Emergency management of heart failure- Value of the GTN patch

Just after listening about heart failure management in the ED on EMRAP, I had a patient who reinforced what I had learnt. 

The end stage renal failure, acutely short of breath, cold, clammy and diaphoretic patient makes me clammy and diaphoretic too. In such circumstances, attempting to set an IV cannula in these patients is a true challenge indeed.

I had a patient just like that. My colleagues and I spent about 30mins trying to insert and IV cannula. She was sitting upright and acutely short of breath. She looked like she needed a GTN infusion. But there was no IV access!!! I decided to slap on a GTN patch.

Lo and behold, by the time the cannula was in (I had to use ultrasound guidance btw), she was much less breathless and felt so much more comfortable. By the time, the IV was in, she no longer needed a GTN infusion.

Moral of the story: don't under estimate the power of a GTN patch. Sometimes, in the heat of an emergency, we forget to take a step back and think of alternative solutions to a problem.

Hence I decided to share some articles on the acute management of heart failure,

1) do not delay the GTN.... either as a transdermal patch or sublingual or as an infusion. It acts by:

• reducing the preload and afterload; hence work of the heart
• dilates coronary arteries and improve cardiac perfusion

2) start non invasive ventilation early as it can significantly reduce the need for intubation

3) for the acute APO, diuretics as monotherapy may not be as effective and it should be used together with nitrates (on the other hand, for those which chronic fluid overload with an acute exacerbation, diuretics is the mainstay)

4) another option to reduce afterload is an ACE inhibitor like captropril or enalapril

Here is a good website with links to the references:

http://thechartreview.org/acute-pulmonary-edema-nitro-vs-lasix/

Other cardiology subtopics

Symptom approach
STEMI

Cardiac Ultrasound

Stridor vs wheeze

As with any presenting complains to the GP or the Emergency department, clarification of the complain itself is utmost essential.

When I initially first started off in the ED (emergency department) as a patient complained of a symptom, I didn't always question it. We sometimes assume our understanding and the patients' understanding of a symptom is the same. Well, 1 word can mean many things to different people.

A classic example is wheeze. Some people regard any noisy breathing as wheeze. However, noisy breathing can come from a blocked nose, from stridor or it can indeed be a very loud audible wheeze. 

Having worked in the Children's Emergency helps me to appreciate the variety of such cases and train my ears and clinical acumen. For example, a parent presented with noisy breathing and the child was triaged as a wheezing child. Indeed the child was wheezing but he also had a hoarse voice and applied slightly stridorous. When I asked him to cough, there was that characteristic 'barking cough'. Lo and behold, it was croup. The parents have never come across it before and hence were not familiar with this barking cough.

While on the other end, a baby triaged as wheeze was mainly having a blocked nose.

Hence, moral of the story:

1) clarify the symptoms. if it doesn't fit the picture, re-think the diagnosis

2) stridor and a hard audible wheeze can sometimes be hard to differentiate

3) always rule out foreign body ingestion

Here are some articles I came across while checking this out:

http://www.emsworld.com/article/10324617/pediatric-wheezing-and-stridor

http://www.healio.com/pediatrics/respiratory-infections/news/online/%7Bc298b29a-9144-4fb5-8ce5-d2579b3a69dd%7D/clinicians-commonly-misidentify-respiratory-sounds-in-children

EM Cardiac ultrasound

Great summary to localise MI territories