CCS Case: Acute Decompensated Heart Failure

Case: Acute Decompensated Heart Failure

Clinical Setup

• Presentation: 72-year-old male with known systolic heart failure presenting with 2 days of progressive dyspnea, orthopnea, bilateral leg edema, bibasilar crackles, SpO2 88% on room air, BP 168/98.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access; restrict IVF (heparin lock or minimal rate — do NOT bolus fluids).
   • Oxygen: nasal cannula, escalate to BiPAP if severe distress/hypoxia.
   • Place patient upright (head of bed elevated).
2. Focused Exam (Minute 1–2):
   • Lung exam (crackles), Heart exam (S3 gallop), JVP assessment, extremity edema exam.
3. Diagnostics (Minute 2–5):
   • ECG 12-lead stat, CXR portable AP (pulmonary edema, cardiomegaly, effusions).
   • CBC, BMP (creatinine baseline before diuresis), BNP, troponin, ABG if severe hypoxia.
   • Echocardiogram (assess ejection fraction).
4. Therapeutics & Consultation (Minute 5–12):
   • Furosemide IV stat (loop diuretic).
   • Nitroglycerin sublingual or IV if hypertensive and no contraindications.
   • ACE inhibitor (e.g., Enalapril) once stabilized if no hypotension, hyperkalemia, or AKI.
   • Cardiology consult for new or worsening HF management.
   • Daily weights, strict intake/output, sodium restriction.
   • Advance clock 30–60 min; re-examine lungs, vitals, urine output.
5. Disposition (Minute 12–15):
   • Admit to telemetry ward; transfer to ICU if requiring BiPAP, pressors, or IV vasodilators.
6. Final 2 Minutes:
   • Counsel on daily weights, low-sodium diet, fluid restriction, medication compliance, smoking and alcohol cessation.
   • Schedule cardiology and primary care follow-up; arrange repeat BMP and weight check within 1 week.