Prehospital (EMS) Protocol for Acute Heart Failure / Pulmonary Edema During Ambulance Transport
Prehospital (EMS) Protocol for Acute Heart Failure / Pulmonary Edema During Ambulance Transport
(Adapted from ESC, AHA/HFSA 2022, NICE 2025, Canada, Australia, Canadian and Australian EMS guidelines)
1. Rapid Recognition (without physician)
Practical EMS Rule for Acute Severe Dyspnea
1. Any patient presenting with acute severe dyspnea, inspiratory crackles, and low oxygen saturation should be treated as having acute pulmonary edema or acute heart failure until proven otherwise.
2. Supporting features include: pink frothy sputum, orthopnea, tachypnea, tripod posture, hypertension, and a history of heart disease or hypertension.
3. If the main finding is wheeze without crackles in a patient with asthma or COPD history, consider bronchospasm instead.
4. Importantly, EMS is not required to confirm the final etiology; the goal is to ensure safe stabilization and transport.
How EMS Can Recognize Acute Heart Failure
1. Primary clues: sudden severe shortness of breath, crackles on chest auscultation, and low oxygen saturation.
2. Visual cues: upright sitting posture, agitation, and pink frothy sputum.
3. Vital signs: tachypnea, tachycardia, and often elevated blood pressure.
4. History clues: known heart failure, coronary artery disease, hypertension, or recent fluid overload.
If these features are present, EMS should treat and stabilize the patient as acute heart failure / pulmonary edema until the diagnosis is confirmed in hospital.
2. Stabilization: Airway, Oxygenation, and BP-Guided Pharmacology
EMS Initial Management of Suspected Acute Heart Failure / Pulmonary Edema
1. Primary Actions
• Ensure airway, breathing, and circulation (ABC).
• Position the patient upright.
• Apply monitoring: SpO₂, ECG leads, blood pressure, respiratory rate.
• Obtain a brief history (CHF, medications, comorbidities).
• Establish IV access.
2. Oxygenation and Ventilation
• First-line: CPAP/BiPAP if available and not contraindicated.
• If NIV not available: use high-flow O₂, targeting SpO₂ 92–96% (88–92% if COPD).
• Prepare for advanced airway only if hypoxemia is refractory or collapse is imminent.
3. Blood Pressure–Guided Pharmacology
• Hypertensive (SBP ≥110–120 mmHg):
* Give sublingual nitroglycerin (0.3–0.6 mg) every 5 minutes, up to 3 doses.
* Check BP before each dose.
* Contraindications: SBP <100, RV infarct, severe aortic stenosis, recent PDE-5 inhibitor use.
* IV nitroglycerin is hospital-based, not practical for EMS.
• Normotensive (SBP 100–110 mmHg):
* Prioritize CPAP and rapid transport.
* Consider SL nitroglycerin only if SBP is stable and congestion is severe.
* Loop diuretics may be considered in known CHF with fluid overload.
• Hypotensive (SBP <100 mmHg):
* Avoid nitroglycerin and diuretics.
* Give cautious fluids only if hypovolemic.
* Prepare for vasopressors/inotropes under physician direction.
5. Role of Loop Diuretics
• Not routine in EMS practice (per ESC, AHA, NICE, Canada, Australia).
• May be considered only if: patient has known CHF, already on loop diuretics, shows clear volume overload, and SBP ≥100 mmHg.
• If administered: IV furosemide 40–80 mg, or 1–2× the patient’s usual home dose.
6. Non-Cardiogenic Pulmonary Edema (NCPE)
• Causes: sepsis, ARDS, neurogenic injury, toxins, TRALI, high-altitude exposure.
• In EMS: differentiation from cardiogenic pulmonary edema is often unreliable.
• Management: oxygen ± CPAP, supportive care, and rapid transfer to hospital.
• Avoid nitrates and diuretics if NCPE is strongly suspected.
7. Special Populations
• Pregnancy: avoid supine position, use left lateral tilt; provide O₂ ± CPAP; give GTN only with caution if SBP ≥110; transfer to a cardiac–obstetric facility.
• Elderly: higher risk of hypotension → always check BP before each SL GTN dose; avoid routine morphine.
• Obesity: use ramped position; ensure CPAP mask seal; higher pressures may be required.
• COPD/Asthma: aim for SpO₂ 88–92%; try to distinguish wheeze (bronchospasm) from crackles (pulmonary edema).
8. Contraindications to Nitroglycerin
• SBP <100 mmHg.
• Recent use of PDE-5 inhibitors (sildenafil, tadalafil).
• Severe aortic stenosis.
• Suspected right ventricular infarction.
9. Documentation & Handover
• Record vital signs, SpO₂, ECG, NIV settings, and SL GTN doses.
• Note the patient’s response to interventions.
• Provide a structured handover to the ED team for continuity of care.
Key Takeaways for Jordan EMS
1. Rapid recognition: severe dyspnea with crackles should be managed as acute heart failure/pulmonary edema until proven otherwise.
2. Early CPAP: initiate promptly if available and not contraindicated.
3. Sublingual GTN: 0.3–0.6 mg every 5 minutes, up to 3 doses, only if SBP ≥110 mmHg.
4. Avoid IV nitrates in the prehospital setting.
5. Loop diuretics are not routine; consider only in patients with known CHF, clear fluid overload, and SBP ≥100 mmHg.
6. NCPE (non-cardiogenic pulmonary edema): provide oxygen and supportive measures only.
7. Special populations: adjust approach in pregnancy (left lateral tilt), elderly (caution with BP), obesity (ramped position/CPAP seal), and COPD/asthma (O₂ 88–92%).
8. Hospital pre-alert: notify receiving ED early for rapid transition to advanced management.
Source (links):
• ESC 2023 HF Guidelines (Eur Heart J): https://academic.oup.com/eurheartj/article/44/37/3627/7246292
• AHA/ACC/HFSA 2022 HF Guideline (PubMed): https://pubmed.ncbi.nlm.nih.gov/35379503/
• AHA/ACC/HFSA 2022 Full-text PDF: https://achpccg.com/wp-content/uploads/2024/02/Heidenreich-et-al_2022_AHA-ACC-HFSA-Guideline-for-the-Management-of-Heart-Failure-A-Report-of-the-American-College-of-Cardiology-American-Heart-Association-Joint-Committee-on-Clinical-Practice-Guidelines.pdf
• NICE NG106 (updated Sept 2025): https://www.nice.org.uk/guidance/ng106
• BC Emergency Health Services CPG: https://www.bcehs.ca/clinical-practice-guidelines
• Ambulance Victoria CPG: https://www.ambulance.vic.gov.au/clinical-practice-guidelines
• Cureus (journal homepage): https://www.cureus.com/
• Journal of Clinical Medicine – Heart section: https://www.mdpi.com/journal/jcm/sections/Emergency_Med
