Skills Review: The CHF Patient

          As an EMT-B, there will be times when your assessment and treatment skills will be put to the test as you find yourself on scene with a critical patient and no ALS backup. Your ability to recognize patients with critical symptoms and do the most good for them within the EMT-B scope of practice could have a tremendous impact on patient survival. The importance of rapid but accurate assessment of both the clinical presentation and the patient's history cannot be overemphasized. This article will review BLS assessment and care of the congestive heart failure (CHF) patient.

WHAT IS CHF?

     CHF is defined as "failure of the heart to pump efficiently, leading to excessive blood or fluid in the lungs, the body or both."¹ It occurs when the metabolic demands of the body can no longer be met due to insufficient ventricular output. Given that there are approximately 400,000 new cases diagnosed each year, and that CHF is the most common cause of hospitalization in patients over age 65, understanding what it is and how to recognize and treat it in the prehospital setting is of importance for providers at all levels.

WHAT CAUSES CHF?

     CHF results when damage or weakness in the area of the left ventricle allows blood to back up into the pulmonary circulation and lungs. This can occur any time after a myocardial infarction (MI), heart valve damage or longstanding high blood pressure, but it usually happens between the first few hours and first days after an acute MI.² When assessing the patient showing signs and symptoms of CHF, it is important to raise your index of suspicion with respect to acute MI. In addition to MI, an environmental stress, such as extreme heat or cold, can lead to acute left heart failure and produce pulmonary edema. For example, sudden changes in the environment, such as moving patients from a warm house into cold winter air to the ambulance, could provoke acute pulmonary edema, so patients should be properly packaged to protect them from the environment.

THE CLINICAL PICTURE

     Although this is a cardiac emergency, the most outward sign the EMT-B will see in a CHF patient is shortness of breath. Because the fluid build-up results in edema, it tends to clog the affected organs, causing poor exchange of oxygen between the lungs and blood and causing the patient to experience shortness of breath. Lung sounds will likely reveal rales or crackles, and some patients will cough up pink, frothy sputum or blood-tinged saliva. Patients will often be sitting bolt-upright and want to let their legs "dangle" off the bed or stretcher. The assessment challenge can occur when a patient has a history of several chronic conditions like CHF and COPD; however, since definitive diagnosis is not the role of the EMT-B, the focus should remain on maintaining a patent airway, providing oxygenation and obtaining a comprehensive patient history.

     Knowing that a lack of oxygen to the brain causes irreversible damage in a short period of time, if the patient is not breathing adequately, it's time to get back to basics. When caring for a patient experiencing CHF, prompt assessment of both rate and quality of breathing is vital to determining how to provide oxygenation. Simply put, even if the patient is conscious, high-flow oxygen via NRB mask will be ineffective if his breathing is inadequate. To determine whether passive oxygenation via NRB or active oxygenation via BVM is most appropriate, rate and quality of breathing are key.

REMEMBER SAMPLE

     So far, we have talked about only a part of the S (signs and symptoms) and what to do to provide immediate care to ensure oxygenation of the CHF patient. We must also gather the rest of the information to complete our SAMPLE history while treating the patient, assessing vital signs and not unnecessarily delaying transport. Remember, we are talking about a critical patient with no ALS backup available.

     If the CHF patient is experiencing shortness of breath, it will not only be difficult to obtain information, but could also compromise the patient's condition by forcing him to exert himself. With this in mind, family, friends, medical identification devices and patient medications present in the home are just some of the creative ways to obtain the information we need to treat the patient's signs and symptoms and also provide for the basis of their continuum of care. Something as simple as misspelling the patient's name could delay the hospital's access to patient records and compromise their ability to make treatment decisions based on both clinical picture and past history.

SUMMARY

     CHF is a critical emergency and EMT-Bs must be ready to act decisively, trust their assessment and clinical skills and provide care within their scope of practice. In the final analysis, "when the CHF patient calls EMS, it is clear that Starling's law is no longer allowing the patient to compensate."³ The need for prompt, efficient and effective emergency care at all levels cannot be over-emphasized.

SIDEBAR: KEY PATIENT CARE CONSIDERATIONS

• Ensure patent airway (with adjuncts if necessary)
• Position patient to lessen the burden of breathing
• Provide high-flow supplemental oxygen
• Ensure adequate ventilation (assisted if necessary)
• Prepare to suction

GLOSSARY

     Chronic Obstructive Pulmonary Disease (COPD): A disease characterized by the lungs' decreased ability to perform ventilation.

     Congestive Heart Failure (CHF): A condition in which the heart's reduced stroke volume causes fluid overload in the body's other tissues.

     Pulmonary Edema: An effusion or escape of serous fluids into the alveoli and interstitial tissues of the lungs.

     Starling's Law of the Heart: A law of physiology stating that the more the myocardium is stretched, up to a certain amount, the more forceful the subsequent contraction will be.³

REFERENCES

1. Limmer D, O'Keefe M. Emergency Care, 10th Ed. Upper Saddle River, NJ: Pearson Prentice Hall, 2007.

2. Browner B, Pollak A, Gupton C., eds. Emergency Care and Transportation of the Sick and Injured, 8th Ed. Sudbury, MA: Jones and Bartlett Publishers, 2002.

3. Bledsoe B, Porter R, Cherry R. Essentials of Paramedic Care. Upper Saddle River, NJ: Pearson Education, Inc., 2003.

BIBLIOGRAPHY

Dalton A, Limmer D, Mistovich J, Werman H. Advanced Medical Life Support, 2nd Ed. Upper Saddle River, NJ: Pearson Education, Inc., 2003.

John R. Brophy is an EMT-B instructor, EMS supervisor, fire department captain, and former Navy Corpsman. He is the author of the book Leadership Essentials for Emergency Medical Services. Contact him at brophyjohnr@aol.com.