Level 1: Acute CHF with Hypotension (SBP < 90 torr)
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1 PENNSYLVANIA HOSPITAL ED ACUTE CONGESTIVE HEART FAILURE STANDING DERS Level 1: Acute CHF with Hypotension (SBP < 90 torr) Intake: Vital signs Pulse oximetry Weight Allergies: Obtain old chart Obtain old ECGs Obtain old CXRs Initiate _ peripheral IV/s with and draw bloods Notify PCP of ED arrival Monitoring: Cardiac monitor Oximeter Cuff pressure q _ min Invasive lines: Respiratory: Oxygen via NC at _ L/min Oxygen via FM at _ % CPAP at 5-7.5cm H20, oxygen bleed-in to keep sats > _ % BLPAP at 10/5, titrate to effect, oxygen bleed-in to keep sats > _ % ventilator settings if intubated: Tests: ECG Digoxin level if patient on digoxin CBC and SMA-7 pcxr CKMB and total CK, Trop I ABG BNP bedside echocardiogram PT if patient on warfarin
2 Medications: INOTROPES: Dopamine _ µg/kg/min IV and titrate to SBP > 100 torr Milrinone 50 µg/kg IV over 10 min and then _ µg/kg/min IV and titrate to SBP > 100 torr Dobutamine _ µg/kg/min IV Amrinone 0.75 mg/kg over 15 min and then _ µg/kg/min; titrate to SBP > 100 torr Norepinephrine 0.1 µg/kg/min titrated up to effect NESIRITIDE: Nesiritide 2 µg/kg IV bolus and then 0.01 µg/kg/min once SBP > 100 torr; hold if SBP < 90 torr ACE-I: Captopril 25 mg SL if K < 4.8 and creatinine < 1.8 Enalaprilat 1.25 mg IV over 5min if K < 4.8 and creatinine < 1.8 DIURETICS: Lasix _ mg IVP once SBP > 100 torr Bumex _ mg IVP once SBP > 100 torr ADJUNCTS: Enoxaparin 40 mg SQ for DVT prophylaxis ASA _ mg PO Diet: NPO other: _
3 Activity: Trendelenberg for SBP < 90 torr complete bedrest Foley catheter other: Additional Orders:
4 PENNSYLVANIA HOSPITAL ED ACUTE CONGESTIVE HEART FAILURE STANDING DERS Level 2: Acute CHF with Hypertension (BP > 160/110 torr) _ Intake: Vital signs Pulse oximetry Weight Allergies: Obtain old chart Obtain old ECGs Obtain old CXRs Initiate _ peripheral IV/s with and draw bloods Notify PCP of ED arrival Monitoring: Cardiac monitor Oximeter Cuff pressure q _ min Invasive lines: Respiratory: Oxygen via NC at _ L/min Oxygen via FM at _ % CPAP at 5-7.5cm H20, oxygen bleed-in to keep sats > _ % BLPAP at 10/5, titrate to effect, oxygen bleed-in to keep sats > _ % ventilator settings if intubated: _ Tests: ECG Digoxin level if patient on digoxin CBC and SMA-7 pcxr CKMB and total CK, Trop I PA and lat CXR BNP ABG PT if patient on warfarin bedside echocardiogram
5 Medications: DIURETICS: Lasix _ mg IVP Bumex _ mg IVP PROMPT OFFLOAD AGENTS: NTG mg SL q 5-10min up to 4 times MS 2-4 mg IVP PRN breathlessness, anxiety, or pain; may repeat x 1 in 15min INTRAVENOUS OFFLOAD AGENTS: Nesiritide 2 µg/kg IV bolus and then 0.01 µg/kg/min NTG by infusion µg/kg/min Nitroprusside 0.1 µg/kg/min titrated up to effect If no response to SL NTG, start nesiritide as above If no response to IV NTG, start nesiritide as above AND D/C NTG IV ACE-I: Captopril 25 mg SL if K < 4.8 and creatinine < 1.8 Enalaprilat 2.5 mg PO if K < 4.8 and creatinine < 1.8 Enalaprilat 1.25 mg IV over 5 min if K < 4.8 and creatinine < 1.8 ADJUNCTS: Enoxaparin 40 mg SQ for DVT prophylaxis ASA _ mg PO
6 Diet: NPO low-salt renal ADA _ cal restrict PO fluids to _ cc/24h other: _ Activity: complete bedrest Foley catheter bedrest with BRPs other: Additional Orders:
7 PENNSYLVANIA HOSPITAL ED ACUTE CONGESTIVE HEART FAILURE STANDING DERS Level 3: Acute CHF with Normotension (SBP > 90 AND < 160 torr) Intake: Vital signs Pulse oximetry Weight Allergies: Obtain old chart Obtain old ECGs Obtain old CXRs Initiate _ peripheral IV/s with and draw bloods Notify PCP of ED arrival Monitoring: Cardiac monitor Oximeter Cuff pressure q _ min Invasive lines: Respiratory: Oxygen via NC at _ L/min Oxygen via FM at _ % CPAP at 5-7.5cm H20, oxygen bleed-in to keep sats > _ % BLPAP at 10/5, titrate to effect, oxygen bleed-in to keep sats > _ % ventilator settings if intubated: Tests ECG CBC and SMA-7 CKMB and total CK, Trop I BNP PT if patient on warfarin Digoxin level if patient on digoxin pcxr PA and lat CXR ABG bedside echocardiogram
8 Medications: DIURETICS: Lasix _ mg IVP Bumex _ mg IVP NARCOTICS/ANXIOLYTICS: MS 2-4 mg IVP PRN breathlessness, anxiety, or pain; may repeat x 1 in 15min; hold if SBP < 90 torr OFFLOAD AGENTS: NTG mg SL q 5-10min up to 4 times NTG _ inch to anterior chest wall NTG by infusion µg/kg/min; hold if SBP < 90 torr Nesiritide 2 µg/kg IV bolus and then 0.01 µg/kg/min; hold if SBP < 90 torr If no response to SL or transcutaneous NTG, start _ IV NTG IV nesiritide as above If no response to IV NTG, start nesiritide as above AND D/C NTG IV ACE-I: Captopril 25 mg SL if K < 4.8 and creatinine < 1.8 Enalaprilat 2.5 mg PO if K < 4.8 and creatinine < 1.8 Enalaprilat 1.25 mg IV over 5min if K < 4.8 and creatinine < 1.8 DOBUTAMINE: Dobutamine _ µg/kg/min IV ADJUNCTS: Enoxaparin 40 mg SQ for DVT prophylaxis ASA _ mg PO
9 Diet: NPO low-salt renal ADA _ cal restrict PO fluids to _ cc/24h other: _ Activity: complete bedrest Foley catheter bedrest with BRPs other: Additional Orders:
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