Patient generally presents with shortness of breath, often rapid in onset. Precipitating conditions include hypertension, myocardial infarction, pulmonary embolism, fluid overload, and medications (B-Blockers). Classic picture of rales, JVD, and dependent edema is often confused by additional findings such as wheezing.

1. Perform patient assessment and ABC's.
2. Quickly obtain relevant medical history if possible. If patient will tolerate, simultaneously sit patient upright or in position of comfort to facilitate improved respiratory effort.
3. Administer high-flow oxygen, preferably by NRM, or appropriate device to insure adequate oxygenation. Apply pulse oximetry device and document O2 saturation levels.
4. Be prepared to assist ventilations by positive pressure ventilation if necessary and tolerated by patient.
5. Monitor vital signs in accordance with S.O.P. protocol.

1. Establish IV access using D5W or NS, run at TKO rate. Closely monitor IV drip rate, do not overhydrate the patient.
2. If patient also complaining of Chest Pain, contact Medical Control and request order for Nitroglycerin 0.4 mg SL if BP greater than 100 Systolic, (up to 3 doses 1.2 mg).
3. Morphine Sulfate is also indicated if the CHF patient is having Cardiac Chest Pain, refer to Chest Pain Protocol.

1. Attach and monitor ECG. Treat dysrhythmias as necessary. If time and patient condition allow, obtain 12 Lead ECG.
2. The following therapies are appropriate in this protocol (Preferred order is NTG, MS, & Lasix).
   1. Nitroglycerin 0.4 mg SL every 5 minutes up to 1.2 mg
   2. Morphine sulfate 4 mg Slow IVP, repeat 2 mg doses every 5 minutes up to 10 mg.
   3. Furosemide 40-80 mg IVP (consider larger dosing [60-80mg] in patients already taking furosemide and lower doses [20-40] in patients without prior exposure to the medication).

3. If patient is significantly hypotensive prior to nitrates, treat for Cardiogenic Shock. Contact Medical Control and request initiation of Dopamine HCL @ 5-20 mcg/kg/min. Titrate infusion to adequate BP and/or resolution of respiratory distress.