Medical wards in the government sector in Sri Lanka are mainly known for being overcrowded, but they are also possibly the best place for any medical student or intern doctor to learn. Handling a ward by yourself as an intern doctor in Sri Lanka for 6 months with no registrar doctors around will possibly have you set for life – there will be no medical emergency that you cannot handle.

Dr. Paba is an post-intern doctor currently working in the government healthcare sector of Sri Lanka. Her experience in the chaotic medical wards of a local hospital has made her an expert in the management of medical emergencies. She has a passion for medicine, and hopes to one day specialize as a medical physician.

On a personal note, Paba (or pabsicle as I call her) has been one of my besties throughout my medical career. Her passion and determination to perservere is one I truly admire. She was my study partner throughout the ERPM examinations here in Sri Lanka, and still today we continue to be each other’s biggest supporters. 

In our day to day life as medical doctors we come across many medical emergencies. Due to the ageing population and modern medical innovations found to prolong lives of cardiac patients, the prevalence of heart failure has increased vastly. Therefore, acute heart failure is a medical emergency we see on a daily basis and it is imperative we know how to provide the best care to such patients.

So what happened?

A 77-year-old obese lady presents to the Primary care unit (PCU) at 12.05am with severe breathlessness that became unbearable at night whilst she was getting ready for bed. She was finding it difficult to breathe and could not lie down flat (orthopnoea). She is a known patient with ischeamic heart disease, left ventricular failure and hypertension. At the PCU she was given oxygen via a face mask, catheterized and IV Lasix/furosemide 40mg STAT dose and sent to the ward.

At the ward, a brief history was taken. The patient had been suffering from a productive cough for the past five days and had missed a few of her “pee-pills” (laymen term for Lasix/furosemide). She has had exertional dyspneoa for the past couple of months, but the symptoms had gotten worse since the cough started. She was unable to engage in her day to day activities. She has no chest pain but had been experiencing orthopnea and paroxysmal nocturnal dyspnea. Her past medical history is as above with no significant past surgical history. Her drug history consists of a cocktail of anti-anginals, anti-hypertensives and diuretics, to which she was occasionally non-compliant.

On examination she was dyspnoeic, sweaty with warm peripheries and had bilateral pitting oedema. She was tachycardic with BP was 220/ 110 and a oxygen saturation of 95% when on face mask oxygen at 5L/min and had a RR of 25 bpm. On auscultation she had bi-basal fine crepitations with additional coarse crepitations heard in the right basal area.

So what did we do?

The main aim of management was to provide immediate relief of symptoms, haemodynamic stabilization and to find an aetiology for the acute episode. As this was an acute emergency, the patient was immediately connected to a cardiac monitor. She was propped up and high flow oxygen was applied. She was already cannulated and a stat dose of furesomide had already been given, but a further dose of 80mg furesomide was also administered. Catheterization had already been done and it is very important that fluid balance is monitored in critical care patients, especially those with cardiac and renal emergencies.

Urgent blood tests were sent including a full blood count, C-reactive protein, Serum Creatinine, Blood Urea and electrolytes, Liver function tests and cardiac enzymes (Trop I). BNP (Beta natriuretic peptide) is not available in the government healthcare sector, but is an important investigation in heart failure (BNP> 100pg/ml suggestive of HF). It is a hormone secreted by cardiac cells in response to stretch. An urgent 12-lead ECG and Echocardiogram was done to show ischaemic insults and arrhythmias. Chest x-ray was also done for signs of acute left ventricular failure (alveolar oedema – Bat wing appearance, Kerley B lines, cardiomegaly, dilate prominent upper lobe vessels and pleural effusions).

An IV infusion of furosemide (10mg/hr) was commenced as in low doses it produces vasodilation, reduces the right atrial pressure and pulmonary capillary wedge pressure to promotes diuresis. An IV infusion of GTN (glycerly trinitrate) 2.5mcs/hr was also commenced to reduce pulmonary congestion (at low doses it causes venodilation reducing the preload and at high doses causes atrial vasodilation which reduces the afterload). IV antibiotics were also commenced as a respiratory focus is most likely the cause of infection – IV cefuroxime which is broad spectrum was commenced.

She was closely monitored and her IV furosemide and IV GTN was adjusted according to her BP. Her symptoms drastically improved and the patient was able to comfortably lie down in her propped up bed.

Her investigation reports included:paba

• Hb- 12.5, WBC- 17 with neutrophils 84%, and platelets 309
• CRP- 145
• Creatine- 0.89
• Urea – 29
• Serum electrolytes and Liver function tests – normal
• Trop I – Negative
• ECG – No acute ischaemic changes
• CXR – see below

Chest X-ray – showing cardiomegaly and other features of acute ventricular failure.

 

• Echo- Left ventricular hypertophy and ejection fraction was 50-55%

6 hours later, her blood pressure reduced to normal and her IV GTN was omitted. She was eventually weaned off the lasix infusion and a fixed dose was given. Further, in addition to the fluid balance monitoring, her daily weight was also noted.

Her final diagnosis was acute on chronic heart failure exacerbated by right lung pneumonia.

Prior to discharge it is important to ensure that:

• Exacerbating factors have been addressed
• Diuretic therapy has been successfully transitioned to oral medication, with discontinuation of IV vasodilator and inotropic therapy for at least 24 hours
• Medications have been optimized
• Provide lifestyle advice such as salt and fluid restriction
• Patient has a proper discharge plan with clinic follow-up

Discussion

Acute heart failure refers to the rapid onset or worsening of symptoms of heart failure. It is an urgent medical condition requiring urgent evaluation and treatment.

It is recommended that the initial diagnosis of acute heart failure is based on a thorough history of assessing symptoms, prior cardiovascular history and finding out the potential precipitants. Further the clinical signs and symptoms of congestion+/- hypoperfusion should be assessed by physical examination and a provisional diagnosis be made, which can be confirmed later by investigations.

Below is an algorithm from the European Society of Cardiology which gives you an ‘at a glance’ view of the management. Patients with a low blood pressure (“Cold”) must be handled with care as they may require inotropes whilst also receiving diuretics which despite being the mainstay of acute heart failure management, can also further reduce the blood pressure.

Source: European society of Cardiology

Heart failure is an extremely common emergency presentation in Sri Lanka and its’ management depends on the presence of congestion and vitals. Hopefully this case presentation gave you a quick overview of this condition and will help you with the management of these patients. As always, please do leave any comments below.