Fluid therapy: Crystalloid a) Isotonic b) Avoid hypertonic and hypotonic solutions No strong evidence for colloid volume expanders. |
Attention: most patients are congested. Usually, fluid therapy is not appropriate and may induce respiratory distress. Fluids should be administered with unequivocal clinical and ultrasonographic signs of hypovolemia. |
Normal LVEF + “ kissing walls ” + IVC < 10mm + absence of B-lines Highly preload dependent |
Normal LVEF + IVC < 10mm + absence of B-lines |
HR < 100 bpm (usually on medication) + RV diameter < LV diameter + absence of D-shape + IVC < 10 mm + absence of B-lines |
LVEF + RV diameter < LV diameter + absence of D-shape + IVC < 10 mm + absence of B-lines |
Vasopressors |
Low dose dobutamine – avoid tachycardia. |
Dobutamine |
Avoid dobutamine (avoid tachycardia) |
Dobutamine |
Low dose norepinephrine – avoid tachycardia |
Norepinephrine |
Low dose norepinephrine – avoid tachycardia. |
Norepinephrine |
Other drugs |
Short-acting vasoactive amines are options (phenylephrine) |
No strong supportive evidence |
If tachycardia (even sinus rhythm), beta blocker may be used; short-acting vasoactive amines may be options (phenylephrine). Milrinone if PAH. |
Milrinone if PAH |
Intra-aortic balloon |
Possible benefit |
Contraindicated |
No evidence |
Possible benefit |
Interventionist / other strategies |
Consider the percutaneous balloon valvuloplasty as a bridge for definitive intervention; extracorporeal membrane oxygenation as a bridge for definitive intervention |
No strong supportive evidencea |
Consider percutaneous balloon mitral valvuloplasty if favorable (anatomical criteria and absence of contraindications) |
Percutaneous ventricular assist device as a bridge for definitive intervention. Without current evidence for MitraClip |
Management of hypoxemia
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Aortic stenosis
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Aortic regurgitation
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Mitral stenosis
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Mitral regurgitation
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Non-invasive ventilation: avoid deep sedation and opioids |
Possible, even in mild hypotension |
Possible, even in mild hypotension |
Possible, even in mild hypotension; avoid in severe PAH and/or RV dysfunction |
Possible, even in mild hypotension; avoid in severe PAH and/or RV dysfunction |
Advanced airway management No strong evidence for premedication with lidocaine Sedation strategies (choose one): a) Propofol b) Etomidate c) Ketamine d) Midazolam plus (choose one): a) Succinylcholine b) Rocuronium Initial mechanical ventilation: tidal volume 6 mL/Kg, plateau pressure < 30 mmHg, titrated PEEP and driving pressure < 20 mmHg |
Hypotension often occurs after intubation; attention to the choice of medications during sedation and maintain vasopressors readily available |
Intubation is usually well tolerated |
Avoid ketamine; marked hypotension after intubation when there is PAH |
Intubation is usually well tolerated |
Diuretics (furosemide; no evidence for other classes in emergency setting) |
Administer only if lung congestion; avoid if compensated oxygenation |
Usually necessary |
Usually necessary |
Usually necessary |
ptimize the pressure-volume curve until definitive treatment
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Aortic stenosis
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Aortic regurgitation
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Mitral stenosis
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Mitral regurgitation
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Rhythm Amiodarone can be used in all scenarios according to clinical judgment in stable patients with acute supraventricular arrhythmia. |
Maintain sinus rhythm if possible |
Consider chronic stable AF as sinus tachycardia. Diltiazem and esmolol may be carefully used. |
Maintain sinus rhythm if possible |
Consider chronic stable AF as sinus tachycardia. Diltiazem and esmolol may be carefully used. |
Heart rate |
Avoid excessive tachycardia in non-sinus rhythm with amiodarone, diltiazem, verapamil, esmolol, metoprolol tartrate, lanatoside C |
Avoid routine use of beta blockers. Diltiazem and esmolol may be carefully used. |
Avoid tachycardia in all rhythms with amiodarone, diltiazem, verapamil, esmolol, metoprolol tartrate, lanatoside C |
80–100 bpm Avoid intense decrease. Diltiazem and esmolol may be carefully used |
Preload: POCUS should monitor IVC and other dynamic parameters |
Avoid diuretics and nitrates (nitroglycerin, isosorbide) |
In stable patients with lung congestion, it is reasonable to use of vasodilator regardless of class -nicardipin, hydralazine, captopril, and enalapril |
Avoid routine use of vasodilators |
In stable patients with lung congestion, it is reasonable to use of vasodilator regardless of class -nicardipin, hydralazine, captopril, and enalapril |
Afterload |
Nitroprusside if MAP > 60 mmHg, especially if low LVEF; avoid fast SV reduction (worsening of coronary perfusion) |
Nitroprusside. Nitroglycerin should be an alternative. In stable patients with lung congestion, it is reasonable to use of vasodilator regardless of class -nicardipin, hydralazine, captopril, and enalapril |
Avoid low afterload (decreases coronary perfusion) |
Prevent increase; nitroprusside; nitroglycerin should be an alternative. In stable patients with lung congestion is reasonable to use of vasodilator regardless of class -nicardipin, hydralazine, captopril, and enalapril |
Contractility |
Levosimendan |
No strong supportive evidence |
No strong supportive evidence |
Avoid myocardial depression |