Contents

• This assignment is based on the following case study –
• On December 28th a 68 year old woman presents to the Emergency Department with a sudden onset of acute shortness of breath. She was discharged from hospital 5 days previously following an acute anterior septal myocardial infarction. Her MI was treated with a bare metal stent and she was discharged home on day 5. Discharge medications included oral clopidgrel, aspirin, metoprolol, perindopril and atorvastatin.
• Prior to her hospital admission she was generally well. She has a past medical history of hypertension and type II diabetes and her body mass index is 35. Her husband states that since discharge from hospital she has been busy with Christmas celebrations, and noted that she has also been suffering during a recent heatwave. He noted that she may have ‘forgotten’ some medication.
• On arrival to the ED the following vital signs are noted:
• Respiratory rate 28
• Hr 130 Rhythm sinus tachycardia
• BP 140/100
• Oxygen saturation 94% on 6 litre oxygen via face mask.
• She is noted to be cool and clammy and capillary refill is greater than 3 seconds.
• Upon lung auscultation fine crackles are noted bilaterally.
• An IV line is inserted and routine bloods are taken. She is commenced on a GTN infusion and given 40 mg of IV frusemide. She is transferred to the ICCU with a diagnosis of acute heart failure.
• Upon arrival to the ICU the following assessment is noted.
• CVS
• Her cardiac rhythm is sinus tachycardia at a rate of 133 bpm. Her current ECG demonstrated resolving acute anterior septal myocardial infarction with Q waves present
• Blood pressure dropped to 85/70 on arrival to the ICU. She has one IV line in situ and is not receiving any IV fluid.
• She is pale, cool and sweaty. There is no peripheral swelling and JVP is estimated at 6 cms above the sternal angle. Capillary refill remains poor.
• A echocardiogram has been performed and demonstrates an ejection fraction of 50% with poor diastolic filling.
• RESP
• She is being nursed in a Fowlers position and is tachypnoeic, rate of 35, depth is shallow and he has a dusky appearance, particularly around her mouth.
• She is unable to speak complete sentences as she cannot ‘catch her breath’.
• On lung auscultation she has fine crackles from bases to high midzone regions equal on both sides.
• She maintains an oxygen saturation of only 88-90% despite increases in her oxygen therapy to 10L/Non Rebreathing Mask since arrival in the ED.
• CNS
• She is extremely anxious and restless, and admits to a pain score of 5/10.
• RENAL
• She had an estimated 200 mls urine output following the IV frusemide given in ED with no further urine output.
• GIT
• Our patient is extremely nauseated and vomits readily. Treatment with Stemetil and Maxalon has not helped.
• Treatment in the ICU include the following:
• A CVC and Arterial line is inserted and invasive haemodynamic monitoring is commenced.
• The GTN infusion was ceased and 250 mls of Hartman’s solution given. She is commenced on dobutamine infusion of 500 mg /100 mls 5% Dextrose titrated to a MAP of 70 mm Hg.
• She is commenced on Mask CPAP, initially at 100% Oxygen with 10 cm PEEP.

Description

This assignment answers the following questions on the case study –
A 68 year old woman presents to the Emergency Department with a sudden onset of acute shortness of breath.
Question 1
a. Using a PRIMARY SURVEY framework LIST the signs and symptoms of acute heart failure that the tutorial case patient is exhibiting.
b. Choose TWO signs or symptoms that are listed and describe in detail the pathophysiology of heart failure (and related compensatory systems) related specifically to each sign or symptom.
Question 2
a. Considering the above TWO signs or symptoms, describe in detail the physiological effect of CPAP in providing relief for this patient.