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

Goals and Metrics
Patient Education
Provider Resources
Differential Diagnosis
Child 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
Cardiology Consultation
  • 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
Further Diagnostic Work-up
Treatment for Initial Acute Heart Failure
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;