Dyspnea and acute left heart decompensation

What are the essential steps of managing a dyspneic patient in the Stroke Unit? The differential is long but important. Here are the basic steps

  • Take a history
  • Ask your nurses
  • Look at the vitals
  • Do a physical exam: the lung, the heart, the JVP, the abdomen, the skin

Usually, this is enough to manage your patient. Yet, if in doubt:

  • get an ABG
  • get a chest xray
  • get an EKG
  • do labs: CRP, CBC, D-Dimer, BNP. TnI

If still in doubt, ask the ICU resident. He is quite interested in helping you, because if not successful, he has to deal with the patient; and as usual, he has no beds.

Finally, if we arrive at acute left heart decompensation:

  • Determine the nature of CHF (left + right? systolic/diastolic? forward/backward? etiology?)
  • Give Lasix (start with 40 migs) – did you know why it is called Lasix? Ask wikipedia – it is surprisingly simple and has a lot to do with pharmakokinetics…
  • Consider MSI, Nitro
  • Consider non-invasive ventilation

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