Pulmonary HTN

Vicious Cycle
-hemodynamics worsen with excess preload –> increased RV volume leads to RV bowing into LV and prevention of LV from adequately filling –> decreased CO and coronary perfusion –> RV ischemia further limits LV filling and output  pulm HTN cycle.png
-red flags: hypoxemia, hypotension, hypercarbia, acidosis (signs of and triggers for further decompensation)

Management
-FIRST make sure pt has functioning epoprostanol iv infusion if came in with PICC line (half life minutes)
if in shock, may try 250mL boluses but what pt truly needs is inotropes: Norepi or dobutamine
—do NOT give push-dose phenylephrine – the afterload will kill pt
—terbutaline improves inotropy but can worsen ischemia
-allow for permissive hypercapnea with acidosis 7.15 – 7.2 tolerable

Ancillary management
-treat afib via aggressive rhythm control (cardioversion and amio) rather than rate control as these patients’ CO is heavily dependent on atrial kick
-if intubation necessary, consider propofol for bronchodilatory effect

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