Saturday, October 17, 2015

Hipertensión pulmonar

emDocs - October 16, 2015 - Author: Simon E - Edited by: Koyfman A & Bright J
Take-Home Messages
  • Patients with PH quickly decompensate – worry about obstructive and cardiogenic shock.
  • Bedside echo is your #1 tool in undiagnosed PH – Assess the RV, is there hypertrophy? What is the RV:LV ratio? Is it >1? Is there septal bowing? What does the IVC tell you about the patient’s intravascular volume status?
  • Get a troponin – patients with severe PH often suffer from coronary ischemia secondary to RCA perfusion deficits.
  • Your goals as an EM physician should be to:
    • Reverse Underlying Causes When Possible
  • Optimize RV Preload
    • Use your knowledge gained from the bedside echo to help you. REMEMBER: RV failure and hypotension are MORE COMMONLY the result of increased RV afterload and hypervolemia.
    • Intravascular hypovolemia: 250-500cc crystalloid boluses
    • Intravascular hypervolemia: controlled diuresis
  • Support Systolic Function
    • Dobutamine is FIRST LINE: 2mcg/kg/min-10mcg/kg/min
    • Milrinone is SECOND LINE: 0.375mcg/kg/min-0.75mcg/kg/min
    • HYPOTENSION = Norepi
  • Maintain RCA Perfusion
    • Norepi: Start at 0.05mcg/kg/min but caution with high doses = worsens pulmonary vasoconstriction
    • No Phenylephrine: worsens RV systolic function
  • Reduce RV Afterload
    • SpO2 > 90%
    • AVOID PPV in hypotensive patients
    • Try to avoid intubation and mechanical ventilation at all costs, but if you need to intubate: etomidate, lung-protective ventilator settings, and avoid permissive hypercapnea
  • Rate Control Dysrhythmias
    • Rate control is much more important than rhythm control – PH patients are dependent upon the atrial kick to maintain CO
    • Cardiovert when indicated