CHF but hypotensive/shock

[unchartedem]

So I recently had this patient 80 something who presented in/like CHF however was hypotensive to like 80's. No FRANK evidence of MI just based on ekg only. Chest had fluid, legs had fluid. I wasn't really sure what the best option was or at least what the best option to start was. Would you start pressors first and then when the BP is better give the CHF cocktail( nitrates, lasix, etcc..) and if so what pressor would you start?...Dobutamine(because of the inc. cardiac output), but then that could drop your pressure even more. Dopamine?... But then that could inc myocardial O2 demand. Would you give a small fluid challenge maybe? It seems like all the information I read is on CHF with normal BP or hypertension and the debates involve rather ramping up the nitro full blast or not. Right now I'm trying to figure out the opposite spectrum. The help you guys give is always appreciated.

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[pratik7]

What were his other vitals? people with significant end stage CHF often run low with their BP. What was their resp distress like? I am a fan of CPAP. While it can lower the BP, in my experience it is minimal and transient. They become less tachpenic which can help their systemic perfusion. It also reduces the preload from the positive pressure. If you look at starlings curve in decompensated CHF, CO will go down with increased preload. Dobutamine by itself can reduce the BP further so I would prob add dopamine if the above failed.

my 2 cents

 

[deleted65604]

So I recently had this patient 80 something who presented in/like CHF however was hypotensive to like 80's. No FRANK evidence of MI just based on ekg only. Chest had fluid, legs had fluid. I wasn't really sure what the best option was or at least what the best option to start was. Would you start pressors first and then when the BP is better give the CHF cocktail( nitrates, lasix, etcc..) and if so what pressor would you start?...Dobutamine(because of the inc. cardiac output), but then that could drop your pressure even more. Dopamine?... But then that could inc myocardial O2 demand. Would you give a small fluid challenge maybe? It seems like all the information I read is on CHF with normal BP or hypertension and the debates involve rather ramping up the nitro full blast or not. Right now I'm trying to figure out the opposite spectrum. The help you guys give is always appreciated.

You are describing about the worst patient you can have as an ER doctor. Their prognosis sucks. You are flogging a useless heart and that is counter-productive. Could they have had a PE? Do they have pulmonary hypertension? Are they a GI bleed? Do they have a pericardial effusion?

I'd give a little fluid challenge, digoxin, and gentle levophed. I'd add dobutamine if they weren't already really tachycardic. Giving lasix and nitro to a hypotensive patient as well as bipap are all going to drop the pressure, so I wouldn't do any of those things in the patient you are describing. I'd be happy with a systolic pressure above 90, then I'd talk to the cardiologist. They could place a balloon pump to temporize things until the underlying cause was found and corrected if possible. A bolus dose of phenylephrine would last 15 or 20 minutes and by you some time to get access, and some basic bloodwork back while you started drips, and got some basic blood-work back.

However, I agree with the above poster, we need more info. Please describe as much of the history and phyical as you can and say post the vitals (and baseline blood pressure), EKG, chest x-ray, cbc, bnp, stool quaic, etc.

 

[pinipig523]

Dobutamine - decreases pulm resistance.

Dopamine - increased after load

Then start nitro drip.

 

[Arcan57]

Hypotensive CHF sucks about as much as anything in medicine, especially if there's bad valvular disease as well. I almost always start dobutamine, I'll usually give lasix, and I'll obviously hold off on nitro. BiPAP is useful if they're not oxygenating.

The important thing is not to focus on BP as a number, but to try and get a rough idea of tissue perfusion. If there BP is in the 80s but they are mentating and your interventions are resulting in improved cap refill or increased urine output then you're winning. Look for reversible or at least treatable causes (CHF is a huge risk factor for PE per the cardiac literature). And remember that they didn't get this edematous overnight (unlike their hypertensive brethren), so you're not going to get them back to baseline in the ED. Get cards involved early since they're going to need a CCU bed.

 

[xaelia]

Train wreck, grim prognosis.

Might avoid phenylephrine - will increase your SVR and make the numbers on the monitor look better, but decreases cardiac output.

Might not do the fluid challenge mentioned above - if they look volume overloaded, they've fallen off the preload end of their Starling curve; need to get fluid out.

As mentioned above, need to determine what it is specifically about this presentation that changed their homeostasis and reverse it.

 

[WilcoWorld]

I'm thinking digoxin (even though it will take a while to work) and BiPAP. Yes, I know BiPAP can decrease your pressure, but this is thought to be from increased intrathoracic pressure causing a decreased preload. Since the patient described sounds hypervolemic, I don't think that this would be as much of a problem here. On the pro side for BiPAP is that it will decrease the work of breathing and improve oxygenation, both of which will help a failing heart.

Agree with the above though - these are really tough patients.

 

[Apollyon]

By definition, pulmonary edema and hypotension is cardiogenic shock.

By common experience, as stated, these are sick and difficult patients. Before the advent of noninvasive CPAP, it was a devil's bargain of sorts - awake, alert SOB people, who were hypotensive. Sit up to breathe, low BP. Lie down, BP better (such as it was), worse SOB. Now, putting the "catcher's mask" on has helped greatly.

 

[UnderwaterDoc]

PGY 1 here so cut me some slack.

Can't you just intubate this patient? Tube, high peep, and pressors wouldn't do it?

 

[pseudoknot]

PGY 1 here so cut me some slack.

Can't you just intubate this patient? Tube, high peep, and pressors wouldn't do it?

It may end up there, but it doesn't change the fundamental problem with the heart. High PEEP is still going to drop your pressure. Pressors are going to increase oxygen demand on the heart. Finding the right fluid balance in these people, often an extremely narrow window, is one of the more difficult problems in critical care.

 

[jdh71]

Dobutamine - decreases pulm resistance.

Dopamine - increased after load

Then start nitro drip.

This.

 

[Hamhock]

This.

This #2

...but I would replace dopamine with levophed.

Dobutamine, pause...then levophed...SBP 90s is acutually near my goal, not really hypotension as long as other indications of perfusion are improving.

...especially weary of the ETT here, unless there is a clear reversible cause...very difficult to get off the vent.

HH

 

[doctorFred]

agree with dobutamine + levo. wouldn't touch dopamine with a 10 foot pole. seen too much peri-dopamine arrhythmias. that's my personal bias though.

 

[jdh71]

This #2

...but I would replace dopamine with levophed.

Dobutamine, pause...then levophed...SBP 90s is acutually near my goal, not really hypotension as long as other indications of perfusion are improving.

...especially weary of the ETT here, unless there is a clear reversible cause...very difficult to get off the vent.

HH

But . . . sick hearts love the vent. I think the reticence is very valid and definitely an appropriate concern, but we almost always get everyone off a vent eventually. We always have the option to trach, and the handful of cases of failure to wean from the vent because of heart failure, we were generally able to get the patient home on intermittent home vent through trach. Palliative tells me these guys tend to live a nice ending this way. Though the trach is psychologically difficult to accept initially but then these are end stage hearts.

 

[jdh71]

agree with dobutamine + levo. wouldn't touch dopamine with a 10 foot pole. seen too much peri-dopamine arrhythmias. that's my personal bias though.

I think once you've gone the dobutamine route, and all of it's B1 activity, that adding in the dopamine is a bit of a moot point; however, your point is well taken. I simply think in these patients I get a better kidney response with the dopamine, and the last thing any of us want to do is tank the beans any more than is already happening in the context of cardiogenic shock. I don't have any evidence (that I know of) to back up my intuition here.

 

[doctorFred]

I think once you've gone the dobutamine route, and all of it's B1 activity, that adding in the dopamine is a bit of a moot point; however, your point is well taken. I simply think in these patients I get a better kidney response with the dopamine, and the last thing any of us want to do is tank the beans any more than is already happening in the context of cardiogenic shock. I don't have any evidence (that I know of) to back up my intuition here.

great avatar though.