Congestive Heart Failure & Acute Pulmonary Edema (Quiz 3)

3 basic steps of medical management with CHF

1. Identify causative factors -- Correction (hypertension, CAD (stents), obesity,smoking) -- Stabilization 2. Life-style modifications 3. Drug therapy -- Digitalis, etc.

What anesthetic would you use for Dental Management?

2 carps lido 1:100,000 epi MAX

Congestive Heart Failure (CHF)

A combination of left & right ventricular failure with evidence of both systemic & pulmonary congestion existing

What CHF pts may not be able to tolerate a supine chair position

ASA type II-IV Unless emergency situation we do not see ASA IV

Cor Pulmonale

Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels. (right sided failure is caused by a lung problem, independent of the left side)

Signs/Symptoms of Acute Pulmonary Edema:

All S&S of heart failure plus: Initial symptom is a dry cough but can change into moist as episode worsens Increased anxiety Tachypnea Cyanosis Dyspnea at rest Frothy pink Sputum (blood tinged) pt. feels like they are suffocating Cyanosis Pallor Sweating

Pulsus alternans

Alternating pulse; A physical finding with arterial pulse waveform showing alternating strong and weak beats.

Pulmonary Embolism

Blocking of a pulmonary artery due to a blood clot

What is the most common cause of CHF

Coronary Artery Disease (CAD)

Common causes of CHF?

CAD Hypertension Valvular heart disease Myocarditis Cardiomyopathy Infective endocarditis Congenital heart disease Pulmonary hypertension Pulmonary embolism Endocrine diseaes

Diaphoretic

Cold sweat

Orthopnea

Difficulty breathing laying down (positional)

What meds are used to manage or treat CHF?

Diuretics - HBP Inotropic agents - makes contraction of heart more forceful (stop backflow) Vasodialators - Reduced BP

What are medications used to manage or treat CHF?

Diuretics - HBP Inotropic agents - makes contraction of heart more forceful (stopping backflow) Vasodialators - Reduced BP

What is the key sign difference between CHF & acute pulmonary edema?

Dyspnea at rest Pink frothy Sputum

Peripheral edema

Edema (accumulation of fluid causing swelling) in tissues perfused by the peripheral vascular system

If pt is on Digoxin what anesthetic would you administer?

plain anesthetic NO EPI

What vitals would be signs for CHF?

Elevated BP Increased heart rate Increased respiratory rate

Pulmonary hypertension

Elevated pressure in lungs

When a pt is on digoxin what drugs do you avoid?

Erythromycin and Clarithromycin same pathway - digoxin absorption is increased and causese toxicity

Pulsus Alternans

Extra beat or alternating weak and strong beats

What happens when blood sits in vessels too long in left sided failure?

Fluid diffuse through the capillaries --> blood sits in lungs --> fluid leaks out into alveoli --> person is drowning in fluid in lungs

How does the Renin/angiotensin system balance cardiac insufficiency?

Fluid excretion Increased preload stretching of the heart-increases contractility

What is Cardiomyopathy and why is it bad?

Heart growth You only have a set amount of area in the chest. If heart is trying to grow it can't grow out, so it grows in. Reducing size of chambers. Reducing stretch, reducing elastic rebound, causing less output of blood.

What would be some examples of peripheral resistance on the heart?

High BP Valvular defects Prolonged continuous demands for increased cardiac output Bombarding the heart with epinephrine

What is the leading cause of LV failure?

Hypertension

When is acute pulmonary edema common?

Immediately after MI if the left ventricle damage is significant (why we don't see pt 6 months after MI)

In what case would right sided failure happen first?

In serious breathing conditions (ex. asthma). It causes high pressure in lungs, which can cause right sided failure before left.

Predisposing factors in HF:

Increased workload on heart (ex. sleep apnea) Damaged muscular walls of heart through: Ischemia (CAD, MI)

How is weight a sign of potential, quickly occurring CHF?

Indication of heart failure that is occurring quickly is quick weight gain (fluid weight) Poor circulation, not getting fluid to kidneys to excrete.

Myocarditis

Inflammation of the heart muscle Due to infection, drugs, etc.

Can we see someone with decompensated CHF?

It depends on their status, if they are aware of it, on oxygen.

What is the problem with CHF?

It is back where the congestion is happening (not a problem going through)

Which ventricle is more vulnerable to heart disease & disorders of blood supply?

Left Ventricle

Acute Pulmonary Edema

Life threatening condition marked by an excess of serous fluid in the alveolar spaces or tissues of the lungs w/extreme difficulty breathing (pulmonary=lungs)

Inotropic agents

Makes contraction of heart more forceful (stops backflow)

What would be some ways to prevent CHF in clinic?

Med History Questionnaire Medications Dialogue History Physical Eval/Exam Vital Signs

Can you use an epi cord on a pt. w/CHF?

NO

What drugs do you avoid w/ a CHF pt?

NSAIDS

Compensated CHF

No symptoms present

acute pulmonary edema

Occurs when an excessive amount of fluid collects in the spaces between the alveoli and capillaries, disturbs normal gas exchange

General signs/symptoms of CHF:

Pallor Sweating L. Vent. hypertrophy Narrow pulse pressure (high diastolic) Pulsus Alternans Enlarged liver & spleen Ascites Weakness & undo fatigue Dyspnea during exertion Hyperventilation Nocturia Parxysmal nocturnal dyspnea Wheezing (cardiac asthma)

What is the 1st sign & symptom of Right Ventricular Failure?

Peripheral edema

Signs/Symptoms of Right Ventricular Failure:

Peripheral edema Weakness & undo fatigue Cyanosis - also present due to lack of O2 Prominent jugular veins Enlarged liver & spleen Cor Pulmnale

CHF ASA 3:

Pt. experiences dyspnea or undue fatigue with normal activites

CHF ASA 4:

Pt. experiences dyspnea, orthopnea, & undue fatigue at all times

CHF ASA 2:

Pt. experiences mild dyspnea or fatigue during exertion Anyone w/a systemic disease

Paroxysmal Nocturnal Dyspnea

Random sleeping and difficulty breathing

When does Right Ventricular Failure usually develop?

Usually develops after left. vent. failure has been present for a variable amount of time

What is the difference between Right sided failure and Left sided failure?

Right sided failure the congestion is in the periphery - edema and swelling in the extremities Left sided failure is congestion in the lungs - breathing problems

What would you physically evaluate/examine for CHF?

Skin & mucous membrane color Nail beds & lips Neck & ankles -check for pale palor, syonotic, swollen veins and ankles, cyanotic nail beds and lips

Decompensated CHF

Symptomatic

Management of HF & Acute Pulmonary Edema in Dental office

Terminate procedure Remove dental materials from mouth STAT SITUATION/CALL 911 Position pt comfortably (unconscious lay down/conscious sit up) Conscious - calm pt Unconscious - CAB Conscious/Unconscious - Give O2, monitor vitals, alleviate symptoms, alleviate apprehension, bloodless phlebotomy if necessary, discharge pt, modify subsequent dental treatment

How does sleep apnea play a role in CHF?

When you stop breathing in your sleep it puts extreme pressure on heart, but you are not getting oxygen in your body and you wake yourself up gasping for air (suffocating yourself) Usually left fails first caused by coronary artery, then right will fail. It can cause both left & right failure.

When may heart failure develop?

Whenever the heart labors for extended periods of time against peripheral resistance.

Can a pt. w/CHF, who is under good control w/no complications have routine dental care?

Yes

If Renin-Antiogensin-system is not working properly could that cause CHF?

Yes! It helps monitor BP. BP gets too high, heart begins working too hard...

Ascites

abnormal accumulation of fluid in the peritoneal cavity

What is Digitalis?

aka Digoxin Common medication - acts on heart Can treat/cause arrhythmias. Makes heart hypersensitive

Paroxysmal nocturnal dyspnea (PND)

attacks of severe shortness of breath and coughing that generally occur at night, usually waking the person up.

frothy pink sputum

cough or saliva that is blood tinged BIG SIGN OF APE-CALL 911

Bloodless phlebotomy

could be performed in a dental setting to help manage lung congestion in patients suffering from acute pulmonary edema put turniquets on 3 limbs, rotate every 5 minutes to help relieve heart from having to pump blood through body

Right ventricular failure

dominated by systemic venous congestion & peripheral edema

Endocrine disease

due to excess or deficiencies of hormones. Making heart work too hard.

Who is at more risk of CHF?

elderly

Nocturia

excessive urination at night

What are the most acquired disorders that lead to CHF?

failure of the left ventricle

Tachypnea

fast breathing

Heart failure

may involve failure of left ventricle, right ventricle, or both

CHF ASA 1:

pt. does not experience dyspnea or undue fatigue with normal exertion

Precipitating factors of Acute Pulmonary Edema

salty meal non-compliance w/meds Infection -we could see an oral infection that could cause acute pulmonary edema if they have a heart condition

Dyspnea

shortness of breath

Left ventricular failure

symptoms are associated with pulmonary congestion & respiratory distress

Signs/Symptoms of Left Ventricular Failure:

weakness & fatigue Dyspnea Frequent urination Orthopnea Paroxysmal Nocturnal Dyspnea Pale & Diaphoretic (mod-severe LVF) High BP(more so diastolic) Increased heart rate Pulsus Alternans Tachypnea --Pt may have own O2 tank 24/7

Can we see someone with compensated CHF?

yes