General treatment should follow standard ABC resuscitation guidelines. High-flow high-concentration oxygen should be administered. Addition of CPAP may be considered to improve oxygenation and aid hemodynamics. Early mechanical ventilation should be instituted promptly in severe cases for the reasons described previously.
Diuretic therapy is usually inappropriate; the vast majority of patients presenting in acute heart failure, and even many with acute-on-chronic failure, are hypovolemic on hospital admission as a consequence of sweating, vomiting, not drinking, and third-space fluid shifts. The beneficial immediate vasodilating effect of a loop diuretic is quickly negated by an often brisk diuresis. This further exacerbates any existing hypovolemia for which the body attempts to compensate by additional vasoconstriction, thereby placing an extra load on the heart which results in further reductions in cardiac output.
Vasodilatation is thus desirable and can be rapidly achieved, resulting in symptomatic relief, by four sublingual puffs of glyceryl trinitrate (nitroglycerin) spray followed by an intravenous nitrate infusion titrated to optimal effect. A patient presenting with low-output failure and hypotension may be unable to tolerate nitrates unless hypovolemia has been corrected and obstruction to flow excluded (e.g. pericardial tamponade). Myocardial function will remain compromised until an adequate perfusion pressure and flow are achieved. This may necessitate the 'blind' use of an inotrope such as epinephrine (adrenaline) until more sophisticated monitoring can be introduced.
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