Managing Acute Heart Failure in the Emergency Department Patient case study 1 Case Introduction 3 Initial Diagnosis and Care Plan 2 Case Details and Initial.

Managing Acute Heart Failure in the Emergency Department Patient case study 1 Case Introduction 3 Initial Diagnosis and Care Plan 2 Case Details and Initial Triage 5 Revised Diagnosis and Care Plan 7 Teaching Points Discussion and Conclusions 4 Diagnostic Results 6 Disposition Decision Author: Salvatore Di Somma, MD, PhD Glossary Click on the icons for more information ? ? Questions

Salvatore Di Somma, MD PhD Emergency Medicine Department, Sant’ Andrea Hospital, School of Medicine & Psychology, University of Roma “Sapienza” (Rome; Italy) Salvatore Di Somma, MD PhD Emergency Medicine Department, Sant’ Andrea Hospital, School of Medicine & Psychology, University of Roma “Sapienza” (Rome; Italy) CASE INTRODUCTION More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home

Background This is the ER of an academic tertiary care hospital in a large urban city Approximately 55,000 patients are admitted to this ER annually, of which 2,200 cases were AHF. This ED handles any type of emergency During this case, 1 attending and 1 fellow were on duty You have access to (less than 30 minutes) ECG, bedside ultrasound and comprehensive echo, biomarkers data and chest X ray You have access to a cath lab Background This is the ER of an academic tertiary care hospital in a large urban city Approximately 55,000 patients are admitted to this ER annually, of which 2,200 cases were AHF. This ED handles any type of emergency During this case, 1 attending and 1 fellow were on duty You have access to (less than 30 minutes) ECG, bedside ultrasound and comprehensive echo, biomarkers data and chest X ray You have access to a cath lab CASE INTRODUCTION ECG=electrocardiogram; echo=echocardiogram; ER=Emergency Room Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home

Chief Complaint and Vital Signs History of Present Illness and Review of systems Past History, Allergy History, Medications, and Social History Physical Examination CASE DETAILS AND INITIAL TRIAGE HPI Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Author: Salvatore Di Somma, MD, PhD Click on the icons for more information

Chief Complaint “I am short of breath” Chief Complaint “I am short of breath” CASE DETAILS AND INITIAL TRIAGE More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home

Vital Signs (at Triage) BP: 220/140 mmHg HR: 180 bpm RR: 40 brpm Temperature: 36.4°C / 97.5°F O 2 sat: 97% with O 2 14 L/min supply Vital Signs (at Triage) BP: 220/140 mmHg HR: 180 bpm RR: 40 brpm Temperature: 36.4°C / 97.5°F O 2 sat: 97% with O 2 14 L/min supply CASE DETAILS AND INITIAL TRIAGE BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; O 2 sat=oxygen saturation; RR=respiration rate Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home

History of Present Illness 46-year-old female brought to the ED by ambulance for sudden onset of acute shortness of breath that occurred with vomiting. Symptoms began less than 30 minutes prior to arrival. She also complains of a productive cough for the last few days. History of Present Illness 46-year-old female brought to the ED by ambulance for sudden onset of acute shortness of breath that occurred with vomiting. Symptoms began less than 30 minutes prior to arrival. She also complains of a productive cough for the last few days. CASE DETAILS AND INITIAL TRIAGE HPI ED=Emergency Department More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Review of Systems + cough but no fever No abdominal pain No back pain No rash No fatigue No black or bloody stools Review of Systems + cough but no fever No abdominal pain No back pain No rash No fatigue No black or bloody stools CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Past History April 2013: right lung lobectomy for lung cancer treated with radiotherapy Recent deep vein thrombosis treated with oral anticoagulant Past History April 2013: right lung lobectomy for lung cancer treated with radiotherapy Recent deep vein thrombosis treated with oral anticoagulant CASE DETAILS AND INITIAL TRIAGE More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Allergy History, Medications, and Social History Allergies Adverse reaction with Novocaine Social History Never smoked Very rare alcohol No illicit drug use Medications Methylprednisolone: 16 mg/day (related to the history of cancer) Warfarin on the basis of scheduled INR values INR=international normalized ratio CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Physical Examination (Focused Exam) +JVD Severe respiratory distress (RR: 40 brpm) Wheezing and bilateral inspiratory rales Tachycardic (HR:180 bpm) Aortic II/VI systolic murmur and unspecified gallop rhythm No peripheral edema Profuse warm sweating Rest of the exam is unremarkable Physical Examination (Focused Exam) +JVD Severe respiratory distress (RR: 40 brpm) Wheezing and bilateral inspiratory rales Tachycardic (HR:180 bpm) Aortic II/VI systolic murmur and unspecified gallop rhythm No peripheral edema Profuse warm sweating Rest of the exam is unremarkable CASE DETAILS AND INITIAL TRIAGE bpm=beats per minute; brpm=breaths per minute; HR=heart rate; JVD=jugular venous distension; RR=respiratory rate Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Initial Plan of Care INITIAL DIAGNOSIS AND CARE PLAN Clinical Impression (Initial Diagnosis) and Differential Diagnosis Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home Author: Salvatore Di Somma, MD, PhD Click on the icons for more information Disposition Decision

Clinical Impression (Initial Diagnosis) and Differential Diagnosis Acute cardiogenic pulmonary edema Pulmonary edema secondary to hypertensive crisis Pulmonary edema secondary to ACS Pulmonary edema secondary to severe aortic stenosis Aspiration pneumonia as dyspnea began after vomiting Pulmonary embolism because patient has a history of DVT on warfarin, cancer history and sudden onset of dyspnea Clinical Impression (Initial Diagnosis) and Differential Diagnosis Acute cardiogenic pulmonary edema Pulmonary edema secondary to hypertensive crisis Pulmonary edema secondary to ACS Pulmonary edema secondary to severe aortic stenosis Aspiration pneumonia as dyspnea began after vomiting Pulmonary embolism because patient has a history of DVT on warfarin, cancer history and sudden onset of dyspnea INITIAL DIAGNOSIS AND CARE PLAN ACS=acute coronary syndrome; BP=blood pressure Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Initial Plan of Care Diagnostic plans: Vein cannulation with i.v. Laboratory tests included BNP and Hs Troponin I Blood gas analysis ECG (12 leads and continuous cardiac monitoring) POCT bedside ultrasound of heart, lungs and inferior vena cava Chest X ray Therapeutic considerations: Diuretics (furosemide) i.v. Nitrates i.v. Nebulized  -agonist (albuterol) and anti-cholinergic (ipratropium) Corticosteroids i.v. Oxygen Potential rate or rhythm control depending on further evaluation with ECG Initial Plan of Care Diagnostic plans: Vein cannulation with i.v. Laboratory tests included BNP and Hs Troponin I Blood gas analysis ECG (12 leads and continuous cardiac monitoring) POCT bedside ultrasound of heart, lungs and inferior vena cava Chest X ray Therapeutic considerations: Diuretics (furosemide) i.v. Nitrates i.v. Nebulized  -agonist (albuterol) and anti-cholinergic (ipratropium) Corticosteroids i.v. Oxygen Potential rate or rhythm control depending on further evaluation with ECG INITIAL DIAGNOSIS AND CARE PLAN BNP=B-type natriuretic peptide; ECG=electrocardiogram; i.v.=intravenous; POCT=point of care testing More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Initial Plan of Care (cont’d) As diagnostic work up is ongoing: NIV is immediately started i.v. nitrates are begun and titrated aggressively to symptoms and BP Initial Plan of Care (cont’d) As diagnostic work up is ongoing: NIV is immediately started i.v. nitrates are begun and titrated aggressively to symptoms and BP INITIAL DIAGNOSIS AND CARE PLAN BP=blood pressure; i.v.=intravenous; NIV=non-invasive ventilation Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

DIAGNOSTIC RESULTS Lab Results Ancillary Imaging Chest X ray ECG Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home Author: Salvatore Di Somma, MD, PhD Click on the icons for more information Disposition Decision

ECG DIAGNOSTIC RESULTS Click here for ECG: Interpretation Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

ECG: Interpretation Supraventricular tachycardia, 180 bpm ST depression throughout the precordium, no clear P waves ECG: Interpretation Supraventricular tachycardia, 180 bpm ST depression throughout the precordium, no clear P waves bpm=beats per minute DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Chest X ray Click here for Chest X ray: Interpretation DIAGNOSTIC RESULTS ? ? QUESTION Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Chest X ray: Radiology Interpretation Obtained within 1 hour from presentation Findings Signs of previous right lobectomy Multiple bilateral areas of consolidation, mainly in the right middle zone with pleural effusion Cardiac enlargement Chest X ray: Radiology Interpretation Obtained within 1 hour from presentation Findings Signs of previous right lobectomy Multiple bilateral areas of consolidation, mainly in the right middle zone with pleural effusion Cardiac enlargement DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Ancillary Imaging Bedside (2 minutes) thoracic ultrasound was performed: Ancillary Imaging Bedside (2 minutes) thoracic ultrasound was performed: Click here for Ancillary imaging: Interpretation Chest echocardiogram Echocardiogram DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Ancillary Imaging: Interpretation Chest echo Bilateral “comet-tail” signs Echocardiogram Myocardial hypokinesis Normal left and right sections dimensions Absence of pericardial effusion IVC Appears full with no collapsibility with respiration Ancillary Imaging: Interpretation Chest echo Bilateral “comet-tail” signs Echocardiogram Myocardial hypokinesis Normal left and right sections dimensions Absence of pericardial effusion IVC Appears full with no collapsibility with respiration DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Lab Results (or POCT Results) (reference range) Hb:17 g/dL ( 12–16 g/dL) WBC:18.480/  L (4.3–18.8/  L ) PLT: 288.000/  L(140–400/  L ) BUN: 20 mg/dL (5–25 mg/dL) Creatinine: 1.21 mg/dL (0.7–1.1 mg/dL) Na + :139 mmol/L (136–145 mmol/L) K + : 3.2 mmol/L (3.5–5.1 mmol/L) PCT: 0.08 ng/mL (<0.05 ng/mL) BNP*: 52.2 pg/mL (<100 pg/mL) HS-TnI # : 20 pg/mL (0–15.6 pg/mL) INR: 2.83 (0.9–1.2) D-dimer 505 ng/mL (<243 ng/mL) (reference range) Blood Gas Analysis O 2 :14 L/min pH:7.05 (7.35–7.45) pCO 2 :67 mmHg (35–45 mmHg) pO 2 :121 mmHg (80–100 mmHg) Lactate: 13.9 mmol/L(<2 mmol/L) HCO 3 ‾: 18.5 mmol/L(22–26 mmol/L) SO 2 : 97% Lab results were obtained within 1 hour from admission, while results of point of care blood gas analysis and biomarkers were obtained within 15 minutes ? ? QUESTION *Abbott Diagnostic Assay, # Abbott Diagnostic Assay. BNP=B-type natriuretic peptide; BUN=blood urea nitrogen; Cr=creatinine; Hb=hemoglobin; HS-TnI=high-sensitivity troponin I; INR=international normalized ratio; PCT=procalcitonin; PLTs=platelets; WBC = white blood cell count DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Next actions REVISED DIAGNOSIS AND CARE PLAN Revised Clinical Impression and Differential Diagnoses Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home Author: Salvatore Di Somma, MD, PhD Click on the icons for more information Disposition Decision

REVISED DIAGNOSIS AND CARE PLAN Revised Clinical Impression and Differential Diagnoses REVISED DIAGNOSIS AND CARE PLAN Presence of: Sudden onset of dyspnea Elevated BP levels Acute respiratory failure Bilateral “comet tails” Normal right side cardiac function Absence of: Gradual worsening dyspnea Fatigue Lower limb edema Fever Our diagnostic hypothesis: Flash pulmonary edema in hypertensive crisis with potential aspiration pneumonia BP=blood pressure Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Next Actions Patient immediately started: Furosemide 100 mg as i.v. bolus Nitroglycerin 0.9 mg/h (15  g/min) as i.v. infusion Morphine 5 mg as i.v. bolus Next Actions Patient immediately started: Furosemide 100 mg as i.v. bolus Nitroglycerin 0.9 mg/h (15  g/min) as i.v. infusion Morphine 5 mg as i.v. bolus REVISED DIAGNOSIS AND CARE PLAN i.v.=intravenous Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Disposition Patient rapidly improved during her ED course (<4 hours) Patient was then admitted to the Emergency Medicine ward (hospital floor – this ED has its own inpatient service as well) with continuous monitoring and frequent re-evaluation for 72 hours with progressive clinical and hemodynamic improvement NIV was slowly weaned ACS was excluded with further HS-TnI and serial ECG evaluation Disposition Patient rapidly improved during her ED course (<4 hours) Patient was then admitted to the Emergency Medicine ward (hospital floor – this ED has its own inpatient service as well) with continuous monitoring and frequent re-evaluation for 72 hours with progressive clinical and hemodynamic improvement NIV was slowly weaned ACS was excluded with further HS-TnI and serial ECG evaluation DISPOSITION DECISION H ACS=acute coronary syndromes; ED=Emergency Department; HS-TnI=highly-sensitive troponin I; NIV=non- invasive ventilation Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

TEACHING POINTS, DISCUSSION AND CONCLUSIONS Discussion and Conclusions Teaching Points Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home Author: Salvatore Di Somma, MD, PhD Click on the icons for more information Disposition Decision

Teaching Points Hypertensive crisis can generate pulmonary edema due to acute vasoconstriction (increased afterload) BNP may be falsely negative in flash pulmonary edema Patients often improve very quickly. Prompt regression of signs and symptoms after rapid treatment Teaching Points Hypertensive crisis can generate pulmonary edema due to acute vasoconstriction (increased afterload) BNP may be falsely negative in flash pulmonary edema Patients often improve very quickly. Prompt regression of signs and symptoms after rapid treatment TEACHING POINTS, DISCUSSION AND CONCLUSIONS BNP=B-type natriuretic peptide Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Discussion and Conclusions Flash pulmonary edema is a general clinical term used to describe a particularly dramatic form of acute heart failure It is a medical emergency marked by the sudden accumulation of fluid in one’s lungs. It should be noted that despite prompt treatment, it is possible for one’s condition to rapidly deteriorate, resulting in the need for intubation and/or death Flash pulmonary edema has been difficult to study given the severity of the patient’s symptoms and the rapid resolution with prompt treatment, often to the point of complete resolution of signs and symptoms in the ED Discussion and Conclusions Flash pulmonary edema is a general clinical term used to describe a particularly dramatic form of acute heart failure It is a medical emergency marked by the sudden accumulation of fluid in one’s lungs. It should be noted that despite prompt treatment, it is possible for one’s condition to rapidly deteriorate, resulting in the need for intubation and/or death Flash pulmonary edema has been difficult to study given the severity of the patient’s symptoms and the rapid resolution with prompt treatment, often to the point of complete resolution of signs and symptoms in the ED TEACHING POINTS, DISCUSSION AND CONCLUSIONS More ED=emergency department Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Discussion and Conclusions cont’d Natriuretic peptide levels may be ‘negative’ when the onset of AHF is very rapid, such as flash pulmonary edema Later measurement would demonstrate an elevated natriuretic peptide level. However, flash pulmonary edema is a clinical presentation The presentation is dramatic and prompt diagnosis and treatment is essential to minimize morbidity and mortality A key element of management is prompt diagnosis of this very distinct presentation Discussion and Conclusions cont’d Natriuretic peptide levels may be ‘negative’ when the onset of AHF is very rapid, such as flash pulmonary edema Later measurement would demonstrate an elevated natriuretic peptide level. However, flash pulmonary edema is a clinical presentation The presentation is dramatic and prompt diagnosis and treatment is essential to minimize morbidity and mortality A key element of management is prompt diagnosis of this very distinct presentation TEACHING POINTS, DISCUSSION AND CONCLUSIONS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Questions

QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct Incorrect answer The correct answer is E. DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct Incorrect answer The correct answer is E.. DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct QUESTION 1 What would you interpret from this chest x-ray? A.Multiple bilateral areas of alveolar edema, mainly in the right middle zone with pleural effusion. Cardiac enlargement B.Interstitial edema and cardiac enlargement C.Pleural effusion with atelectasis areas D.Right pneumonia E.All are correct Correct answer All of these answers are correct. DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis Correct answer DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis QUESTION 2 I Initially thought this patient may be alkalotic from tachypnea secondary to hypoxia. However this patient is acidemic and retaining CO 2. Why? A.Severe respiratory distress with respiratory muscle failure B.A mixed picture secondary to obstructive airway disease C.The main pathophysiological alteration is metabolic acidosis Incorrect answer The correct answer is A. DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results HomeDisposition Decision

Glossary of terms Acute Medicine Also known as emergency medicine ward CHA 2 DS 2 -VASC A clinical prediction rule for estimation of stroke risk in patients with atrial fibrillation CHEM7 US terminology. A basic metabolic panel including Na, K, Cl −, HCO 3 − or CO 2, blood urea nitrogen, creatinine and glucose Community heart failure team UK terminology. A specialist community heart failure nursing service working in partnership with Hospital Trusts Consultant UK terminology. The equivalent role in the US would be an attending/staff physician C/O Complaining of EHMRG Emergency Heart Failure Mortality Risk Grade. A tool that could be used to assess mortality risk at discharge. Note, this tool has not been prospectively validated. Clinical judgement is important GP General practitioner. UK terminology. The equivalent role in the US would be family physician R/O Ruled out Stat statim (Latin) referring to speed Specialist UK terminology. See consultant

Managing Acute Heart Failure in the Emergency Department Patient case study 1 Case Introduction 3 Initial Diagnosis and Care Plan 2 Case Details and Initial.

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Managing Acute Heart Failure in the Emergency Department Patient case study 1 Case Introduction 3 Initial Diagnosis and Care Plan 2 Case Details and Initial.

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