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Heart Failure


Please only use this protocol for previously diagnosed disease



Inclusion Criteria

  • Previous history of CHF
  • Acceptable VS: SBP >100, R < 32, HR <130
  • Pulse-ox >90 on room air after initial treatment, correctable to > 92 on Oxygen by NC.
  • High likelihood of correction to baseline status within 24 hours with good home support
  • No acute co-morbidities (like pneumonia, atrial fibrillation, altered mental status, etc.)

Exclusion Criteria

  • New onset CHF
  • Acute cardiac ischemia (EKG changes, positive cardiac markers, ongoing ischemic chest pain, unstable angina) or new arrythmias
  • Unstable VS after treatment (HR>130, SBP<85 or >180, RR>32, Pox<92 on O2 by NC)
  • Acute co-morbidities - sepsis, pneumonia, new murmur, confusion
  • Abnormal labs - Severe anemia (Hb<8), renal failure (BUN>40 or Cr>3), Na<135
  • Patient requiring vasoactive drips, invasive or noninvasive ventilation (bipap)
  • Evidence of poor perfusion (confusion, cool extremity, weakness, N/V)

Potential Interventions

  • Cardiac monitoring, strict Intake/Output, vital signs Q4hr, weight on arrival
  • Oxygen per respiratory guidelines with pulse oximetry (continuous or q4hours)
  • Serial EKGs, and cardiac markers (TnI, CK, and CK-MB) - 3 and 6hrs from 1st lab draw.
  • Medication as indicated – IV diuretics (home dose), nitropaste, ACE Inhibitors, ASA
  • Repeat electrolytes q6 hours or prn
  • Echocardiography (if not done within 30d) and cardiology consultation - as indicated
  • CHF education and smoking cessation education

Discharge Criteria

Home

    • Subjective improvement – no chest pain, orthopnea, or exertional dyspnea above baseline
    • Acceptable VS (O2 sat at baseline or >94%, RR <20HR<100, SBP >100 or baseline,).
    • Negative serial ECGs and cardiac markers, good electrolytes, acceptable echo if done
    • Evidence of adequate diuresis – 1L urine, decrease in weight, decrease in JVD
    • CHF discharge checklist (ACEi, β-blocker, HF/ diet/ smoking education, close followup)


Admit

    • New ischemic EKG changes, arrhythmia, cardiac markers, or evidence of cardiac ischemia
    • Persistent hypoxia, rales, dyspnea
    • Poor response to therapy - Failure to improve subjectively
    • Poor home support
    • Physician judgment




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