Heart Failure

Heart failure is a complex condition that can be summed up as "insufficient cardiac output to support healthy circulation." Patients with heart failure have a dysfunction in the muscle of their right and/or left ventricle that results in two distinct sets of symptoms. First, blood backs up in the veins, this causes the outwardly visible swelling, respiratory issues, and further lowers cardiac output. Second, as heart failure progresses the cardiac output drops so low that the body no longer gets sufficient oxygen which can lead to death.

Heart failure is a self-supporting process, as cardiac output drops the body naturally retains fluid in an attempt to increase the blood volume and increase cardiac output. However, the damaged heart cannot tolerate the additional fluid which causes the cardiac output to drop further, eventually leading to the signs and symptoms listed here.

This section will review the signs, symptoms, and management of heart failure at the EMT level. It groups the various causes and types of heart failure together as their management at the EMT and AEMT level is identical, the subtypes of heart failure and their specific management details will be reviewed in later sections for paramedic providers. 

Signs and Symptoms of Heart Failure

Symptoms: Symptomatic heart failure universally presents with orthopnea, or shortness of breath while lying flat, this is due to the backed up blood pooling in the lungs. Fatigue is also a common symptom due to both decreased respiration and decreased oxygen delivery by the heart. The majority of patients will also present with shortness of breath, chest pain, and anxiety, this is due to pulmonary edema, which occurs with failure of the left ventricle as blood pools in the lungs leading to the alveoli filling with fluid. Respiratory symptoms may be absent in some patients, these patients can still be extremely ill. 

Exam Signs: The exam findings of heart failure are best broken down into cardiac, respiratory, and skin findings. 

Cardiac findings are ironically the least obvious and limited to a more detailed exam; patients will generally have additional heart sounds, often called "murmurs, rubs, or gallops." These sounds are due to excess fluid in the heart. Patients in the early stages of heart failure will often be hypertensive as the body holds on to excess fluid, this later changes to hypotension as the overloaded heart can no longer effectively squeeze.

Respiratory findings are centered around the condition known as pulmonary edema. As blood backs up in the lungs fluid crosses the capillaries and enters the alveoli, replacing the air that normally fills them. The earliest sign of this is cough and tachypnea, followed by accessory muscle use. A variety of abnormal lung sounds may also be present, with crackles and wheezing increasing in severity as the condition worsens. In severe situations, the oxygen saturation seen on pulse oximetry may dramatically drop. Not all forms of heart failure exhibit this finding, those that do are generally termed congestive heart failure (CHF).

The skin is the most obvious indicator of heart failure, patients will often have dramatic edema of the lower extremities, with swelling of the ankles and shins often preventing proper wear of sock, shoes, and pants. As heart failure gets more severe cyanosis of the skin and diaphoresis are both possible secondary to decreased perfusion from dropping cardiac output. 

Assessment and Treatment

After identifying a patient with potential heart failure based on the symptoms above the next best step is to support their respiration and increase oxygen delivery to the tissues of the body. This is generally done with oxygen via a non-rebreather mask set to 15lpm. However, more severe patients may require ACLS intercept and advanced airway placement and/or mechanical ventilation.

Monitor the patient's blood pressure and mental status while in transit, dramatic drops in blood pressure or decreasing mental status are both signs that more aggressive oxygenation and/or airway interventions are required. If ACLS providers are unavailable it is appropriate to use a bag-valve-mask to support respiration. The use of a ventilator or Bilevel Positive Airway Pressure machine can be helpful in these patient's, in many jurisdictions, only AEMT and Paramedic providers are trained to use these devices. 

Always avoid giving fluids to heart failure patients despite hypotension as this will dramatically decrease blood pressure by further stressing the fluid overloaded heart!