Standard initial management in Heart failure

• Supplemental Oxygen
• Endotracheal intubation with mechanical ventilation is indicated if instability
• Cardiac monitoring
• pulse oximetry
• 12-lead electrocardiogram
• Intravenous access
• Frequent vital sign assessments.
• Chest radiography
• Complete blood cell count
• Electrolytes
• BNP level
• Cardiac markers

Acute Pulmonary Edema

• Intravenous diuretics, diuresis can begin 10 to 15 min after intravenous furosemide. If urine output is inadequate in 20 to 30 min, the diuretic dose is increased and repeated.
• Furosemide Dose  
            No prior use: 40 mg IVP
            If prior use: Double last 24-h usage (range, 80–180 mg)
            If no effect by 20–30 mins: re-double dose

Natriuretic Peptide Assay(BNP levels) in Heart Failure

These proteins are released by ventricular pressure or volume stimulus.
Age < 50    BNP level cut point = 450 pg/ml
Age 50-75  BNP level cut point = 900 pg/ml
Age >75     BNP level cut point = 1900 pg/ml


There are confounders to BNP as an HF test. BNP is increased in the elderly, women, those with cirrhosis or renal failure, possibly those on hormone replacement therapy, and probably those with pulmonary embolus and primary pulmonary hypertension. 

Precipitating Heart failure

• Hypertension
• Endocrine
• Anemia
• Rheumatic heart disease
• Toxin
• Failure to take meds
• Arrhythmia
• Infection
• Lung (pulmonary embolism)
• Electrolytes
• Diet (excess Na+)

Child-Turcotte-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems for staging cirrhosis.

Child-Turcotte-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems for staging cirrhosis.

Child-Turcotte-Pugh scoring system Numerical Score Parameter 1 2 3 Ascites None Slight Moderate to severe Encephalopathy None Slight to moderate Moderate to severe Bilirubin (mg/dL) < 2.0 2–3 > 3.0 Albumin (g/dL) > 3.5 2.8–3.5 < 2.8 Prothrombin time (seconds increased) 1–3 4–6 > 6.0 Total numerical score and corresponding Child-Turcotte-Pugh class  Score  Class  5–6 A 7–9 B 10–15 C MELD scoring system  MELD = 11.2 loge (INR) + 3.78 loge (bilirubin [mg/dL]) + 9.57 loge (creatinine [mg/dL]) + 6.43 (Range 6–40).

INR, international normalized ratio. Prognosis Factors determining survival include ability to stop alcohol intake and the Child-Turcotte-Pugh class The Model for End-Stage Liver Disease (MELD) is used to determine priorities for liver transplantation

Corrected calcium in hypoalbumin

Corrected calcium = serum calcium + 0.08 (40 - serum albumin)

Normal range: 9-10.5 mg/dL

Treatment of hypomagnesium

Medication

Oral replacement is appropriate for mild symptoms, while IV replacement is indicated for severe clinical effects.

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