A 68-year-old patient presents with severe breathlessness, SpO2 88%, bilateral crackles, and elevated JVP. CXR shows pulmonary congestion. What is the immediate management priority and which medications should be initiated first?
1 Answer
The first-line management of acute decompensated heart failure (ADHF) with pulmonary edema includes: 1. Positioning: Sit patient upright (high Fowler's) to reduce preload. 2. Oxygen/NIV: High-flow O2 or BiPAP/CPAP if SpO2 <90% or persistent respiratory distress. 3. IV Furosemide: 40–80 mg IV bolus (loop diuretic) to reduce preload and congestion. 4. IV Nitrates (GTN/Isosorbide): Reduce preload and afterload; cautious use if SBP <90 mmHg. 5. Morphine: Can reduce anxiety and preload (use cautiously — associated with worse outcomes in some studies). 6. Monitor: Continuous pulse oximetry, ECG, urine output hourly, electrolytes. If cardiogenic shock is suspected, avoid aggressive diuresis and consider inotropes (dobutamine) and urgent echocardiography. Beta-blockers should be withheld acutely. Always identify and treat the underlying cause (e.g., ACS, arrhythmia, hypertensive emergency).
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