The Hypotensive CHF Patient: Mistakes I Have Made
Few things in medicine are as educational as reviewing the mistakes of colleagues. Dr. Peter Deblieux of the Departments of Pulmonary and Critical Care Medicine and Emergency Medicine at the University Medical Center in New Orleans recently gave a lecture on “Treating the Hypotensive Heart Failure Patient”. This is a difficult patient to manage in the ED. This lecture will be posted shortly on EMedHome.com as part of the University of Maryland Department of EM’s Cardiology Conference lectures.
Dr. Deblieux ended the lecture with a section entitled “Mistakes I Have Made”. We thought it would be of value to share these actual encounters for everyone’s benefit, and are doing so with Dr. Deblieux’s permission.
(A)
A 58 year-old man presents with an ST-Elevation acute MI with serial runs of Ventricular Tachycardia with a pulse. The patient is awake and alert with a BP of 88/52 mm Hg. Amiodarone is administered. Amiodarone administration results in a drop of the BP to 70/44 mm Hg and the patient loses consciousness.
Lesson: There is a hesitancy to use electricity in unstable CHF patients, particularly when the patient is awake and talking. Preferentially treat dysrhythmias in a hypotensive patient with electrical cardioversion. Amiodarone and lidocaine can worsen hypotension.
(B)
A 69 year-old female presents with Acute Decompensated Heart Failure with crackles at the bases. Her RR is 32, BP is 86/52 mm Hg and her HR is 124 bpm. The SaO2 is 98% on 100% NRB. A decision is made to use push-dose pressors and phenylephrine is given. The BP increases to 116/92 mm Hg, the heart rate decreases to 42 bpm. and the crackles worsen.
Lesson: Phenylephrine can cause increased myocardial work and induce bradycardia (that typically doesn’t respond to atropine). (“For patients with existing heart failure, use of bolus-dose phenylephrine may place them at risk for worsened cardiac function. More studies are needed to specifically evaluate the effects of phenylephrine on patients with heart failure. Until such data becomes available, it may be prudent to avoid phenylephrine use in this patient population” – Am J Emerg Med. 2018;36:1802).
(C)
A 72 year-old man presents to the ED with acute decompensated heart failure, complaining of chest tightness. Crackles are noted at the apices. His BP is 96/66 mm Hg. Lasix, aspirin, and sublingual NTG are given. The patient loses consciousness with a BP of 50/palp.
Lesson: Hold SL NTG if the BP is tenuous. Use IV NTG which has a short half-life and can be immediately discontinued.
(D)
A 65 year-old male presents with Acute Decompensated Heart Failure. His RR is 40 with a SaO2 of 92% on 100% NRB, a BP of 94/70 mm Hg and a HR of 134 bpm. A decision is made to perform RSI. Etomidate and Succinylcholine are administered. A Code ensues.
Lesson: In patients with shock states, consider resuscitation before RSI.
EMCY 