*First Draft 6/2011. Contributing staff: Dr. Charles Moore, Dr. Robert Long, Dr. Richard Summers, Leslie Hood, RN Tammy Thomas, RN, Cori Bitner, RN, Jason Zimmerman, RN.

CHF Treatment Algorithm

Patient presents to AED with s/s of CHF

s/s of CHF: Orthopnea DOE/SOB Recent weight gain Ascites Jugular vein distention Peripheral edema Rales on auscultation

Triage per AED policy

Is respiratory failure

imminent?

YES NO

Consider: Bipap/CPAP ETT intubation NTG or other vasodilator for elevated BP Probable ICU admit

Cardiogenic shock or

symptomatic hypotension?

NO

YES

Consider: IV access Inotrope Hemo-dynamic monitoring ABGs Probable ICU admit

Complete H&P CBC,Chem8, Mag,Phos,Ca+, proBNP,Troponin, PT/PTT/INR CXR, EKG Loop Diuretic

Is Decompensated CHF likely?

Critical Severity: ICU CRITERIA Dyspnea with ≥ 1 of the following:

• HR >120, RR >35, SBP <90 • Mental Status changes • IV medication requiring titration • Mechanical ventilation • Afib/flutter >120bpm, SBP <90 • Unresponsive to ED treatment

Moderate Severity: TELEMETRY CRITERIA

• SBP ≥90 or at baseline • RR >26 • Requires continuous cardiac monitoring • Rales/rhonchi (often absent) • Poor response to ED treatment

Low Severity: OBSERVATION CRITERIA

• O2 sat ≥ 90% or PaO2 ≥ 60 on room air • SBP >100 or at baseline • No evidence of ischemia on EKG • At least 1 negative cardiac enzyme resulted • Responsive to ED treatment

NO

Consider other

diagnosis and

treatment.

Yes

DISCHARGE CRITERIA

• Ambulatory for 3-6 minutes with little to no dyspnea

• Reduced body weight

• Resolution of rales • No significant

alterations in electrolytes

• VS stable or at baseline for at least 8 hours.