboli, septic shock, and venous air embolism.
What is the most common cause of CHF?
Coronary artery disease
Also a loss of left ventricle muscle, ongoing ischemia, and a decreased diastolic ventricular compliance
Why can pregnancy be a cause of CHF?
Pregnant women can develop a condition known as preeclampsia. This is an onset of hypertension in pregnancy.
What are common findings of an ECHO for a CHF patient?
Valve wall motion abnormalities and decreased left ventricular function
What are common findings of an ECG for a CHF patient?
Ischemia and past MI
What are common findings on a chest x-ray for a CHF patient?
- 1. cardiomegaly
- 2. Cephalization of the pulmonary vessels (PCWP 12-18 mmHg)
- 3. Kerly B lines (PCWP 18-25 mmHg)
- 4. Perihilar infiltrates (PCWP >25 mmHg)
When administering medications for CHF, what is the main goal?
To achieve a PCWP 15-18 mmHg with cardic index >2.2 while maintaining blood pressure.
What are the two most common diuretics used for CHF?
Lasix and Bumex
Why are nitrates used for CHF?
They decrease myocardial O2 demand by lowering preload and afterload.
What are the two most common nitrates used?
Nitro and Nipride
What two inotropes are commonly used for CHF?
Dopamine and Dobutamine (Dobutrex)
Inamrinone and Melrinone are also used to increase cardiac contractility and vasodilate.
What is known as a front line cardiac drug?
Morphine (Remember MONA)
morphine, oxygen, nitrates, aspirin
Why do you often put the head of bed up for a patient with CHF?
To decrease venous return and in turn decrease the preload. You will often see the patient sitting up in bed with their feet dangling off the side.
How much oxygen should you administer for a CHF patient?
100% even if they are COPD.
What is an NBRC choice for treating CHF? This is something that is no longer used clinically!
Alternating tourniquets and phlebotomy removal of 500cc.
Besides nitrates, inotropes, and analgesics, what are other medications used for CHF?
ACE inhibitors and Beta-blockers
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