What is the appropriate initial treatment for a patient with acute heart failure in the prehospital setting?

Prehospital Management of Acute Heart Failure

The initial prehospital treatment for acute heart failure should include oxygen therapy, non-invasive ventilation for respiratory distress, upright positioning, and early administration of intravenous furosemide and vasodilators based on blood pressure. 1

Initial Assessment and Monitoring

• Establish non-invasive monitoring immediately:

  • Pulse oximetry (SpO2)
  • Blood pressure
  • Respiratory rate
  • Continuous ECG

• Assess for signs of respiratory distress:

  • SpO2 < 90%
  • Respiratory rate > 25/min
  • Increased work of breathing
  • Orthopnea

Oxygen and Ventilatory Support

1. Position patient upright to reduce work of breathing

2. Oxygen therapy:

   • Administer oxygen if SpO2 < 90%
   • Target SpO2 94-98% (avoid hyperoxia)
   • Monitor with pulse oximetry

3. Non-invasive ventilation for patients with respiratory distress:

   • CPAP is preferred in prehospital setting (simpler than PS-PEEP)
   • Start as soon as possible in patients with acute pulmonary edema
   • Requires minimal training and equipment 1
   • Monitor for hypotension as CPAP can reduce blood pressure

Pharmacological Management

Based on Blood Pressure:

For SBP > 110 mmHg:

• IV vasodilators (e.g., nitroglycerin) AND diuretics
• Vasodilators reduce preload and afterload
• Particularly beneficial with hypertension

For SBP < 110 mmHg:

• IV diuretics as first-line therapy
• Avoid vasodilators due to risk of hypotension

Diuretic Therapy:

• IV furosemide dosing:

  • New-onset HF or no maintenance diuretic therapy: 40 mg IV 1
  • Established HF or on chronic oral diuretics: IV bolus at least equivalent to oral dose

• Monitor response:

  • Respiratory status
  • Blood pressure
  • Heart rate
  • Urine output if possible

Medications to Avoid or Use with Caution:

• Opioids: Not recommended routinely as they may increase rates of mechanical ventilation, ICU admission, and mortality 1

• Sympathomimetics/vasopressors: Very limited role in AHF without cardiogenic shock; reserve for persistent hypoperfusion despite adequate filling status 1

Special Considerations

• For patients with atrial fibrillation and AHF:

  • Consider IV cardiac glycoside for rapid ventricular rate control
  • Beta-blockers are preferred first-line treatment for rate control 1

• For patients with COPD:

  • Monitor closely for hypercapnia with oxygen therapy
  • PS-PEEP may be preferred over CPAP if hypercapnia develops 1

Transport Considerations

• Rapid transfer to nearest hospital, preferably with cardiology department and/or CCU/ICU 1

• Continue monitoring during transport:

  • Vital signs
  • Respiratory status
  • Response to treatment

• Communicate pre-arrival information to receiving facility:

  • Initial presentation
  • Treatments administered
  • Response to treatment

Pitfalls to Avoid

1. Delayed treatment: Early administration of appropriate therapy is crucial for improved outcomes

2. Excessive oxygen: Can cause vasoconstriction, reduce cardiac output, and worsen ventilation-perfusion mismatch in COPD patients 1

3. Inappropriate use of vasodilators: Avoid in hypotensive patients (SBP < 110 mmHg)

4. Routine use of opioids: Associated with higher rates of mechanical ventilation and mortality 1

5. Misdiagnosis: More than one-third of patients receiving prehospital furosemide may not have heart failure as their final diagnosis 2

By following this structured approach to prehospital management of acute heart failure, paramedics can effectively stabilize patients and potentially improve outcomes through early intervention while minimizing risks.