see also: [[Pulmonary Hypertension]], [[Congestive Heart Failure]], [[Peri-intubation collapse]] > [!references]- > see: [Deranged physiology - right heart failure](https://derangedphysiology.com/main/required-reading/cardiology/Chapter%205132/right-heart-failure), [cardiac ICU - pulmonary hypertension](x-devonthink-item://C5BE7A05-6B49-44F9-A896-007551DBE78A?page=441) > - [Management of Crashing Patients with Pulmonary Hypertension - Greenwood 2015](bookends://sonnysoftware.com/ref/DL/207779) > - [Pulmonary Hypertension and Right Ventricular Failure in Emergency Medicine - 2015 Wilcox](cubox://card?id=7247211468771296586) — [bookends PDF](bookends://sonnysoftware.com/ref/DL/230990) > - [Pulmonary hypertension and right ventricular failure - first10em](cubox://card?id=6826101067164420621) > - [Getting it 'Right': Pulmonary Hypertension in the ED - EMOttawa Blog](https://emottawablog.com/2017/08/getting-right-pulmonary-hypertension-ed/) > - [Biomechanics of the Right ventricle 2014](https://onlinelibrary.wiley.com/doi/10.1086/677354) - [bookends pdf](bookends://sonnysoftware.com/ref/DL/220139) > management of right heart failure is intrinsically similar to management for [[Pulmonary Hypertension]] as RV failure is the hallmark of decompensated pulmonary hypertension; see this article for more information about the pathophysiology ## Causes (organised by pathophysiology) - pressure overload - left heart failure (most common) - [[Pulmonary Embolism]] - RV outflow tract obstruction - pulm stenosis - volume overload - Tricuspid regurgitation - pulm regurgitation - carcinoid syndrome - renal failure - ischaemia - RV [[ACS|myocardial infarction]] - ischemia contributing to RV dysfunction in CHD and RV overload states - intrinsic myocardial disease - cardiomyopathy and heart failure - arrhythmogenic right ventricular dysplasia - sepsis - pericardial disease - constrictive [[Pericarditis]] - congenital defect - tetralogy of fallot - inflow limitation - tricuspid stenosis - SVC stenosis ## causes of RV failure (organised by system) - vascular - left-sided HF (most common) - PE - [[Pulmonary Hypertension]] of any cause - RV outflow tract obstruction - ARVC - right-sided infarct - tricuspid or pulm regurg - ASD - infection - tricuspid [[Endocarditis]] - sepsis - myocarditis - neoplastic - carcinoid - SVC obstruction from tumour or radiotherapy - atrial myxoma - traumatic - contusio cordis -- right heart contusion - autoimmune - rheumatic valvulitis - SLE - sarcoiditis - congenital - endocrine - severe acidosis → pulmonary hypertension # haemodynamic management for severe right heart failure see also: [[Pulmonary Hypertension#Management|pulm HTN management]] | issue | rationale | ED management | | ---------------------- | ----------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------- | | Ventilation | avoid hypercaponea and hypoxia -- both will vasoconstrict pulmonary arteries | - avoid intubation if possible<br>- NIV if needed but careful with PEEP | | volume mgmt | avoid hypervolaemia (acute strain and pressure on LV)<br>- in acute RV failure (eg infarct), need ↑ preload | - usually lasix<br>- may need urgent RRT<br>- rarely need fluid bolus unless definite volume depletion | | BP control / ionotropy | keep systolic BP > RVSP <br>MAP > 65 | adrenaline or [[Dobutamine]] infusion<br>+/- [[Noradrenaline\|norad]]<br>vasopressin OK; needs central line | | decrease RV afterload | improve RV failure and V/Q mismatch | inhaled nitric oxide or prostacyclin (not usually available in ED) | | aspect | mgmt | | ------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | preload | acute: ↑ preload<br>chronic: ↓ preload (not much; diuretics, GTN) | | afterload | 1. prevent pulm vasoconstriction:<br>- < PEEP 6-10 (as low as possible)<br>- avoid intubation and NIV<br>- SpO2 > 92%<br>- PaCO2 35-45<br>- pH 7.35 - 7.45<br>- SBP > pulm BP (but avoid too much norad)<br>2. ↑ pulm vasodilation<br>- not really in ED, eg Nitric oxide, etc | | contractility | - [[Dobutamine]] for acute right infarction if PA pressure normal<br>- [[Milrinone]] if PA pressure up <br>- levosimendan |