The Canadian Association of Emergency Physicians (CAEP) Acute Heart Failure Best Practices Checklist (April 2025) – Comprehensive Practical Review
The Canadian Association of Emergency Physicians (CAEP) Acute Heart Failure Best Practices Checklist (April 2025) – Comprehensive Practical Review
Source:
Stiell IG, et al. CAEP Acute Heart Failure Best Practices Checklist. CAEP, April 2025.
Introduction
CAEP published the Acute Heart Failure (AHF) Best Practices Checklist in April 2025. This ED-focused tool bridges cardiology guidelines (ESC, American Heart Association (AHA)/Heart Failure Society of America (HFSA), Canadian Cardiovascular Society (CCS)) with real-time emergency care by:
• Providing stepwise diagnostic and therapeutic actions tailored to the Emergency Department (ED).
• Standardizing care and enabling registry-ready data (vital signs, oxygen, diuretics, Non-Invasive Ventilation (NIV), di…
[2:34 pm, 25/09/2025] Dr Jamal Aldabbas Card Socity: Jordan EMS – Practical Prehospital Protocol for Acute Heart Failure / Pulmonary Edema
(Adapted from ESC, AHA/HFSA 2022, NICE 2025, Canadian and Australian EMS guidelines)
Source references: Cureus (Sept 2025), Journal of Clinical Medicine (2025), ESC 2023, AHA/ACC/HFSA 2022, NICE 2025, Canadian EMS 2023, Ambulance Victoria 2024.
Keynotes:
1. Rapid Recognition (without physician)
Practical EMS Rule for Acute Severe Dyspnea
• Any patient presenting with acute severe dyspnea, inspiratory crackles, and low O₂ saturation should be treated as acute pulmonary edema/acute HF until proven otherwise.
• Supporting features: pink frothy sputum, orthopnea, tachypnea, tripod posture, hypertension, and history of heart disease or hypertension.
• If the main finding is wheeze without crackles in a patient with asthma/COPD → consider bronchospasm.
• EMS does not need to confirm final etiology; aim = safe stabilization and transport.
How EMS Can Recognize Acute HF
• Primary clues: sudden severe dyspnea, crackles, low O₂ saturation.
• Visual cues: upright sitting, agitation, pink frothy sputum.
• Vitals: tachypnea, tachycardia, often elevated BP.
• History clues: known HF, CAD, hypertension, recent fluid overload.
If present, EMS should treat/stabilize as acute HF/pulmonary edema until confirmed in hospital.
2. Stabilization: Airway, Oxygenation, and BP-Guided Pharmacology
Primary Actions
• Ensure ABC.
• Position upright.
• Monitoring: SpO₂, ECG, BP, RR.
• Rapid history (CHF, meds, comorbidities).
• Establish IV access.
Oxygenation and Ventilation
• First-line: CPAP/BiPAP if available.
• If not: high-flow O₂, SpO₂ target 92–96% (88–92% if COPD).
• Prepare for advanced airway only if refractory hypoxemia/impending collapse.
Blood Pressure–Guided Pharmacology
• Hypertensive (SBP ≥110–120):
• SL GTN 0.3–0.6 mg q5min, max 3 doses.
• Check BP before each dose.
• Contraindications: SBP <100, RV infarct, severe AS, recent PDE-5i.
• IV GTN is hospital-based.
• Normotensive (SBP 100–110):
• Prioritize CPAP + rapid transport.
• SL GTN only if SBP stable + congestion severe.
• Consider loop diuretic if known CHF + overload.
• Hypotensive (SBP <100):
• Avoid GTN and diuretics.
• Cautious fluids if hypovolemic.
• Prepare vasopressors/inotropes under medical control.
5. Role of Loop Diuretics
• Not routine in EMS (ESC, AHA, NICE, Canada, Australia).
• Consider only if: known CHF, on diuretics, volume overload, SBP ≥100.
• If given: IV furosemide 40–80 mg, or 1–2× home dose.
6. Non-Cardiogenic Pulmonary Edema (NCPE)
• Causes: sepsis, ARDS, neurogenic, toxins, TRALI, high altitude.
• In EMS: differentiation is unreliable.
• Management: O₂ ± CPAP, supportive, rapid transfer.
• Avoid GTN/diuretics if NCPE strongly suspected.
7. Special Populations
• Pregnancy: avoid supine; left lateral tilt; O₂ ± CPAP; GTN only if SBP ≥110; transfer to cardiac–obstetric facility.
• Elderly: higher risk of hypotension → check BP before GTN; avoid morphine.
• Obesity: ramped position; ensure CPAP mask seal; higher pressures may be needed.
• COPD/Asthma: target O₂ 88–92%; distinguish wheeze vs crackles.
8. Contraindications to Nitroglycerin
• SBP <100 mmHg.
• Recent PDE-5 inhibitor use (sildenafil, tadalafil).
• Severe aortic stenosis.
• Suspected RV infarction.
9. Documentation & Handover
• Record vitals, SpO₂, ECG, NIV settings, GTN doses.
• Note patient’s response.
• Provide structured handover to ED team.
Key Home Messages for Jordan EMS:
1. Rapid recognition: severe dyspnea + crackles = treat as AHF/PE.
2. Early CPAP if available.
3. SL GTN (0.3–0.6 mg, max 3 doses) only if SBP ≥110.
4. Avoid IV nitrates prehospital.
5. Loop diuretics not routine; only in known CHF + overload + SBP ≥100.
6. NCPE: oxygen/supportive only.
7. Adjust care for pregnancy, elderly, obesity, COPD/asthma.
8. Always pre-alert hospital for rapid advanced management
