Answer
1) Radiological finding
a. Fluid in the transverse fissure
b. Cardiomegally
c. Bilateral interstitial shadows at both lungs predominantly at the perihilar regions
d. Blunting both costophrenic angles
e. Kerley B lines on the left
f. Prominent upper lobe veins
g. Peribronchial cuffing.
2) Provisional diagnosis
Heart failure with Acute Pulmonary Edema changes.
3) Management of the patient.
a) Acute management
- Triage the patient to the red zone equipped with resuscitation trolley and cardiac monitoring
- Secure the ABC. (1. patency of airway, 2. 100% O2 via nasal prong, if not improved, consider high flow mask and may require intubation. 3. IV access with 2 large bore needle. 4. Fluid resuscitation if hypotension)
- Investigation (Chest x-ray, ABG, PT/aPTT, RFT/LFT, cardiac biomarker, natriuretic peptide)
- Monitoring of the patient (1. Cardiac monitoring, 2. ECG, 3. Pulse oxymetry)
- Positioning the patient (sit upright)
- Analgesia and sedation if patient is distressed or in pain (1. IV morphine 2.5- 5mg stat+ IV metaclopromide 10 mg stat, 2. Maintain patient with IV morphine infusion, 3. If patient in severe distress, consider sedation with midazolam)
- Diuretic/ vasodilator in the presence of pulmonary congestion (1. Nitoglycerin infusion, 2. IV lasix 20-40 mg stat and repeat the dose)
- Continuous bladder drainage to monitor urine output.
- Consider pacing, antiarrythmics or electroconversion if presence of arrhythmia
- Correction of acidosis if present
- In case of cardiogenic shock; consider Inotropes infusion (1. start with single inotropes; dobutamine. 2) if BP not picking up, add dopamine. 3) if still not picking up, consider triple or quadruple inotropes with infusion noradrenalin and bolus adrenalin), Swan- Ganz catheter and intra aortic ballon pump
b) Post stabilization
- Admit patient to the medical ward if stable or CCU if patient on inotropes or require resuscitation.
- Recognize the possible causes and treat.
- Echocardiography, coronary angiogram.
- Continue diuretic and add ACE inhibitor/ ARB and beta blocker.
- Fluid challenge
- Re access the patient
c) Long term goal therapy
- Pharmacological therapy (ACE inhibitors, angiotensin II type 1 (AT1) receptor blockers, β-blockers, diuretics, and spironolactone). Reduce mortality and improve survival rate up to five years.
- cardiac resynchronization therapy with or without implantable cardioverter defibrillator to prevent sudden cardiac death
4) Classification of Heart Failure
a) New onset ( i. first presentation, ii. Acute or slow onset)
b) Transient (recurrent or episoidic)
c) Chronic (i. persistent, ii. Stable, worsening or decompensated)