ED nurses should know which therapies to use
Congestive heart failure (CHF) requires quick thinking and action, stresses David Wilcox, MD, FACEP, medical director for ConnectiCare, an HMO in Farmington, CT, and associate professor of emergency medicine at University of Massachusetts Medical School in Worcester.
"You can really help the patient by giving the right medications early on and preventing them from having to be intubated," he says. Here are therapies for CHF commonly used in the ED:
• Nitroglycerin.
When a CHF patient comes to your ED with acute symptoms, nitroglycerin is the first line of treatment, says Wilcox. "You may use a spray, IV if necessary, or sublingual tablets," he notes. "This opens up the blood vessels to the heart, and helps the heart work better. It’s the quickest thing you can do."
• Lasix.
Another medication given early on in an exacerbation is Lasix, a diuretic that helps the body get rid of excess fluid, manufactured by Hoescht Marion Roussel in Kansas City, MO.
"The reason a patient has difficulty breathing is because there is fluid building up in the lungs," Wilcox explains.
However, Lasix takes time to become effective — from several minutes to a half hour, he says. "Give it early on, but don’t expect it to work immediately," Wilcox says.
• Morphine.
Morphine is still used if patients have chest pain or severe anxiety. "It settles down the patient’s anxiety and dilates the blood vessels so fluid won’t pool in lungs," says Wilcox. "We are probably using morphine a little less quickly now than in the past, but it still is part of armotarium used for these patients."
However, side effects include decrease of the respiratory drive. "For patients on the more severe end of the scale, you don’t worry so much about giving them morphine, because you are probably intubating them and supporting their breathing that way," says Wilcox.
• Vasopressors.
If the heart failure is bad enough that the patient is hypotensive, you may need to put them on vasopressors, such as dopamine, says Wilcox. "These are beta agonists and increase the ability of the heart muscle to pump," he explains.
• Standard triple therapy.
This consists of a diuretic such as Lasix to lower the filling volume of the heart or the preload, a positive inotropic such as digitalis that increases contractility, and a vasodilator that lowers preload and afterload like nitroglycerin or an ACE (angiotensin converting enzymes) inhibitor.
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