Emergency Department, ICU, and Inpatient Clinical Pathway
for Children with Suspected Acute Heart Failure

Patient at High Risk for
Heart Failure

History of:
  • Prior heart failure
  • Cardiomyopathy
  • Heart transplantation
  • Metabolic/mitochondrial disease
  • (e.g., Duchenne muscular dystrophy)
Family history of:
  • Heart failure
  • Cardiomyopathy
  • Heart transplantation

History and Physical Exam

  • MD/APP/RN rapid assessment
  • ABCDE, mental status
  • Monitor VS
  • Consider O2 therapy
  • Immediate IV access

Initial Evaluation to Consider

  • CBC, troponin-I, BNP, BMP, LFTs
  • CXR, ECG
  • VBG lactate, mixed venous O2 saturation from central line access
  • ED team consults Cardiology for concern of suspected
    acute heart failure
  • Evaluate need for immediate diuretic, additional therapies
  • Determine timing, location of echocardiogram
  • Disposition to appropriate unit
Warm and Wet
  • Increased ventricular filling pressures
  • Pulmonary edema w/adequate perfusion
Cold and Wet
Increased ventricular filling pressures
  • Pulmonary edema w/poor perfusion
  • Require ICU care
Cold and Dry
Normal ventricular filling pressures
  • Pulmonary edema w/poor perfusion
  • Dire condition
Require ICU care
Persistent symptoms
Escalation of Care
  • Respiratory support
  • Mechanical support
  • Chronic IV inotrope
    (milrinone)
  • Transplant
Improved function, symptom relief

Transition to PO Medications

Discharge Planning

Posted: February 2016
Revised: February 2023
Authors: J. Rossano, MD; K. Lin, MD; T. Conlon, MD; S. Helman, RN; M. Franco, MD; J. Lavelle, MD; M. O'Connor, MD; R. White, RN; A. Patton, RN; M. Yowell, CRNP; E. Ramsey, PharmD; C. Wittlieb-Weber, MD; D. Burstein, MD; H. Collier, PharmD;