The EM Educator Series: Heart Failure and Flash Pulmonary Edema

Author: Alex Koyfman, MD (@EMHighAK) // Reviewed by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome back to the EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Case 1:

A 79-year-old female with a history of heart failure, coronary artery disease, diabetes, and hypertension is brought in by family with worsening shortness of breath and peripheral edema over 8 days. She denies fevers, chest pain, abdominal pain, cough, and back pain. Her daughter accompanies her and states she has had multiple admissions for similar issues “When she doesn’t take her medications and eats a lot of soup.” She is overall well appearing and nontoxic, and her vital signs include BP 162/92 mm Hg, RR 19, HR 77, saturation 97% on room air, and T 97.4F. She has crackles at the bases of her lungs, and her legs demonstrate 2+ pitting edema.

Case 2:

A 63-year-old male with a history of heart failure, coronary artery disease, and hypertension presents with severe shortness of breath. He is brought immediately to the resuscitation bay. He is diaphoretic and in respiratory distress. His vital signs include BP 221/107 mm Hg, RR 28, HR 104, saturation 89% on room air, and T 98.2F. He has diffuse crackles on pulmonary exam, but there is no apparent peripheral edema.

Considerations:

• What are the different types of heart failure?
• How can patients present with heart failure, and what is flash pulmonary edema? Are all patients with flash pulmonary edema truly volume overloaded?
• What laboratory testing is recommended? What is the utility of BNP?
• What imaging is recommended? How does ultrasound change your management?
• What management is recommended when it comes to medications and the airway?

Suggested Resources: 

• Articles
  • Core EM – Acute Pulmonary Edema
  • EMCrit – SCAPE
  • Emergency Medicine Cases
  • EmDOCs HF Myths Part 1
  • EmDOCs HF Myths Part 2
  • EmDOCs HF management pearls and pitfalls
  • EmDOCS – BNP in the ED
  • EmDOCs – Furosemide for acute pulmonary edema treatment
• Journal Articles
  • Diagnosis of HF in the ED
  • Management of HF in the ED
  • HF MisconceptionsHF Disposition