Tuesday, 28 July 2015

Right Sided Heart Failure

It's often difficult to differentiate right sided heart failure from left sided - because left goes on to cause right!

Pathophysiology

Caused by respiratory problems, and by progression of left sided heart failure. 

Signs
High JVP
Pitting oedema
RUQ pain - hepatomegaly 
Loud P2, and heave 

Investigations
ECG: If the ECG is normal, heart failure is unlikely
  Reduced ECG amplitude (more air between heart and leads)
  Prominent P waves
  Right axis deviation
  RBBB (Broad QRS > 120 ms, RSR’ pattern in V1-3 (‘M-shaped’ QRS complex), Wide, slurred S wave in the lateral leads (I, aVL, V5-6))
  Sagging of ST segment below baseline 
http://lifeinthefastlane.com/ecg-library/basics/p-wave/



P Waves: 
P mitrale (bifid P waves), seen with left atrial enlargement.
P pulmonale (peaked P waves), seen with right atrial enlargement.
P wave inversion, seen with ectopic atrial and junctional rhythms.
Variable P wave morphology, seen in multifocal atrial rhythms.
--> if P waves are inverted check lead placement

Management
Reduce hypoxia and hypercarbia
Ventilation and PEEP
Inotropes and vasopressors
RV assist device may be useful 

http://lifeinthefastlane.com/ecg-library/copd/
http://lifeinthefastlane.com/ecg-library/basics/p-wave/
http://lifeinthefastlane.com/ccc/right-ventricular-failure/
http://www.rcemlearning.co.uk/references/pulmonary-hypertension-and-right-heart-failure/
http://www.rcemfoamed.co.uk/portfolio/rcem-belfast-day-3/ 

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