Author Archives: Patrick Barrett

Congestive heart failure exacerbation management

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Most of the third years, and probably the second years at this point, know pretty well how to manage CHF exacerbations. However, there are differences in managing the normotensive vs. hypertensive vs. hypotensive exacerbation, and I’ll try to provide some tricks in managing your run-of-the-mill CHF exacerbation as well (credits to Amal Mattu and Scott Weingart).

 

First, try to determine the cause of the exacerbation. Determining the cause of the exacerbation, however, can be difficult – most patients aren’t honest about their salt/food/drug intake or medication compliance, or do not understand their disease process. The most common cause of an exacerbation is dietary or medication non-compliance. However, in all cases, ischemia needs to be considered. More rare cases can be valvular dysfunction such as rupture (auscultation or BSUS), myocarditis (check a troponin if it fits the clinical scenario), arrhythmias (check HR and an EKG), hypertensive crisis (often secondary to medication and dietary non-compliance, or drugs), or high-output failure (such as anemia, sepsis, AV-fistula in a dialysis patient, thyrotoxicosis). (1)

 

Next comes diagnostics. There are debates on whether troponins and BNPs need to be ordered on every CHF exacerbation. For example, many of these patients will have chronically elevated troponins and BNPs, and you’ll be stuck trending them. A BNP is of limited value in the ER except in maybe determining is the patient’s dyspnea secondary to a COPD exacerbation or CHF exacerbation, or if the BNP is normal then it should make you consider alternative diagnoses. Amal Mattu suggests that if you’re going to admit the patient, get everything (CBC, CMP, BNP, trop, EKG, CXR) because the inpatient teams like to trend trops/BNPs (even if the evidence doesn’t really back up trending BNPs). If it’s simply diet or medication non-compliance, you might only need to check electrolytes, because diuretics can cause electrolyte disturbances. ABGs aren’t typically helpful unless the patient is hypoxemic. Overall, not much other testing needs to be done for your non-critically ill patients. (1)

 

As for management, this becomes tricky because it depends on many things. What is the patient’s blood pressure? What is the cause of their exacerbation? Are they volume-overloaded, euvolemic, or dry? Are they septic? In general you have three goals: decrease the preload, decrease the afterload, and (in some cases) increase LV function. PLEASE watch this Amal Mattu lecture and you will master CHF exacerbations (2). For management, let’s start with the classic hypertensive patient.

 

Hypertensive patient: The patient’s heart is straining against a high amount of SVR and can’t perfuse their kidneys. Fluid backs up into the lungs. Don’t immediately jump to your loop diuretics (it’s debatable, and should only be done if hyper or maybe euvolemic). We fix this problem by fixing two problem: decreasing the SVR in order to perfuse the kidneys, and decreasing preload to “turn off the faucet” that’s overflowing a bathtub (lungs). Lasix won’t work if you aren’t perfusing the kidneys. One of the best and quickest agents we have is nitroglycerin. You have three options: 0.4mg sublingual tab, nitro paste, and a nitro bolus and drip. Scott Weingart (3) recommends the nitro drip, starting with a bolus of 400 mcg (that’s one sublingual nitro tab) over 2 minutes, and then drop to 100 mcg/min and titrate up until SVR is decreased. Your nurses will often question if you want to start the rate that high, and the answer is yes, but you MUST monitor your patient closely because high doses of nitro can tank your patient’s BP if you aren’t careful. Also, nitro also decreases preload, which can prevent fluid from backing up into the heart and therefore the lungs. (Nitro often gives patients a headache – give ‘em some Tylenol.) This can fix patients in minutes, because you’re redistributing fluid out of the lungs and into the vasculature or the rest of the body! BiPAP will save these patients by pushing fluid out of their lungs and can prevent intubation. The other thing to consider is IV ACE Inhibitors. Enalapril (enalaprilat) is the only IV form we have, and it has to come from pharmacy, but ACE Inhibitors are very good at afterload reduction and will help move the fluid from the lungs into the rest of the body. If nitro isn’t working, consider adding on enalapril.

 

Normotensive patients: just because their BP isn’t high doesn’t mean you can’t use nitro. However, be judicious, because you don’t want to cause hypotension, but remember that even normotensive patients can tolerate a sublingual nitro without issue. Lasix if clinically volume overloaded. BiPAP as needed for respiratory difficulties. Otherwise, nothing too tricky here.

 

Hypotensive patients: these are actually your cardiogenic shock patients. They are sick as snot. They could also be septic (! Hi Dr. Shoff), or could be having an MI. Your management of these patients is very difficult and much different than your typical CHF exacerbation management. First, determine if the patient is “warm” or “cold” (feel their extremities), and then determine if “wet” or “dry” (pulmonary edema). (4) The most common presentation is “cold and wet”, but removing fluid from them will make them worse. Obviously, if they have pulmonary edema, do not give them fluid.  HOWEVER, norepinephrine is the best agent to use and is proven in many studies. Epinephrine is your second-line agent. Avoid dopamine (SOAP-II trial demonstrated harm of dopamine vs. norepinephrine). Get basic labs, troponin, BNP, EKG, CXR, lactic acid level, blood cultures, and get reliable access. Get a digoxin level if they’re on dig, or if they can’t tell you if they are. Use BiPAP early for their respiratory status. Your BSUS can greatly aid you in what is going on and how to treat it. If the heart isn’t squeezing well, give drugs to make it do so. If it’s hyperdynamic, maybe the heart isn’t the problem. You can provide inotropic support (epi, milrinone) if on BSUS you see their EF is terrible, and if it’s caused by an MI they need urgent revascularization. Be careful – milrinone can cause hypotension. Digoxin is actually an alternative and can be given IV.

 

If you want a checklist version in treating the cardiogenic shock patients, Weingart supplied this: https://i2.wp.com/emcrit.org/wp-content/uploads/2016/11/chflist.jpg

 

Note: A study published in 2017 (5) tried to see if “time-to-furosemide” was beneficial. Initially, the study looks grossly positive (2.3% vs. 6% mortality in the “early” treatment vs “late” treatment arms, respectively), however, “early” was defined as <1 hour and “late” was defined as all furosemide given after 1 hour. You can see the potential issues with this.

 

(1) https://www.emrap.org/episode/emrap2018august/cardiology

(2) https://www.youtube.com/watch?v=AEKzT98EZHQ

(3) https://emcrit.org/emcrit/scape/

(4) https://emcrit.org/ibcc/chf/

(5) https://www.ncbi.nlm.nih.gov/pubmed/?term=time-to-furosemide

 

Life and Death: An Ethical Dilemma

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I had just arrived for my night shift when my colleagues notified me that a level one trauma was coming in in about 10 minutes. EMS had called over the radio, “61-year-old female with self-inflicted GSW to the left chest. Tachycardic, 94% on room NRB. Vitals otherwise stable. ETA 10 minutes.” A level one trauma was paged out, and I headed to the trauma room to prepare. A chronically ill-appearing female rolled in, in no distress at all, sitting mostly upright on the EMS stretcher. The tension lessened somewhat due to her stable appearance.

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“I don’t want anything done for me. I have a living will. I don’t want any help. I just want to die.” These were the first words she spoke as she arrived.

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I had not encountered this before. I hesitated for a second before telling Carol (her name has been changed to protect her identity) that since this was a suicide attempt we were obligated to help her. I turned to my attending, questioning what I had just said and asked what I actually should do.  My attending said that the assumption was that she was not of sound mind (did not have capacity) and therefore required assistance. In addition, to her dismay, EMS had not brought her living will to the ED.

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Carol’s work-up in the trauma room showed a GSW to the left chest just lateral and above the left nipple, and an exit wound to the left upper back. Shockingly, she had no pneumothorax on the chest x-ray or ultrasound, and no cardiac injury. The bullet had struck her breast implant and traversed around her ribs, fracturing one, and exited out her back without causing any major injury.

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“Let me die. I don’t want to live.” Carol made sure we understood her wishes, but we ignored them for the time being. She was taken to the CT scanner and was stable, and eventually was admitted to the trauma service.

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Carol had a nurse assigned to her as a one-on-one sitter in the ED, who, over the span of the next two hours, learned a lot about her. Carol was a very sick individual. She had had uterine cancer, a cystectomy and subsequent urostomy, transverse myelitis resulting in paralysis of both legs, many abdominal surgeries, and multiple other comorbid medical conditions. She had been in the hospital numerous times already this year, and had actually been seen by palliative care as an inpatient two months prior. In the nurse’s perspective (and mine, after hearing about their conversations), she was of sound mind. She had capacity, and she understood her current situation very well. She was depressed, but had more than enough reason to be. She knew she was chronically ill, and was apparently told by her doctors that nothing else could be done for her situation, and that she would end up dying from one of her many chronic illnesses. On her last visit to the ED (the day prior, diagnosed with a UTI), her code status was clearly a DNR in our system. Upon arrival to the ED the following day, this was reversed, and she was made a full code.

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It is rather well known that most individuals who live after a failed suicide attempt end up regretting it. However, Carol didn’t – not one bit. “I’ve lived a long, good life. I know what’s coming for me, and I don’t want to experience it. I don’t want to suffer. I’m ready to die.”

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Since my encounter with Carol, I set out to research what I should do in this situation, and most of my research led me to advice from the legal world. If a physician knowingly treats somebody who has a signed DNR order, the consequences can be dire, including suspension, revocation of license, and a fine of up to $10,000(1). However, there seems to be no real consensus as to what the right answer is in the case of attempted suicide. There are many case reports detailing this situation, and in the majority of cases, care is ultimately withdrawn and the DNR is respected. Sometimes, it depends on the state in which the Advance Directive was created, as there may be a clause in which a suicide attempt voids the AD. One article even stated that time should be dedicated to decide if the “suicide attempt was reasonable, given the patient’s terminal condition”(2).

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As much as we would like medicine to be black and white, it isn’t, and this case only reinforces that fact. So, in the chance you are involved in a situation like this, what is the right thing to do? From what I have read, the right answer for us as emergency physicians is probably to treat the patient like you would any other that comes to your door. Oftentimes, these situations require lengthy psychiatry consults and an ethics consult, and extensive discussions with family and the patient (if possible). Most people who attempt suicide and survive end up regretting their decision, and you should treat your patient as though they will, too.

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(1) http://www.caseyfrank.com/articles/how-to-reconcile-directives-with-suicide.pdf

(2) https://www.chausa.org/docs/default-source/general-files/case-study—a-terminally-ill-suicide-attempt-patient-in-the-ed-pdf.pdf?sfvrsn=0

Always keep your differential broad

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I had a case in our department that I won’t forget for a while, and it reminded me to keep my differential broad even if the suspected diagnosis seems blatantly obvious.

 

An early 40’s female presented to our ER about 5 days after an MVC in which she was the restrained driver, where the car rolled onto its side going about 40s-50s MPH. + LOC, + airbags. Paramedics arrived on scene after a while when she was up and walking, and she refused to be taken to the ER. Over the following 5 days, she had near constant neck pain as well as a worsening headache and worsening abdominal and “rib” pain on the lower left side.

She presented to our ER in a hallway bed, where her initial HR was in the mid 80s, but BP was 80s/40s on multiple checks. O2 sat and temperature were normal. Mental status was normal, and there were no physical signs of trauma on her body. She had tenderness to the L lower and lateral ribs, as well as LUQ/LMQ abdominal tenderness, and lower midline C-spine tenderness. I quickly had her placed in a cervical collar, and brought the ultrasound to bedside a performed a FAST, which was negative (to my surprise).

I ordered fluid boluses, trauma labs, type and crossmatch, and planned to send her for a man scan, but her kidney function showed an AKI and therefore had to wait for one fluid bolus before going to the scanner. BP slowly started to trend upwards, not reaching over mid 90s systolic before she went to the scanner. Of note, she did have a slightly elevated white count in the mid-to-upper teens.

My differential? Trauma, trauma, trauma. She has to be bleeding somewhere, she may have a fractured C-spine, intracranial injury, intraabdominal injury, likely splenic laceration. My FAST just must not have picked it up. Given the history and clinical circumstance, I don’t think I was completely wrong for not having anything else on my differential for this hypotensive patient with concerning physical exam findings 5 days out from a serious car accident.

Once her man scan was done, I looked though the scans and noticed her right kidney was heterogenous with contrast enhancement with stranding around it. No fluid in her pelvis, and the rest of the man scan was entirely negative. Radiology soon called and said she had the “worst case of pyelonephritis I think I’ve ever seen”. A urine sample was finally collected after the scan resulted, which was, no longer to my surprise, infected. Upon talking to the patient, she denied any dysuria or frequency, but said her urine was “green” this morning. She never had any suprapubic pain.

That is the story of how I admitted a patient to medicine for pyelonephritis after getting a man scan and diagnosing it on CT. I don’t think I’ll be changing the top item on my differential, but I think I will keep other causes of hypotension and shock on my differential until they are ruled out in cases of delayed trauma presentation, such as this one.