Left ventricular failure occurs when the left ventricle fails to pump blood successfully, causing backpressure in the pulmonary circulation and pooling of blood. This can lead to acute pulmonary edema if left untreated. The patient presented with shortness of breath, tachycardia, crackles in both lungs, and edema. Treatment focused on improving oxygenation, decreasing venous return, reducing myocardial oxygen demand and off-loading the ventricles using oxygen, nitrates like nitroglycerin, and furosemide. Timely diagnosis and treatment of congestive cardiac failure remains important.

1. LEFT VENTRICULAR FAILURE
AND PULMONARY OEDEMA
Compiled and Presented by: Louis van Rensburg (ALS Paramedic)

2. Dispatch Details
• On Saturday, 01 November 2014, we were dispatched to
Cedile str Kwanonqaba for SOB.
• On arrival, we found a 82-year old male; sitting upright
in bed , pillows stacked behind him.
• Patient found to be anxious and tachyapnea.

3. Further History
• S - Dyspnea/Tachyapnea/Mild Diaphoresis
• A - None
• M - Pharmapress, Amtas, Simvistatin,
Furosemide, Budaflem and Asthavent
(compliant)
• P – Been in Hospital 1 week before.
• L – 16h00
• E – Patient became progressively SOB during
last week. Patient complains of exhaustion
on mild exertion.

4. On Examination
• Vital signs: Bp, 125
/73mmHg; Pulse 124; Respiration Rate
22
• A: Patent, Audible gargling present
• B: Laboured breathing with bi-lateral crackles in all lung
fields. SpO2,45% on RA(FiO2 of 0.21).
• C: Mild Diaphoresis, Weak Bi-lateral pulses
(122bpm),ECG: sinus tachy
• CNS: GCS 15/15, patient full compesmentace.
• General: Pedal oedema and General Body Oedema

5. Management
• A: None, just monitor to prevent sudden
deterioration.
• B: Monitor Spo2(Is it reliable?), Provide
additional O2 what would be effective?
• C: IV and ECG monitoring
• HGT – 5.1mmol/L
• Nitro-lingual spray/tablet – 1X spray/tablet
• Furosemide – 40mg (0.5-1mg/kg)
• Transported patient to hospital (Preferred
Position)

6. Pathophysiology of LVF
• LEFT VENTRICULAR FAILURE when left
ventricle fails to pump blood successfully.
• Backpressure of blood causes pooling into
pulmonary circulation.
• Unmanaged-Acute Pulmonary oedema

7. Causes of LVF
• Myocardial Infarct
• Valvular heart disease
• Rapid AF (Why?)
• Hypertensive heart disease

8. Management
• Emergency treatment aimed at
▫ Improving oxygenation and ventilation
▫ Decreasing the venous return
▫ Decreasing myocardial oxygen demand
▫ Improving myocardial contractility
▫ Off-Loading the ventricles

9. Management
• Oxygen
▫ 40% Face mask
▫ Non-rebreather
▫ Bag valve mask ventilation
▫ Intubate and ventilate with PEEP
• Nitrates
▫ Spray sublingually or tablets
▫ Reduces preload and afterload
▫ Improves myocardial oxygen delivery
▫ Most of the treatment benefits come from aggressive
use of nitroglycerine

10. Management
• Nitrates
oOur current treatment protocol allows up to 3
sublingual nitroglycerins as long as systolic
blood pressure is greater than 90mmHg
oEvidence suggest that best combination is high
dose nitrates plus low dose furosemide for acute
cardiogenic pulmonary edema (“BestBETs”)

11. Management
• Furosemide
▫ Dilating effect on venous system
▫ Diuretic effect reduces intravascular vol
▫ Has a questionable role in the prehospital treatment of
ACPE. It may help slightly in obvious cases but may be
harmful to those misdiagnosed
• Morphine
▫ Decrease venous return
▫ Reduces anxiety
▫ Little effect on mortality and may increase the
intubation rate

12. CONCLUSION
Diagnosis and treatment of CCF remain
important and challenging and the utilization of
available sources and sound understanding of
the pathophysiology and pharmacotherapy can
produce rewarding results when caring for this
frequently encountered and ever challenging,
diverse patient group.