 Welcome back to part 2 of congestive heart failure. In this section we'll talk about investigations and treatment of heart failure in the emergency department. Depending on the severity of the patient's heart failure, we often have to investigate and treat at the same time. We'll split it up and discuss investigation first. The different modalities include ECG, chest x-ray, ultrasound, and labs. In terms of ECG, we're really looking for any signs of ischemia or infarct. Chest x-ray is extremely important in the patients with left-sided heart failure. There are multiple abnormalities we can see in chest x-ray. One of the early signs of CHF is a phenomenon known as vascular redistribution on the chest x-ray. In a normal chest x-ray, upper lobe vessels are usually much less prominent than lower lobe vessels. That is because the lower lobe vessels carry more pulmonary blood flow. In patients with CHF, as the pulmonary venous pressure increases, the lower lobe vessels become more constricted. That means that more blood is distributed to the upper lobes, which make the vessels more prominent. Let's take a look at this chest x-ray. Can you find the pulmonary vessels? If you look at the caliber of the upper lobe vessels versus the lower lobe vessels, you can see that they are very similar. This is a very early sign of vascular redistribution. The next finding on chest x-ray is known as curly B lines. In normal lungs, extra insistitial fluid go back to the bloodstream through the lymphatics. That is constant. In patients with CHF, as pulmonary venous pressure increases, more and more fluid will leak from the capillary bed. And the lymphatics is no longer able to remove all the fluid. The insistition becomes waterlocked. The fluid first collects in the interlobular septa in the lower lung fields. These thickened interlobular septa shows up on the chest x-ray as parallel, short horizontal line extending to the pleural services, known as curly B lines. What do you think of this chest x-ray? First, do you notice the caliber of the upper lobe vessels are almost the same as the lower lobe vessels? So there is vascular redistribution. And if we were looking at any of these lower lung field interlobular septa, what do we see? You can see that there are multiple parallel lines that are short, that's from the outer pleura. If we blow that up, that's what it would look like. You can see these parallel lines very clearly in the magnified version. These are curly B lines. When the insistition can no longer accommodate excess fluid, it spills into the avioli. On the chest x-ray, they look like ill-defined nodular opacities, such as this chest x-ray. You can see that there are multiple nodular opacities. If you look at the lower lung fields, you can also see curly B lines. Sometimes on the chest x-ray, we see causes of the patient's congestive heart failure. On this chest x-ray, you can see that there is cardiomegaly. What do you see on this chest x-ray? There's cardiomegaly and evidence of previous valve surgery. That side ultrasound is also started to be used in patients with heart failure. In left-sided heart failure, insistitial fluid can be seen. For right-sided heart failure, we can see pericardiofusion and ascites. Labs are usually drawn. We pay special attention to electrolytes, renal function, cardiac troponins. In some centers, special tests such as BNP is also done to help with the diagnosis. Let's talk about treatment. Patients with pulmonary edema are very sick patients. We want to start with ABC. Usually for these patients, the airway is not a concern because it's usually patent. In those who are unable to maintain an open airway because of decreased GCS, we might have to intubate. For breathing, we give them oxygen, usually in the form of non-invasive positive airway pressure using devices such as BIPAP or CPAP. This is a main key therapy in patients with pulmonary edema. For circulation, patients with heart failure has volume that's redistributed into their interstitium. Therefore, they're often intravascularly dry. If they are hypotensive, we can give judicious fluid. There are also some specific therapy. One key treatment for patients with pulmonary edema is nitrates in the form of nitroglycerin. It can be given sublingual or IV. In patients who are sick, it is often started IV and titrated to the patient's blood pressure as nitroglycerin can cause this decrease in blood pressure. For other specific therapies, if the patient seems volume overloaded, we often start them on a diuretic such as furosomide. It is usually used as a second line treatment after the use of BIPAP and nitrates. Furosomide will also draw patients' blood pressure. Finally, if the patient is hypotensive with signs of cardiogenic shock, vasopressors such as epinephrine and dopamine can be considered. We also need to keep an eye out for underlying cause such as ischemia. In terms of disposition, patients with a left side are heart failure if they are unable to maintain their oxygen when they exert themselves, they need to come into the hospital. For patients with right side are heart failure, if they have significant edema or poor exercise tolerance, they might also need to come into the hospital. In summary, we discuss the investigation and treatment of patients with heart failure. Remember, this is a two-prong approach. The investigation includes ECG, chest x-ray with its various findings, bedside ultrasound and labs. For treatment, we start with A, protecting their airway, give oxygen via CPAP or BIPAP, judicious fluid, nitrates, diuretics, and vasopressors as indicated. This is only a framework of treating patients with pulmonary edema. We hope you find this useful. Thank you for watching.