Professional Documents
Culture Documents
Dr AFDHALUN HAKIM,SPJP,FIHA,FASCC
RS Otorita Batam/BP Batam
Acute Heart Failure(AHF)
Definition : Rapid onset symptoms and signs secondary
to abnormal cardiac function
May present with several clinical condition:
Acute Decompensated Heart Failure (de novo/acute on
chronic CHF)
Hypertensive AHF
Pulmonary Edema
Cardiogenenic Shock
High Output Failure
Right Heart Failure
Acute Heart Failure
Heart Failure is a clinical syndrome in which patients have the following features
AND
Signs typical of heart Failure
(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous
pressure, peripheral edema, hepatomegali)
AND
Objective evidence of sructural or functional abnormality of the
heart at rest
(cardiomegaly, third heart sound, cardiac murmurs, abnormality on the
echocardiogram, raised natriuretic peptie concentration
Clinical presentation of
Acute Heart Failure
1. Acutely
decompensated
Chronic HF
2. Hypertensive AHF
3. Acute Pulmonary
Edema
4. Cardiogenic Shock
5. ACS & Heart Failure
6. Isolated right heart
failure
Acute Pulmonary Edema
Definisi
Pathophysiology
Mechanism Cardiogenic PE
Signs and Symptoms
Diagnosis and DD
Management
Prognosis
Acute Pulmonary Edema
Terminology
Definition :
Pulmonary edema is a condition in wich
fluid accumulates in the
lungs(extavasation of fluid from the
pulmonary vasculature into the intertitium
and alveoli of the lung) ,
usually because the heart’s left ventricle
does not pump adequately
Phatophysiolgy ALE
Acute Pulmonary Edema
4Major Pathophysiology Mechanism:
Noncardiogenic(ARDS,CRF,Pneumo
nia,Bad Burn,Drug Intoxication)
Acute Cardiogenic
Pulmonary Edema
P cap
P is
π is
π cap
Mechanism of cardiogenic pulmonary
Edema
Straling Law
Q=K (P cap - P is)- λ (π cap- π is)
Alveoli
Lymp
π is
π is
Vascular Intertitial space
P cap P is
π cap
Alveoli
Mechanism of cardiogenic pulmonary
Edema
Dalam keadaan normal:
Clinical Examination
• Low flow (cool periphery) • High Flow (warm
• S3Gallop,Cardiomegali periphery)
• JVP elevated • Bounding pulses,No
• Crackles wet Gallop,JVP normal
• Crackles dry
Differentiation of Cardiogenic from Non
Cardiogenic Pulmonary Edema
Cardiac • Non Cardiac
Laboratory Test
• ECG :ischemia/infarct • ECG :usualy normal
• CXR: perihilar distribution • CXR : peripheral distribution
• Cardiac enzym increase • Cardiac enzym normal
• PCWP >18 mmHg • PCWP<18 mmHg
Supportive Examination
• Laboratories Study:
- CBC (anemia)
- Electrolytes (hypo kalemia/magnesemia)
- BUN and creatinin
- BGA (Blood Gas Analysis)
•MONF
First Line Action:
• O2 Sungkup (NRM) 10-12 L/min
• Nytroglycerin SL (NTG 0,4 mg,cedocard 5
mg)
• Nitrat IV (ISDN Nitrat) mulai dosis 10
mcg/min
• Furosemide IV (0,5-1 mg/Kg>> Maks 2
mg/KgBB)
• Morphine IV (2-4 mg )
• BB : 60 kg TB : 160 cm
Kasus
• Pem.Fisik
• CM, TD 220/120 HR 110x/m RR 40x/m
• Sat O2 : 90%
• Cor :S1S2 N,Reguler, M(-), Gallop (+)
• Pulmo : Ronchi seluruh lap paru
• Abd/Ext : N
• D/ : Acute Lung Edema ( ec Hipertensi
Emergensi)
• T/:
• O – I – M (Oksigen,IV line ,Monitor)
• Nitrat (ISDN 5 mg ) SL (ulang sp 3x)
• Nitrat (ISDN) IV mulai 10 mcg/m titrasi s/d
maks 200 mcg/m
• Furosemide 40 mg/kgg, sampai 80 mg
• Morphine IV (2-4 mg ) pelan2
Acute Pulmonary Edema,Hypotension and Shock Algoritm
Clinical Sign:Shock,Hypoperfusion,
1 CongestiveHeart Failure,APE
Most likely Problem?
2 6 8 14
APE Volume Problem Pump Problem Rate Problem
7
Administer Bradicardia Tachycardia
-Fluids
-Blood Transfusions 9
-Cause specific Intervention
Consider: Vasopressor Blood Pressure
3
First-Line Action
-O2 and Intubation as needed
-NTG SL
-Furosemide IV 0,5-1 mg/Kg
-MO IV 2-4 mg
First-Line Action
-O2 and Intubation as needed Blood Pressure
-NTG SL
-Furosemide IV 0,5-1 mg/Kg
-MO IV 2-4 mg
Syst BP Syst BP<70 mmHg SBP 70-100 mmHg SBP 70-100 mmHg
BP defines 2nd Signs or Symptoms Signs and Symptoms No Signs or
SBP
Line of action Of shock Of shock Symptoms of shock >100 mmHg
Second-Line Actions-APE
-NTG or Nitroprusside if BP >100 mmHg
-Dopamine if BP 70-100,signs or symptoms .shock
-Dobutamine if BP >100,no signs or symptoms shock
Second-Line Actions-APE
-NTG or Nitroprusside if BP >100 mmHg
-Dopamine if BP 70-100,signs or symptoms .shock
-Dobutamine if BP >100,no signs or symptoms shock