Acute Decompensated Heart Failure by Dr. Elizabeth Profita for OPENPediatrics

Aug 26, 2023

Acute Decompensated Heart Failure by Dr. Elizabeth Profita for OPENPediatrics

In this video, Dr. Elizabeth Profita reviews heart failure, including associated signs and symptoms, and indications of worsening heart failure.

Initial publication date: July 7, 2021.

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Content

1.49 -> [Music]

5.759 -> acute decompensated heart failure by dr

8.24 -> elizabeth profita

10.96 -> hi there i'm dr elizabeth prafita

12.799 -> today's talk will start with an overview

14.639 -> of heart failure including understanding

16.32 -> the causes of heart failure

17.84 -> and reviewing the symptoms and signs of

19.68 -> heart failure we will then learn how to

21.76 -> assess a patient with heart failure by

23.6 -> learning how to assess both their

24.96 -> cardiac

25.519 -> output and volume status we will review

28.16 -> concerning findings in heart failure

29.76 -> that constitute

30.56 -> red flags and we'll finish with a few

32.399 -> patient cases to review the things we've

34.48 -> discussed today

36.48 -> heart failure overview

40.16 -> heart failure is caused either by

42 -> myocardial dysfunction

43.68 -> or normal myocardial function with

46 -> abnormal workload

47.52 -> with myocardial dysfunction the heart is

49.6 -> structurally normal

50.8 -> but the muscle itself isn't able to do a

53.12 -> normal amount of work

54.48 -> this decreased ventricular function

56.559 -> leads to decreased cardiac

58.079 -> output and heart failure causes of

60.32 -> myocardial dysfunction

61.68 -> include cardiomyopathies myocarditis

64.559 -> arrhythmias

65.68 -> drug exposure such as anthracycline and

67.84 -> chemotherapy

68.88 -> and metabolic disorders heart failure

71.92 -> can also result

73.119 -> from increased volume or pressure with

75.2 -> normal myocardial function

77.2 -> examples of volume overload include left

79.6 -> to right shunting lesions such as a vsd

82.32 -> pda or complete av canal defect or valve

85.36 -> regurgitation lesions

87.119 -> volume overload increases the amount of

88.96 -> work the heart has to do and leads to

90.799 -> heart failure over time

92.64 -> examples of pressure overload lesions

94.64 -> include both right-sided lesions such as

96.88 -> pulmonary stenosis or pulmonary

98.56 -> hypertension

99.6 -> or left-sided lesions such as aortic

101.439 -> stenosis or coarctation

103.119 -> in both cases outflow tract obstruction

105.439 -> limits outflow and thus cardiac output

107.84 -> causing heart failure symptoms of heart

110.96 -> failure can vary significantly with age

113.36 -> infants may present with increased work

115.119 -> of breathing sweating with feeds

117.119 -> irritability or poor growth young

120 -> children may present with abdominal pain

122.159 -> nausea vomiting decreased appetite or

124.799 -> chronic cough

126 -> and older children may present with

127.52 -> exercise intolerance anorexia

129.679 -> dyspnea palpitations chest pain or

132.239 -> syncope

134.4 -> findings to look for on exam include

136.319 -> jugular venous distension

138.08 -> respiratory signs such as respiratory

139.92 -> distress tachypnea or crackles

142.56 -> cardiac signs such as tachycardia and s3

145.28 -> gallop

145.92 -> decrease pulses and perfusion

147.76 -> hepatomegaly

148.959 -> and peripheral edema

152.4 -> assessment

155.519 -> we will now discuss how to assess a

157.599 -> patient with heart failure

159.76 -> when initially evaluating a patient with

161.36 -> heart failure it is helpful to think of

163.36 -> them in the context of these four

164.879 -> hemodynamic profiles

166.56 -> along the left side we have cardiac

168.4 -> output from hypoperfusion

170.319 -> to adequate perfusion and along the top

172.64 -> we have volume status from dry to

174.56 -> congested or wet

176.08 -> using these two axes this allows us to

178 -> define four hemodynamic profiles

180.64 -> in the northwest quadrant we have warm

182.64 -> and dry which is the ideal status for

184.64 -> our patients

185.519 -> they have good perfusion and no evidence

187.519 -> of volume overload

189.76 -> in the southwest quadrant we have cold

191.92 -> and dry which is the profile of patients

193.92 -> with low cardiac

194.959 -> output patients have cold extremities

197.28 -> hypotension

198.4 -> renal dysfunction altered mental status

200.879 -> or hyponatremia

202.56 -> in the northeast quadrant we have warm

204.879 -> and wet which is the profile of patients

206.799 -> with volume

207.519 -> overload patients have an s3 gallop

210.159 -> peripheral edema

211.28 -> pulmonary edema and an elevated jugular

213.76 -> venous

214.56 -> pressure in the southeast quadrant is

217.12 -> cold and wet which is a less common

218.879 -> patient profile

219.92 -> and corresponds with decompensated heart

221.76 -> failure and shock and thus will be

223.519 -> uncommon for patients in clinical

225.2 -> settings outside

226 -> of the cardiac intensive care unit

229.12 -> every day it is important to review the

231.2 -> following items to be able to

232.56 -> appropriately assess the patient and

234.239 -> determine their hemodynamic profile

236.959 -> vital signs and vital trends should be

238.72 -> reviewed along with central venous

240.64 -> pressure measurements if available

242.56 -> ins and outs and daily weights telemetry

245.28 -> should be reviewed for patients with any

246.959 -> concern for arrhythmia

248.64 -> when seeing the patient a complete

250.319 -> physical exam should be done assessing

252 -> for volume status and cardiac

253.84 -> output labs and lab trends should be

256.32 -> reviewed including electrolytes renal

258.239 -> function

258.88 -> mixed venous oxygen saturation and bnp

262.079 -> pertinent recent testing should also be

263.759 -> reviewed including chest x-rays echoes

266 -> and cardiac catheterizations

268.8 -> in patients with heart failure we often

270.479 -> trend the mixed venous oxygen saturation

272.72 -> as a surrogate for assessing cardiac

274.56 -> output

275.28 -> we measure the mixed venous oxygen

276.88 -> saturation in the svc or right atrium

279.36 -> typically using a picc line

282.56 -> the cardiac index is your cardiac output

284.88 -> divided by your body's surface area and

286.72 -> is the preferred unit for discussing

288.32 -> cardiac output in pediatric patients

292.96 -> we use the fick principle to estimate

295.04 -> your cardiac index

296.16 -> by using your mixed venous oxygen and

298.24 -> arterial oxygen saturations

300.32 -> if we assume a vo2 max and he and we

302.8 -> know your hemoglobin concentration

307.199 -> cardiac index is then proportional to

309.199 -> your arterial to venous oxygen

311.199 -> difference

312.08 -> if you assume a normal arterial oxygen

314.08 -> saturation of a hundred percent

315.759 -> and the mixed venous oxygen saturation

317.52 -> of seventy percent

318.8 -> this would give you a normal avo2

320.72 -> difference of around thirty percent

322.72 -> in patients with a lower arterial oxygen

324.8 -> saturation as in the case of single

326.56 -> ventricle anatomy

327.68 -> the mixed venous oxygen saturation will

329.44 -> be lower but the avo2 difference should

331.6 -> be similar

332.8 -> if your cardiac output is decreased

335.039 -> mixed venous oxygen saturation will

337.039 -> decrease and your avo2 difference will

339.36 -> increase in patients who have decreased

343.12 -> cardiac output or who are

344.8 -> cold they will present with symptoms of

347.039 -> abdominal pain

348.32 -> nausea fatigue fussiness or pale or gray

351.68 -> color

353.52 -> vital sign review may demonstrate

355.12 -> increased heart rates

356.639 -> or decreased blood pressures

359.919 -> exam may show tachycardia decreased

362.24 -> pulses

363.12 -> delayed capillary refill

367.919 -> cool extremities and in severe cases

370.24 -> altered mental status

373.199 -> labs may demonstrate a decrease in mixed

375.199 -> venous oxygen level

376.639 -> decreased sodium level increased

378.72 -> creatinine

379.759 -> elevated lactate and an elevated bnp

383.12 -> echo may demonstrate a decreased

384.56 -> systolic function with the decreased

386.4 -> ventricular ejection fraction

390.16 -> in patients who have volume overload

392.08 -> they will present with symptoms of

394.24 -> increased worker breathing and

395.36 -> respiratory distress

398.24 -> review of vital signs may show increased

400.319 -> respiratory rate

403.52 -> weight gain and a positive fluid balance

407.12 -> exam may show an s3 gallop

411.36 -> or an s4 gallop

413.06 -> [Music]

416.319 -> tachypnea crackles

424.88 -> hepatomegaly peripheral edema or jugular

427.759 -> venous distension

430.24 -> labs may show an increased central

431.84 -> venous pressure elevated bnp

434.08 -> and a low or normal bun to creatinine

436.4 -> ratio

437.199 -> and a chest x-ray may demonstrate

439.039 -> pulmonary edema

442 -> now we're going to talk about some red

443.599 -> flags in heart failure

446 -> end stage heart failure patients are at

447.919 -> high risk for decompensation and cardiac

450 -> arrest arrhythmia is also poorly

452.24 -> tolerated in patients who already have

454.16 -> ventricular dysfunctions

456.16 -> red flags for heart failure patients

458.08 -> include new symptoms such as nausea

460.479 -> vomiting or fussiness significant

462.88 -> changes in their vital

464 -> signs including tachycardia or tachypnea

467.28 -> exam changes including feeling cold or

470.879 -> with decreased perfusion or blue

473.039 -> coloring and

474.08 -> any arrhythmia including unexplained

476.879 -> sinus tachycardia

479.84 -> the first step when you notice a red

482 -> flag is to see and assess the patient

484.4 -> cardiac patients can rapidly deteriorate

487.039 -> and is very important to assess the

488.639 -> patient at the bedside

490.319 -> you may start by reviewing their vital

492.08 -> sign trends and any recent labs

494.24 -> including blood gases

495.68 -> lactates chemistry or mixed venous

497.759 -> oxygen saturations

499.199 -> if they have respiratory symptoms a

500.96 -> chest x-ray may be

502.319 -> appropriate and if you have any concerns

504.72 -> it is always appropriate to alert the

506.24 -> cardiology fellow in attending

508.08 -> and consider discussing with the cardiac

510.08 -> intensive care unit if there's an

511.84 -> anticipation of need for escalation of

514.08 -> care

515.44 -> case studies

518.56 -> now we'll discuss some patient cases to

521.279 -> test what we've learned today

523.76 -> case 1 you receive a page from a nurse

526.959 -> your patient seems to be having trouble

528.8 -> breathing your patient is a 10 year old

531.2 -> female with dilated cardiomyopathy

533.6 -> who was admitted with a heart failure

535.12 -> exacerbation she has been npo

537.36 -> all day for a picc line placement and

539.6 -> just returned to the floor from

540.8 -> interventional radiology

544.08 -> on the phone you asked the nurse to tell

545.76 -> you more about the breathing

547.2 -> when did it start what does it seem like

550.64 -> you ask what the current fluid and

552.08 -> diuretic plan is

553.92 -> while you're waiting to see the patient

555.36 -> you review the vital sign

556.959 -> with the respiratory rate trend the

558.64 -> heart rate trend and oxygen saturations

561.04 -> you review her ins and outs and her

562.72 -> medication list including diuretic doses

564.959 -> and times

566.56 -> when you see the patient you assess her

568.16 -> respiratory exam her cardiac exam

570.48 -> and her volume status you order labs

574.72 -> with a chemistry and you transduce

576.56 -> essential venous pressure

578.24 -> you obtain a chest x-ray to assess for

580.08 -> pulmonary edema

581.44 -> and if she's desaturated you could

583.279 -> consider using a nasal cannula of oxygen

586.399 -> if you have concern that she appears

588 -> volume overloaded you could consider a

589.839 -> dose of diuretics

592.48 -> in this case the patient had been npo

594.399 -> for the procedure today and had been

595.92 -> kept on full maintenance iv

597.519 -> fluids throughout the day she missed her

599.6 -> afternoon dose of diuretics while at the

601.44 -> procedure

603.12 -> she had increased tachypnea from her

605.44 -> baseline after the procedure

607.36 -> her picc line was transduced for a

608.959 -> central venous pressure and was found to

610.48 -> be elevated at 13 millimeters of mercury

612.959 -> a chest x-ray was obtained with

614.64 -> increased pulmonary edema

616.079 -> she was given an iv dose of diuretics

617.92 -> with improvement in her symptoms

621.12 -> case two you receive a page from your

623.6 -> nurse

624.16 -> your patient doesn't look great he is

626 -> pale and has been vomiting

627.76 -> your patient is a 14 year old male with

629.839 -> dilated cardiomyopathy who is currently

631.92 -> listed for heart transplant

633.68 -> and he was admitted with worsening heart

635.44 -> failure symptoms for milrinone

637.12 -> initiation

638.399 -> a picc line was placed and milron was

640.32 -> started five days ago

642.8 -> on the phone you ask your nurse when did

645.04 -> he last appear well

646.399 -> does he have other symptoms such as

648.079 -> nausea vomiting or belly pain

650.48 -> and remind me what he's currently on for

652.399 -> support

653.6 -> while you're waiting to see the patient

655.12 -> you review his vital signs including his

657.2 -> heart rate trend his blood pressures and

659.04 -> his oxygen levels

660.32 -> such as his oxygen saturation or mixed

662.64 -> venous oxygen saturations

664.399 -> his ins and outs and his urine output

666.399 -> and his recent labs including his mixed

668.32 -> venous oxygen level

669.519 -> a lactate and a hematocrit

673.279 -> in the room you assess his cardiac exam

675.36 -> including pulses

677.04 -> capillary refill

682.24 -> extremity temperature and his neurologic

685.04 -> status

686.8 -> you order labs with a chemistry a blood

688.959 -> gas a mixed venus and a lactate

691.2 -> and in conversation with your cardiac

693.04 -> fellow you consider an echo

695.12 -> if he appears to have poor cardiac

696.8 -> output you could consider

698.16 -> increasing afterload reduction or adding

700.399 -> inotropes

701.6 -> morphe's anemic consider transfusion of

703.92 -> red blood cells

705.2 -> if he appears to have low volume status

707.2 -> you could consider a slow

708.48 -> fluid bolus and if you're worried he may

710.8 -> get sicker you might consider transfer

712.72 -> to the cardiac intensive care unit

715.519 -> in this case his exam showed that his

717.36 -> pulses were weaker and his perfusion was

719.36 -> worse than you remembered

720.8 -> his heart rate was up 10 to 20 beats

722.48 -> from his baseline heart rate

724.16 -> his milron dose had been weaned earlier

726.16 -> in the morning from .75 to .5

729.279 -> his mixed venous oxygen saturation prior

731.36 -> to the wean was 70 percent

733.279 -> a repeat mixed venus was sent and it was

735.279 -> now 55 percent

736.959 -> the transplant attending was called his

738.959 -> mill renowned dose was increased back to

740.92 -> 0.75

742.24 -> and the cicu attending was alerted to

744.399 -> the patient case

746.639 -> case three you get a page from your

748.88 -> nurse your patient's heart rate seems

750.639 -> irregular and the telemetry keeps

752.32 -> alarming

753.92 -> your patient is a two-year-old female

755.76 -> with hypoplastic left heart syndrome who

758.079 -> is status post glen surgery and

759.92 -> currently listed for heart transplant

761.6 -> due to ventricular dysfunction

763.68 -> she was admitted with a heart failure

765.2 -> exacerbation for iv

766.959 -> diuresis when you talk to the nurse on

769.6 -> the phone you ask

770.56 -> how's the patient feeling or appearing

772.959 -> was there any change in her clinical

774.399 -> status or is it just a change in

776 -> telemetry that was noted

778.079 -> before you see the patient you review

779.92 -> her telemetry and her vital sign

782 -> trends including her heart rate and

783.36 -> blood pressures and any recent labs such

785.76 -> as

786.079 -> chemistry for electrolytes in the room

788.639 -> you assess her cardiac exam

790.079 -> and her perfusion you order labs with a

793.92 -> chemistry

794.72 -> and obtain a 12 lead ecg if her

797.6 -> electrolytes are abnormal you could

799.2 -> consider repleting her potassium and

801.2 -> magnesium

802.16 -> with a goal of keeping her potassium

804 -> level above four and magnesium level

806.079 -> above

806.56 -> two if she's having a significant

808.72 -> arrhythmia medical therapy may be

810.639 -> warranted

811.519 -> and if she's in an unstable rhythm she

813.279 -> may require transfer to the cardiac

814.88 -> intensive care unit

816.8 -> in this case the patient had been

818.32 -> receiving high dose iv diuretics

820.88 -> review of her telemetry showed frequent

822.8 -> pvcs with a few couplets

824.72 -> there was no runs of ventricular

826.399 -> tachycardia the patient was well

828.56 -> appearing otherwise with good perfusion

831.04 -> her electrolytes were checked a

832.56 -> potassium was found to be 2.9 and

834.639 -> repletion was given with subsequent

836.399 -> improvement

837.04 -> in pvcs

840.839 -> summary in summary

843.6 -> heart failure can result from myocardial

845.6 -> dysfunction or

847.12 -> normal myocardial function with

848.8 -> increased work such as increased

850.32 -> pressure or volume

852.079 -> symptoms of heart failure can vary

853.6 -> significantly with age

855.68 -> assessment of cardiac output warm or

858.24 -> cold

858.8 -> and volume status wet or dry is

861.839 -> essential to determine management of

863.6 -> heart failure

864.8 -> daily weights vital sign trends ins and

867.6 -> outs

868.16 -> clinical exam and lab testing can be

870.48 -> helpful with management

872.8 -> heart failure patients can deteriorate

874.639 -> quickly red flags include any

876.8 -> significant change in vital signs

878.639 -> heart rhythm or clinical exam review of

881.519 -> vital signs

882.399 -> ins and outs medications and labs can be

885.12 -> helpful in term in determining the

886.959 -> etiology of the

888.399 -> compensation and always remember to ask

890.959 -> for help early

892.079 -> thanks so much

903.04 -> you

Source: https://www.youtube.com/watch?v=YOGye43AU3U