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
http://www.emdocs.net/the-crashing-pulmonary-hypertension-patient/