Clinical Myths and Scientific Truth about heart failure/pulmonary edema management in prehospital setting.

18 Dic

Clinical Myth #1. All heart failure/cardiogenic pulmonary edema (HF/CPE) patients are fluid overladed .

Scientific Truth #1: Just a small part of heart failure/ cariogenic pulmonary edema (HF/CPE) patients are fluid overloaded. Most (>50%) patients are redistributed (from splanchnic circulation and lover limb to pulmonary circle). Use your clinical judgement (poor sensitivity and specificity) or ultrasound (lung US for the presence of ≥3 B lines in ≥2 bilateral thoracic lung zones is reliable and sensitive for pulmonary edema) to establish which kind of patient you are dealing with: Overloaded or Redistributed. That makes the difference.

Clinical Myth #2. All HF/CP patients benefit from diuretic ( Furosemide or other diuretics) therapy.

Scientific Truth #2: Just normotensive overloaded HF/CPE patients can benefit from diuretic ( Furosemide or other diuretics) therapy.

Furosemide can be detrimental on short and long term outcome because:

  • decreases LV function, increasing ventricular filling pressure 

  • increases systemic vascular resistance through activation of the renin-angiothensyn system

  • decreases glomerular filtration rate

Clinical Myth #3. Nitrates small doses continuous infusion is the right strategy in HF/CP patients.

Scientific Truth #3: Nitrates and Non Invasive Positive Pressure Ventilation are effective first line interventions in hypertensive HF/CPE patients.

High doses Nitrates administration is safe. 2 mg bolus of nitrates every 3 min in hypertensive patients (with close blood pressure check) are safe and faster in achieving clinical targets and symptoms relief. 

Clinical Myth #4. Morphine is safe and effective in HF/CP patients because relief anxiety and reduce preload, and has to be part of first line interventions.

Scientific Truth #4: Morphine administration has no evidences of clinical benefit in HF/CPE patients and is not part of first line treatment for HF/CPE patients. Low quality evidence suggests that morphine is associated with worse outcomes when compared to patients not receiving opioids.

Clinical Myth #5. In hypotensive (cariogenic shock) HF/CP patients Dopamine is the first choice vasopressor.

Scientific Truth #5: Norepinephrine is the first line medication to reach target mean arterial pressure and achieve organ perfusion, rather than Dopamine. Evidence suggests that norepinephrine is associated with improved outcomes including
lower mortality and lower risk of dysrhythmia when compared with Dopamine.

Bottom Line Clinical Pearl: Use ultrasound during every step of your clinical pathway in HF/CPE patients.

  • US detection of B-lines for diagnosis in undifferentiated dyspneic patients

  • US of IVC to discriminate between fluid overloaded or redistributed patients

  • Pump/Tank/Pipes US approach for differential diagnosis in undifferentiated shock patients


Liberally adapted from:

Brit Long MD, Alex Koyfman, MD,  Eric J. Chin, MD. Misconceptions in acute heart failure diagnosis and Management in theEmergency Department. American Journal of Emergency Medicine. 2018 Sep;36(9):1666-1673. doi: 10.1016/j.ajem.2018.05.077. Epub 2018 Jun 1


Myth #1

  • Fallick C, Sobotka PA, Dunlap ME. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation. Circ Heart Fail 2011;4:669–75.
  • Zile MR, Bennett TD, St John Sutton M, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 2008 Sep 30;118 (14):1433–41.
  • Chaudhry SI,Wang Y, Concato J, Gill TM, Krumholz HM. Patterns of weight change preceding hospitalization for heart failure. Circulation 2007;116:1549–54
  • Viau DM, Sala-Mercado JA, Spranger MD, et al. The pathophysiology of hypertensive acute heart failure. Heart 2015;101:1861–7.
  • Jambrik Z, Monti S, Coppola V, et al. Usefulness of ultrasound lung comets as a non radiologic sign of extravascular lung water. Am J Cardiol 2004;93(10):1265–70.
  • Mallamaci F, Benedetto FA, Tripepi R, et al. Detection of pulmonary congestion by chest ultrasound in dialysis patients. JACC Cardiovasc Imaging 2010;3(6):586–94.
  • Anderson KL, Fields JM, Panebianco NL, et al. Inter-rater reliability of quantifying pleural B-lines using multiple counting methods. J Ultrasound Med 2013;32(1):115-20.

Myth #2

  • Francis GS, Siegel RM, Goldsmith SR, et al. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Ann Intern Med 1985;103(1):1–6.
  • Kraus PA, Lipman J, Becker PJ. Acute preload effects of furosemide. Chest 1990;98:124–8.

Myth #3

  • Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 1998;351:389–93.
  • Sharon A, Shpirer I, Kaluski E, et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol 2000;36:832–7.
  • Sharon A, Shpirer I, Kaluski E, et al. High-dose intravenous isosorbide-dinitrate i safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol 2000;36:832–7.

Myth #4

  • Sosnowski MA. Review article: lack of effect of opiates in the treatment of acute cardiogenic pulmonary oedema. Emerg Med Australas 2008;20:384–90.
  • Vasko JS, Henney RP, Oldham HN. Mechanisms of action of morphine in the treatment of experimental pulmonary edema. Am J Cardiol 1966;18:876–83.
  • Kaye AD, Hoover JM, Kaye AJ, et al. Morphine, opioids, and the feline pulmonary vascular bed. Acta Anaesthesiol Scand 2008;52:931–7.
  • Riggs TR, Yano Y, Vargish T. Morphine depression of myocardial function. Circ Shock 1986;19:31–8.
  • Miró Ò, Gil V,Martín-Sánchez  FJ, et al.Morphine use in the ED and outcomes of patients with acute heart failure: a propensity score-matching analysis based on the EAHFE registry. Chest 2017 Oct;152(4):821–32.

Myth #5

  • Rui Q, Jiang Y, Chen M, et al. Dopamine versus norepinephrine in the treatment of cardiogenic shock: a PRISMA-compliant meta-analysis. Medicine 2017;96(43):e8402.



Una Risposta a “Clinical Myths and Scientific Truth about heart failure/pulmonary edema management in prehospital setting.”


  1. Clinal Myths and Scientific Truth about heart failure/pulmonary edema management in prehospital setting. — MEDEST | Prehospital and Retrieval Medicine – THE PHARM dedicated to the memory of Dr John Hinds - 19 dicembre 2018

    […] via Clinal Myths and Scientific Truth about heart failure/pulmonary edema management in prehospital sett… […]


Inserisci i tuoi dati qui sotto o clicca su un'icona per effettuare l'accesso:

Logo di

Stai commentando usando il tuo account Chiudi sessione /  Modifica )

Foto Twitter

Stai commentando usando il tuo account Twitter. Chiudi sessione /  Modifica )

Foto di Facebook

Stai commentando usando il tuo account Facebook. Chiudi sessione /  Modifica )

Connessione a %s...

Questo sito utilizza Akismet per ridurre lo spam. Scopri come vengono elaborati i dati derivati dai commenti.


A Site for Intensivists and Resuscitationists


Supporting ALL Ohio EM Residencies in the #FOAMed World


Let's try to make it simple

thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!


More definitive diagnosis, better patient care

Critical Care Northampton

Reviewing Critical Care, Journals and FOAMed

OHCA research

Prehospital critical care for out-of-hospital cardiac arrest


Education and entertainment for the ultrasound enthusiast




Emergency medicine - When minutes matter...

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia


"Live as if you will die tomorrow; Learn as if you will live forever"


Navigating resuscitation

Life in the Fast Lane • LITFL

Emergency medicine and critical care education blog - Emergency Medicine Education

Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED.

The Collective

A Hive Mind for Prehospital and Retrieval Med

Dave on Airways

Thoughts and opinions on airways and resuscitation science


A Free Open Access Medical Education Emergency Medicine Core Content Mash Up

Broome Docs

Rural Generalist Doctors Education


Emergency Medicine #FOAMed

"CardioOnline"Basic and Advanced Cardiovascular medicine" Cariology" concepts and Review -Dr.Nabil Paktin,MD.FACC.دکتـور نبــــیل "پاکطــــین

این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان


Free Open Access Medical Education

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Tour Operator in Florence

Check out our updated blog posts at

EM Lyceum

where everything is up for debate . . .

Pediatric EM Morsels

Pediatric Emergency Medicine Education


Free Open Access Medical Education for Paramedics

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service




Prehospital Emergency Medicine

EM Basic

Your Boot Camp Guide to Emergency Medicine

KI Doc


Emergency Live

Prehospital Emergency Medicine


Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Comments on: Homepage

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-hospital & Retrieval Medicine Team of NSW Ambulance

%d blogger hanno fatto clic su Mi Piace per questo: