From the Guidelines
The recommended field treatment for Congestive Heart Failure (CHF) by paramedics focuses on improving oxygenation, reducing cardiac workload, and managing fluid overload, with the primary goal of reducing morbidity, mortality, and improving quality of life. Paramedics should position the patient upright to ease breathing and administer supplemental oxygen to maintain saturation above 94% 1. Medication management typically includes:
- Oxygen with a target saturation >94%
- Sublingual/intravenous nitrates titrated according to blood pressure
- Intravenous diuretics (furosemide) For severe cases with hypotension, non-invasive positive pressure ventilation like CPAP may be used to improve oxygenation and reduce work of breathing 1. Some key points to consider in the management of CHF include:
- The use of diuretics to reduce fluid overload
- The administration of nitrates to reduce preload and afterload
- The importance of continuous cardiac monitoring to detect arrhythmias
- The need to monitor vital signs frequently to guide treatment These interventions work together to reduce the heart's workload, improve oxygenation, and decrease pulmonary congestion, providing symptomatic relief while transporting the patient to definitive care. Treatment should be tailored based on blood pressure, as hypotensive CHF patients require different management approaches 1.
From the FDA Drug Label
INDICATIONS & USAGE Nitroglycerin Injection is indicated for treatment of peri-operative hypertension; for control of congestive heart failure in the setting of acute myocardial infarction; INDICATIONS AND USAGE Parenteral therapy should be reserved for patients unable to take oral medication or for patients in emergency clinical situations. Edema:Furosemide is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome
The recommended field treatment of Congestive Heart Failure (CHF) by paramedics may include:
- Nitroglycerin (IV) for control of CHF in the setting of acute myocardial infarction 2
- Furosemide (IV) for treatment of edema associated with CHF, particularly when a rapid onset of diuresis is desired, such as in acute pulmonary edema 3
From the Research
Field Treatment of Congestive Heart Failure (CHF) by Paramedics
The recommended field treatment of Congestive Heart Failure (CHF) by paramedics involves several key components, including:
- Assessment and identification of CHF patients
- Administration of oxygen therapy
- Use of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV)
- Medication administration, such as diuretics and nitrates
Assessment and Identification of CHF Patients
Paramedics play a crucial role in accurately identifying CHF patients in the field. A study by 4 found that paramedics correctly identified only about half of the dyspneic patients who proved to have CHF, but their assessment of CHF did have a higher positive predictive value when this diagnosis was made.
Oxygen Therapy and CPAP/NPPV
Oxygen therapy is a critical component of CHF treatment. Studies have shown that CPAP or NPPV can be effective in treating acute cardiogenic pulmonary edema, a common complication of CHF. A study by 5 found that noninvasive bilevel positive pressure ventilation was effective in treating acute cardiogenic pulmonary edema and avoided intubation. Another study by 6 found that prehospital CPAP treatment improved oxygenation and lowered respiratory rate, heart rate, and systolic blood pressure in patients with acute severe pulmonary edema.
Medication Administration
Medications such as diuretics and nitrates are commonly used to treat CHF. However, the evidence on the specific medications and dosages used in the field is limited.
Key Findings
- Paramedics should be trained to accurately identify CHF patients in the field 4
- Oxygen therapy and CPAP/NPPV can be effective in treating acute cardiogenic pulmonary edema 5, 6
- Medication administration, such as diuretics and nitrates, should be guided by local protocols and medical direction
Limitations
- The evidence on the field treatment of CHF by paramedics is limited, and more studies are needed to inform best practices
- The quality of the evidence varies, and some studies have methodological limitations 7