Approach to the Critical Patient

Immediate priorities

Airway and ventilation assessment

Hemodynamic profiling

Immediate escalation triggers

Monitoring and targets

Continuous monitoring bundle

Escalation triggers

Key decision points

EF classification on presentation

Hemodynamic profile guides acute therapy

History

Cardinal symptoms

Dyspnea

Fluid overload symptoms

Precipitant identification

Dietary and medication triggers

Cardiac precipitants

Risk factor history

Major cardiac risk factors

Prior HF history

Social history

Associated symptoms

Pulmonary symptoms

Systemic and low-output symptoms

Physical Exam

Vital signs

Hemodynamic snapshot

Cardiovascular exam

Jugular venous pressure

Cardiac auscultation

Pulmonary exam

Auscultation findings

Pleural effusion signs

Peripheral and abdominal exam

Fluid overload signs

Perfusion exam

Differential Diagnosis

Life-threatening mimics

Immediate threats to exclude

Cardiogenic shock causes

Common mimics

Pulmonary causes

Volume overload from non-cardiac causes

High-output states

Causes of high-output HF

Laboratory Tests

Core metabolic and organ function

Basic metabolic panel

Hepatic function

Cardiac biomarkers

Natriuretic peptides

Troponin

Additional labs

Complete blood count

Iron studies

Thyroid function

Lactate

Lipid panel and HbA1c

Diagnostic Tests

Scoring Systems

Ottawa Heart Failure Risk Score (OHFRS)

NYHA Functional Classification

ACC/AHA Staging System

Hemodynamic Profile Classification

MRI

Cardiac MRI indications

Contraindications and limitations

Clinical utility in HF

CT

Coronary CT angiography

CT chest non-contrast

Diagnostic considerations

Ultrasound

Point-of-care echocardiography

Lung ultrasound

Formal transthoracic echocardiography

Disposition

Admission criteria

ICU level indications

Inpatient admission indications

Observation and discharge criteria

Observation unit candidacy

Discharge criteria

Follow-up planning

Early post-discharge follow-up

Treatment

Immediate respiratory support

Supplemental oxygen

Diuretics

IV loop diuretics

Diuretic resistance management

Vasodilators

IV nitroglycerin

IV nitroprusside

Nesiritide

Inotropes and vasopressors

Dobutamine

Milrinone

Norepinephrine for refractory hypotension

Guideline-directed medical therapy (GDMT) for HFrEF

ARNI or ACE inhibitor or ARB

Evidence-based beta-blocker

Mineralocorticoid receptor antagonist (MRA)

SGLT2 inhibitor

Additional therapies

Hydralazine and isosorbide dinitrate

Ivabradine

IV iron replacement

Device therapy

Special Populations

Pregnancy

Peripartum cardiomyopathy

Medication safety in pregnancy

Delivery and peripartum management

Geriatric

Age-related physiologic changes

Atypical presentation in older adults

GDMT tolerability in elderly

Pediatrics

Epidemiology and etiology in children

Clinical presentation differences

Treatment in children

Background

Epidemiology

Prevalence and incidence

Mortality data

HF subtype distribution

Pathophysiology

Neurohormonal activation

Myocardial remodeling

Hemodynamic consequences

Therapeutic Considerations

GDMT rationale

Decongestion principles

Evidence base highlights

Patient Discharge Instructions

copy discharge instructions

Congestive heart failure home care

Warning signs to return to the emergency room

Activity and lifestyle

References

Guidelines and key sources

Primary guidelines

Landmark clinical trials

Emergency medicine evidence

Coding references