Heart failuremanagement Basic measures

1. Determine likely cause and treat as appropriate, e.g. antiarrhythmic

3. GTN spray SL then commence IV nitrate infusion titrated rapidly until good clinical effect. Beware hypotension which, at low dosage, is suggestive of left ventricular underfilling, e.g. hypovolaemia, tamponade, mitral stenosis, pulmonary embolus

4. If patient is agitated or in pain, give diamorphine IV.

5. Consider early CPAP, BiPAP and/or IPPV to reduce work of breathing and provide good oxygenation. Cardiac output will often improve. Do not delay until the patient is in extremis.

6. Furosemide is rarely needed as first line therapy unless intravascular fluid overload is causative. Initial symptomatic relief is provided by its prompt vasodilating action; however, subsequent diuresis may result in marked hypovolaemia leading to compensatory vasoconstriction, increased cardiac work and worsening myocardial function. Diuretics may be indicated for acute-on-chronic failure, especially if the patient is on long term diuretic therapy but should not be used if hypovolaemic. If furosemide is required, start at low doses then reassess.

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