1 the patient with heart failure cpap as an intervention april 2011 ce condell medical center ems...
TRANSCRIPT
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The Patient with Heart The Patient with Heart FailureFailure
CPAP as an InterventionCPAP as an Intervention
April 2011 CEApril 2011 CECondell Medical CenterCondell Medical Center
EMS SystemEMS SystemSite Code #107200E -1211Site Code #107200E -1211
Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire DistrictReviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
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ObjectivesObjectives
Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS provider will be able to: provider will be able to:
Define heart failure and congestive heart Define heart failure and congestive heart failure.failure.
Identify causes of heart failure.Identify causes of heart failure. Identify symptoms of heart failure.Identify symptoms of heart failure. Identify patterns of medical history related to Identify patterns of medical history related to
the patient with heart failure.the patient with heart failure. Identify current home medications typically Identify current home medications typically
taken by the patient with congestive heat taken by the patient with congestive heat failure.failure.
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Objectives cont’dObjectives cont’d
Identify the difference between the patient with Identify the difference between the patient with congestive heart failure and pneumonia.congestive heart failure and pneumonia.
Identify the assessment of the patient with Identify the assessment of the patient with congestive heart failure.congestive heart failure.
Identify the proper procedure for assessing breath Identify the proper procedure for assessing breath sounds.sounds.
Identify treatment goals and options for congestive Identify treatment goals and options for congestive heart failure following Region X SOP’s.heart failure following Region X SOP’s.
Define CPAP as used by EMS for the patient with Define CPAP as used by EMS for the patient with pulmonary edema.pulmonary edema.
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Objectives cont’dObjectives cont’d Describe how CPAP will benefit the patient with Describe how CPAP will benefit the patient with
pulmonary edema.pulmonary edema. State indications, contraindications and State indications, contraindications and
medications used with CPAP.medications used with CPAP. Describe the process of setting up the CPAP Describe the process of setting up the CPAP
device.device. Describe the process of adding in-line Albuterol Describe the process of adding in-line Albuterol
with CPAP.with CPAP. Describe patient assessment while delivery Describe patient assessment while delivery
CPAP.CPAP. State components to document when using State components to document when using
CPAP.CPAP.
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Objectives cont’dObjectives cont’d
Demonstrate the set up of CPAP.Demonstrate the set up of CPAP. Demonstrate the set-up of regular and Demonstrate the set-up of regular and
in-line Albuterol.in-line Albuterol. Demonstrate adding in-line Albuterol Demonstrate adding in-line Albuterol
with CPAP.with CPAP. Actively participate in case scenario Actively participate in case scenario
discussion.discussion. Successfully complete the post quiz with a Successfully complete the post quiz with a
score of 80% or better.score of 80% or better.
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What is Heart Failure?What is Heart Failure?
A clinical syndromeA clinical syndrome Heart’s mechanical performance (ie: Heart’s mechanical performance (ie:
pumping action) is compromisedpumping action) is compromised Cardiac output unable to meet the demands Cardiac output unable to meet the demands
of the body’s needsof the body’s needs Generally divided into backward Generally divided into backward
ventricular failure (right heart failure) and ventricular failure (right heart failure) and forward ventricular failure (left heart forward ventricular failure (left heart failure)failure)
Can be of a chronic or acute natureCan be of a chronic or acute nature
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Heart FailureHeart Failure
Variety of causesVariety of causes Valve diseaseValve disease Heart diseaseHeart disease
Contributing factors to heart failureContributing factors to heart failure Diet - excess fluid or salt intakeDiet - excess fluid or salt intake HypertensionHypertension Pulmonary embolismPulmonary embolism Excessive alcohol or drug usageExcessive alcohol or drug usage Progression of an underlying diseaseProgression of an underlying disease
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What is CHF?What is CHF? Congestive heart failure = CHFCongestive heart failure = CHF
Condition of excess build-up of fluid in the Condition of excess build-up of fluid in the lungs and/or other body parts/organslungs and/or other body parts/organs
Fluid build-up causes congestion in the Fluid build-up causes congestion in the organs seen as edemaorgans seen as edema
May be brought on by diseased heart May be brought on by diseased heart valves, hypertension, or some form of valves, hypertension, or some form of obstructive pulmonary diseaseobstructive pulmonary disease
Often a complication of AMIOften a complication of AMI
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Fluid build-up in CHF may be Fluid build-up in CHF may be pulmonary, peripheral, sacral, or ascitespulmonary, peripheral, sacral, or ascites
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Understanding CHFUnderstanding CHF
A failure of the pumping action of the heartA failure of the pumping action of the heart
Heart is a 2 sided pumpHeart is a 2 sided pump Right side of heart is a low pressure Right side of heart is a low pressure
systemsystem Left side of heart is a high pressure Left side of heart is a high pressure
systemsystem
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Heart as a PumpHeart as a Pump
Left side of heart muscular Left side of heart muscular Needs to overcome pressure in the arteries to Needs to overcome pressure in the arteries to
push/pump blood push/pump blood Pumps blood flow to the bodyPumps blood flow to the body
Right side of heart less muscularRight side of heart less muscular Pumps blood to the lungsPumps blood to the lungs
• Does not need to be a very aggressive Does not need to be a very aggressive pump with a lot of forcepump with a lot of force
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Starling’s LawStarling’s Law
The more the myocardial muscle is The more the myocardial muscle is stretched, the greater the force of stretched, the greater the force of contraction (the greater the recoil)contraction (the greater the recoil) Greater the preload (amount of blood Greater the preload (amount of blood
returned to the right heart), the farther the returned to the right heart), the farther the myocardium is stretched and the more myocardium is stretched and the more forceful a contraction that results leading to forceful a contraction that results leading to an increased cardiac outputan increased cardiac output
When Starling’s Law fails, the patient is When Starling’s Law fails, the patient is no longer able to compensateno longer able to compensate
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HypertensionHypertension
B/P is a measurement B/P is a measurement of force against the wall of the of force against the wall of the arteries arteries
When vessels stiffen due to calcium build-When vessels stiffen due to calcium build-up (arteriosclerosis) and plaque develops up (arteriosclerosis) and plaque develops (atherosclerosis), vessels are less (atherosclerosis), vessels are less compliantcompliant
Higher pressures are needed to pump Higher pressures are needed to pump blood through stiffer vesselsblood through stiffer vessels
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Right Ventricular FailureRight Ventricular Failure Failure of right ventricle as a forward pumpFailure of right ventricle as a forward pump Back pressure of blood into systemic Back pressure of blood into systemic
venous circulation systemvenous circulation system Common causesCommon causes
Left ventricular failure (AMI)Left ventricular failure (AMI) Systemic hypertensionSystemic hypertension Pulmonary hypertensionPulmonary hypertension Cor pulmonale – heart disease Cor pulmonale – heart disease
due to pulmonary disease due to pulmonary disease (ie; effects of COPD) (ie; effects of COPD)
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Progression of Right Heart FailureProgression of Right Heart Failure
Right ventricle cannot eject all of the blood Right ventricle cannot eject all of the blood outout Fluid/pressure builds upFluid/pressure builds up
• In right atriumIn right atriumBacks up into the venous systemBacks up into the venous system
Results in pedal/dependentResults in pedal/dependent edemaedema Visible as JVDVisible as JVD
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Right Right Sided Sided Heart Heart
Failure -Failure -
A A Systemic Systemic PicturePicture
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Left Ventricular FailureLeft Ventricular Failure Failure of left ventricle to function as a forward Failure of left ventricle to function as a forward
pumppump Back pressure of blood into pulmonary circulationBack pressure of blood into pulmonary circulation
Often causes pulmonary edemaOften causes pulmonary edema Common causesCommon causes
Various types of heart disease Various types of heart disease • Ischemia / acute MIIschemia / acute MI• Coronary artery disease Coronary artery disease
(CAD)-arteriosclerosis/atherosclerosis(CAD)-arteriosclerosis/atherosclerosis• Valve diseaseValve disease• Chronic hypertension - Chronic hypertension - afterload afterload• DysrhythmiasDysrhythmias
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Progression of Progression of Left Ventricular FailureLeft Ventricular Failure
Left ventricle cannot eject all the blood Left ventricle cannot eject all the blood delivered from the right heart via the delivered from the right heart via the lungslungs
Left atrial pressure rises and transmitted Left atrial pressure rises and transmitted to pulmonary veins and capillariesto pulmonary veins and capillaries
These high pressures force blood plasma These high pressures force blood plasma into alveoli (ie: pulmonary edema)into alveoli (ie: pulmonary edema)
Oxygen capacity of lungs reduced Oxygen capacity of lungs reduced Hypoxia developsHypoxia develops Acidosis developsAcidosis develops
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Pulmonary Pulmonary EdemaEdema
Severest form Severest form of congestive of congestive heart failureheart failure Left ventricular forward failureLeft ventricular forward failure
Think Think lleft/eft/llungsungs Patient develops respiratory distress due to Patient develops respiratory distress due to
fluid in the lungsfluid in the lungs Note: Note: extremelyextremely rare to have unilateral pulmonary rare to have unilateral pulmonary
edema; then related to unusual pathology/med hxedema; then related to unusual pathology/med hx
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Pathophysiological Changes in Pathophysiological Changes in Pulmonary EdemaPulmonary Edema
Left ventricle cannot empty effectivelyLeft ventricle cannot empty effectively Fluid moves from capillary beds into Fluid moves from capillary beds into
surrounding interstitial tissue surrounding interstitial tissue alveoli alveoli Fluid in alveoli impedes oxygen exchangeFluid in alveoli impedes oxygen exchange
Surfactant lining alveoli washes outSurfactant lining alveoli washes out Alveoli stiffenAlveoli stiffen Alveoli collapse after each breath and are harder to Alveoli collapse after each breath and are harder to
openopen Lungs develop Lungs develop compliance, airflow compliance, airflow
obstruction, hyperinflationobstruction, hyperinflation to workload of breathingto workload of breathing
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Symptoms of CHFSymptoms of CHF
In the more chronic setting of In the more chronic setting of right heart right heart failurefailure, symptoms usually related to , symptoms usually related to excess fluids in organs and other body excess fluids in organs and other body partsparts
In the more acute In the more acute left heart failureleft heart failure, , symptoms usually related to excess fluid in symptoms usually related to excess fluid in the lungs and therefore respiratory the lungs and therefore respiratory distressdistress
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Signs and Symptoms Signs and Symptoms Right Heart FailureRight Heart Failure
Dependent edemaDependent edema Peripheral edemaPeripheral edema HepatomegalyHepatomegaly SplenomegalySplenomegaly Jugular vein Jugular vein
distension (JVD)distension (JVD) AscitesAscites Weight gainWeight gain
DysrhythmiasDysrhythmias Nausea/vomitingNausea/vomiting FatigueFatigue DizzinessDizziness Syncopal episodesSyncopal episodes WeaknessWeakness
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Signs and Symptoms Signs and Symptoms Left Heart FailureLeft Heart Failure
Shortness of breathShortness of breath DyspneaDyspnea OrthopneaOrthopnea CracklesCrackles WheezingWheezing HypoxiaHypoxia Respiratory acidosisRespiratory acidosis Chest painChest pain
SweatingSweating Productive coughProductive cough Blood tinged sputumBlood tinged sputum CyanosisCyanosis PalpitationsPalpitations DysrhythmiasDysrhythmias HypertensionHypertension Anxiety/restlessnessAnxiety/restlessness
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Typical medical history pattern of Typical medical history pattern of patient with CHFpatient with CHF
HypertensionHypertension Cardiovascular Cardiovascular
disease (CVD)disease (CVD) Myocardial infarction Myocardial infarction
(MI)(MI) Coronary artery Coronary artery
disease (CAD)disease (CAD) ArteriosclerosisArteriosclerosis AtherosclerosisAtherosclerosis
SmokerSmoker Excessive alcohol or Excessive alcohol or
drug usedrug use CocaineCocaine MethamphetamineMethamphetamine Inhaled solventsInhaled solvents PCPPCP
Dietary intake excess Dietary intake excess fluids, excess saltfluids, excess salt
High cholesterolHigh cholesterol
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Typical home medication history Typical home medication history pattern of patient with CHFpattern of patient with CHF
DiureticDiuretic Digoxin Digoxin
contractility force of the contractility force of the heart (inotropic)heart (inotropic)
Home oxygen therapyHome oxygen therapy Anti-hypertensiveAnti-hypertensive
ACE inhibitors (end in “pril”)ACE inhibitors (end in “pril”) Beta blockersBeta blockers
heart rate & force of heart rate & force of contractions contractions B/P B/P
• Often end in “olol”Often end in “olol”
Calcium channel Calcium channel inhibitorsinhibitors• Slows movement of Slows movement of
calcium into small calcium into small muscles wrapped muscles wrapped around blood around blood vessels relaxing vessels relaxing blood vesselsblood vessels
peripheral peripheral vascular resistance vascular resistance relaxing blood relaxing blood vesselsvessels
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Herbal remedies that may be harmful Herbal remedies that may be harmful when mixed with heart failurewhen mixed with heart failure
St. John’s wortSt. John’s wort EphedraEphedra Gingko bilobaGingko biloba KavaKava LicoriceLicorice GinsengGinseng AconiteAconite
Alisma plantagoAlisma plantago Bearberry buchuBearberry buchu Couch grassCouch grass DandelionDandelion Horsetail rushHorsetail rush JuniperJuniper
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EvaluationEvaluation CHF/PECHF/PE PneumoniaPneumonia COPDCOPD
HistoryHistory HTN, heart HTN, heart problemsproblems
n/an/a Lung problemsLung problems
DyspneaDyspnea Orthopnea, Orthopnea, PNDPND
Orthopnea Orthopnea possiblepossible
Chronic; Chronic; pursed lipspursed lips
Recent hxRecent hx Acute weight Acute weight gain, dependent gain, dependent edemaedema
Fever, malaiseFever, malaise Gradual Gradual weight lossweight loss
CoughCough Frothy Frothy sputumsputum
Productive thick Productive thick greengreen
Chronic; Chronic; productiveproductive
OnsetOnset RapidRapid GradualGradual GradualGradual
B/PB/P HighHigh NormalNormal NormalNormal
MedsMeds Dig, anti-HTN, Dig, anti-HTN, diureticdiuretic
Antibiotic, cold prepAntibiotic, cold prep BronchodilatorsBronchodilators, , steroidssteroids
TxTx OO22, NTG, , NTG,
lasix, MSlasix, MSOO22, neb, fluids, neb, fluids OO22, neb, neb
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Separating Signs/SymptomsSeparating Signs/SymptomsSymptomSymptom CHF/PECHF/PE PneumoniaPneumonia COPDCOPD
SOBSOB YesYes YesYes YesYes
CoughCough MaybeMaybe YesYes Early a.m.Early a.m.
SputumSputum Frothy pinkFrothy pink Yellow/greenYellow/green Thick brownThick brown
FeverFever NoNo YesYes NoNo
SkinSkin Cold/clammyCold/clammy Hot/dryHot/dry Normal or duskyNormal or dusky
Chest painChest pain PossiblePossible MaybeMaybe NoNo
Smoking hxSmoking hx PossiblePossible PossiblePossible UsuallyUsually
WheezingWheezing Maybe; Maybe; bilateralbilateral
Maybe; Maybe; same same side as diseaseside as disease
Usually, Usually, bilateralbilateral
CracklesCrackles Yes; bilateralYes; bilateral Maybe; Maybe; same same side as diseaseside as disease
NoNo
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A Note…A Note…
““Old geezers don’t become new Old geezers don’t become new wheezers!”wheezers!”
COPD develops over a long period of time. If COPD develops over a long period of time. If an elderly person does not have a history of an elderly person does not have a history of COPD and they are suddenly wheezing, think a COPD and they are suddenly wheezing, think a cardiac problem or pulmonary edema.cardiac problem or pulmonary edema.
Assume the worst, Assume the worst, hope for the besthope for the best
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Patient Assessment - CHFPatient Assessment - CHF
Acute findingsAcute findings Recent trouble sleepingRecent trouble sleeping
trips to the bathroom at nighttrips to the bathroom at night• Orthopnea with Orthopnea with number of pillows number of pillows• Sleeping in the reclinerSleeping in the recliner• New episodes of paroxysmal nocturnal New episodes of paroxysmal nocturnal
dyspnea (PND)dyspnea (PND) use of nitroglycerin to stop chest painuse of nitroglycerin to stop chest pain use of oxygen use of oxygen
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Patient Assessment - CHFPatient Assessment - CHF General impressionGeneral impression
Labored respirationsLabored respirations Audible noisy respirationsAudible noisy respirations Tripod positioningTripod positioning Frothy sputum productionFrothy sputum production work of breathing – retractions, tachypneawork of breathing – retractions, tachypnea Wheezing/crackles bilaterallyWheezing/crackles bilaterally DiaphoreticDiaphoretic Change in skin color from normChange in skin color from norm Severe anxiety/restlessnessSevere anxiety/restlessness Severe hypertension may be presentSevere hypertension may be present
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Patient Assessment - CHFPatient Assessment - CHF Signs and symptoms pulmonary edemaSigns and symptoms pulmonary edema
TachypneaTachypnea OrthopneaOrthopnea PNDPND Noisy labored respirationsNoisy labored respirations Fine crackles/ralesFine crackles/rales Wheezing – “cardiac asthma”Wheezing – “cardiac asthma” Coarse crackles/rhonchi larger airwaysCoarse crackles/rhonchi larger airways Coughing with frothy blood tinged sputumCoughing with frothy blood tinged sputum
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Obtaining Breath SoundsObtaining Breath Sounds Use flat diaphragm surface of stethoscopeUse flat diaphragm surface of stethoscope Rub stethoscope head between hands to Rub stethoscope head between hands to
warm it up before placing on patient’s skinwarm it up before placing on patient’s skin If audible sounds are heard, ask patient to If audible sounds are heard, ask patient to
cough gently to clear upper airwaycough gently to clear upper airway Auscultate side to side and top to bottomAuscultate side to side and top to bottom Anterior: Posterior:Anterior: Posterior:
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Adventitious (Extra) Breath Adventitious (Extra) Breath SoundsSounds
Check for asymmetryCheck for asymmetry Crackles: high pitched, continuous sounds Crackles: high pitched, continuous sounds
like rubbing hair between fingerslike rubbing hair between fingers Wheezes: generally high pitched, of musical Wheezes: generally high pitched, of musical
qualityquality Stridor: Harsh inspiratory wheeze indicating Stridor: Harsh inspiratory wheeze indicating
upper airway obstruction upper airway obstruction Rhonchi: snoring or gurgling qualityRhonchi: snoring or gurgling quality
Any extra sound not a crackle or wheeze Any extra sound not a crackle or wheeze is usually rhonchi is usually rhonchi
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Decision Making –What to Do?Decision Making –What to Do? Use critical thinking skillsUse critical thinking skills Decide if patient is sick or notDecide if patient is sick or not Obtain current and past historyObtain current and past history Obtain vital signsObtain vital signs LookLook
Skin (wet/dry; color; temp)Skin (wet/dry; color; temp) JVD present or notJVD present or not Peripheral / dependent edema presentPeripheral / dependent edema present Subtle signsSubtle signs
ListenListen Breath soundsBreath sounds
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Making the Right DecisionMaking the Right Decision
Does the medical history include Does the medical history include cardiovascular disease?cardiovascular disease?
Does the physical examination/patient Does the physical examination/patient assessment paint a picture of CHF?assessment paint a picture of CHF?
Use critical thinking skillsUse critical thinking skills Not treating pulmonary edema means the Not treating pulmonary edema means the
body becomes more hypoxic and acidoticbody becomes more hypoxic and acidotic Miss diagnosis (ie: pneumonia) could prove Miss diagnosis (ie: pneumonia) could prove
lethallethal This patient will arrest This patient will arrest
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Treatment Goals for CHFTreatment Goals for CHF
Decrease myocardial workloadDecrease myocardial workload Decrease oxygen demandDecrease oxygen demand Decrease fluid retentionDecrease fluid retention Correct hypoxiaCorrect hypoxia Correct acidosisCorrect acidosis
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Treating CHF/Pulmonary Treating CHF/Pulmonary EdemaEdema
Decrease myocardial workloadDecrease myocardial workload No physical activity (they don’t walk to the No physical activity (they don’t walk to the
rig)rig) Sitting the patient upright; dangle feetSitting the patient upright; dangle feet Administering oxygen – non-rebreatherAdministering oxygen – non-rebreather CPAP to increase oxygen absorption CPAP to increase oxygen absorption
surface of lungssurface of lungs Medications to Medications to preload and afterload preload and afterload
NitroglycerinNitroglycerinMorphineMorphineLasix – additionally works as diureticLasix – additionally works as diuretic
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Treatment Goals for PneumoniaTreatment Goals for Pneumonia
Supply supplemental oxygen as neededSupply supplemental oxygen as needed Treat the bacterial infectionTreat the bacterial infection Hydrate the patientHydrate the patient
• Usually found in the elderlyUsually found in the elderly• Often vague symptoms; use to feeling illOften vague symptoms; use to feeling ill• Immune system often already weakened Immune system often already weakened
so mortality rate is high with this diagnosisso mortality rate is high with this diagnosis
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Region X SOP- Acute Region X SOP- Acute Pulmonary EdemaPulmonary Edema
Begin Routine Medical CareBegin Routine Medical Care Take standard precautionsTake standard precautions Perform assessmentsPerform assessments Identify priority patient and make transport Identify priority patient and make transport
decisionsdecisions• Stay and play?Stay and play?• Load N go?Load N go?
Perform routine tasksPerform routine tasks• IV-OIV-O22-monitor-monitor
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What About the IV and What About the IV and Nitroglycerin?Nitroglycerin?
Region X Medical Directors discussion:Region X Medical Directors discussion: Majority of patients in pulmonary edema will be Majority of patients in pulmonary edema will be
hypertensivehypertensive Nitroglycerin will help reduce preload which will Nitroglycerin will help reduce preload which will
lower blood pressure (beneficial)lower blood pressure (beneficial) Do not delay NTG dose, if no contraindications, Do not delay NTG dose, if no contraindications,
to start the IVto start the IV• If patient deteriorates before IV established, If patient deteriorates before IV established,
can always place an IOcan always place an IO
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Region X SOP- Acute Region X SOP- Acute Pulmonary EdemaPulmonary Edema
Determine if the patient is Determine if the patient is stablestable or or unstableunstable Stability guided by status of perfusion Stability guided by status of perfusion
B/P and level of consciousnessB/P and level of consciousness If stable, the patient can receive more If stable, the patient can receive more
aggressive care including medications and aggressive care including medications and procedures (ie: CPAP)procedures (ie: CPAP)
If unstable, Medical Control needs to If unstable, Medical Control needs to coordinate degree of care provided in the coordinate degree of care provided in the field (ie: meds and CPAP)field (ie: meds and CPAP)
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Region X SOP- Acute Region X SOP- Acute Pulmonary Edema - StablePulmonary Edema - Stable
NitroglycerinNitroglycerin Nitrate vasodilatorNitrate vasodilator Decreases myocardial workloadDecreases myocardial workload
• Dilates arterial and venous systemsDilates arterial and venous systems preloadpreload afterloadafterload
Carefully monitor blood pressureCarefully monitor blood pressure Screen for concomitant use of sexual Screen for concomitant use of sexual
enhancement drugenhancement drug• Viagra or Levitra in last 24 hoursViagra or Levitra in last 24 hours• Cialis in past 48 hoursCialis in past 48 hours
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Stable Pulmonary Edema SOPStable Pulmonary Edema SOP
LasixLasix Loop diureticLoop diuretic Moves sodium (NAMoves sodium (NA++) out of blood vessels) out of blood vessels
• Water follows sodiumWater follows sodium• Potassium (KPotassium (K++) also pulled out) also pulled out
Vasodilation effects within 5 minutesVasodilation effects within 5 minutes• Decreases preloadDecreases preload
Diuresis within 20-30 minutesDiuresis within 20-30 minutes Peaks within 30 minutesPeaks within 30 minutes
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Stable Pulmonary Edema SOPStable Pulmonary Edema SOP
Morphine sulfateMorphine sulfate Narcotic analgesicNarcotic analgesic
• Reduces anxietyReduces anxiety Dilates venous and arterial systemsDilates venous and arterial systems
preloadpreload afterloadafterload blood pressureblood pressure
Stimulates nausea center in the brainStimulates nausea center in the brain Slows respiratory rate in medullaSlows respiratory rate in medulla
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Region X SOP – Pulmonary Edema Region X SOP – Pulmonary Edema Medication RegimenMedication Regimen
Stable patientStable patient Nitroglycerin 0.4 mg slNitroglycerin 0.4 mg sl
• One every 3-5 minutes to max dose of 3One every 3-5 minutes to max dose of 3 Begin CPAPBegin CPAP Lasix 40 mg IVP (80 mg if taken at home)Lasix 40 mg IVP (80 mg if taken at home) Morphine 2 mg IVP slow over 2 minutesMorphine 2 mg IVP slow over 2 minutes
• May repeat 2 mg every 2 minutes to max of 10mgMay repeat 2 mg every 2 minutes to max of 10mg If wheezing, contact Medical Control for If wheezing, contact Medical Control for
possible Albuterol neb treatmentpossible Albuterol neb treatment
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CPAPCPAP
CContinuous ontinuous ppositive ositive aairway irway ppressureressure Delivered throughout the respiratory cycleDelivered throughout the respiratory cycle
Noninvasive ventilatory supportNoninvasive ventilatory support Most beneficial when initiated earlyMost beneficial when initiated early Maintains airway in open positionMaintains airway in open position intrathoracic pressure which intrathoracic pressure which venous venous
return to the heartreturn to the heart Preload and afterload both decrease Preload and afterload both decrease
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Benefits of Benefits of CPAPCPAP
Increases amount of inspired oxygenIncreases amount of inspired oxygen Decreases work load of breathingDecreases work load of breathing Reduces need for intubationReduces need for intubation
Intubation requires ICCU stayIntubation requires ICCU stay
• Increased exposure to risks associated Increased exposure to risks associated with complications due to intubationwith complications due to intubation
• Increases overall hospital length of stayIncreases overall hospital length of stay
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Redistribution of extravascular lung Redistribution of extravascular lung water during use of CPAPwater during use of CPAP
Without CPAP With CPAPWithout CPAP With CPAP
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Indications for CPAPIndications for CPAP
Patient in acute pulmonary edema with Patient in acute pulmonary edema with stable blood pressurestable blood pressure Stable B/P = >100mmHg systolicStable B/P = >100mmHg systolic
FYI – with revised 2011 SOP’s, blood FYI – with revised 2011 SOP’s, blood pressure levels will be shifting to systolic pressure levels will be shifting to systolic of 90 as a consistent guideline throughout of 90 as a consistent guideline throughout the SOP’sthe SOP’s
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Contraindications for CPAPContraindications for CPAP
Decreased or altered level of consciousnessDecreased or altered level of consciousness Inability of patient to protect their airway from Inability of patient to protect their airway from
aspirationaspiration Persistent nausea/vomitingPersistent nausea/vomiting Need for immediate intubationNeed for immediate intubation Hemodynamic instability (B/P<100)Hemodynamic instability (B/P<100)
Note: B/P guideline will be changing to <90 with Note: B/P guideline will be changing to <90 with revised 2011 SOPrevised 2011 SOP
Penetrating chest traumaPenetrating chest trauma
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Medications Simultaneous With Medications Simultaneous With CPAPCPAP
Medications should be started Medications should be started NTG slNTG sl
Then begin CPAP Then begin CPAP Then continue medication administration as indicatedThen continue medication administration as indicated
Lasix – 40mg or 80mg IVPLasix – 40mg or 80mg IVP Morphine – 2 mg IVP repeated every 2 minMorphine – 2 mg IVP repeated every 2 min
CPAP will buy time for the medications to workCPAP will buy time for the medications to work
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Did you know…Did you know…
It is not It is not either / oreither / or (CPAP or meds)(CPAP or meds)
CPAP works CPAP works WITHWITH medications medications in tandemin tandem
Lift the mask to continue administration of Lift the mask to continue administration of more NTGmore NTG
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CPAP EquipmentCPAP Equipment
Fixed whisper Fixed whisper flowflow Connects to Connects to
your oxygen your oxygen sourcesource
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OO22 Tank Duration Tank Duration
Approximate time at 30% FIOApproximate time at 30% FIO22
D tankD tank 30 min. 30 min.
E tankE tank 50 min. 50 min.
M tankM tank 253 min.253 min.
H tankH tank 508 min.508 min.*based on 50 psi output*based on 50 psi output
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CPAP CPAP CircuitCircuitSet-upSet-up
Package Package includes: includes:
Mask Mask TubingTubingHead Head strapstrapCPAP CPAP valvevalveAirAirentrainmententrainment filterfilter
Filter
CPAPvalve
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Most patients need a lot of coaching to Most patients need a lot of coaching to initially tolerate the tight fitting maskinitially tolerate the tight fitting mask
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If The Patient is WheezingIf The Patient is Wheezing Contact Medical Control to consider an Contact Medical Control to consider an
order for Albuterol via nebulizerorder for Albuterol via nebulizer Medical Control needs to give this Medical Control needs to give this
physician’s orderphysician’s order Contact ECRN on radio Contact ECRN on radio
• Needs to give the ED MD a report Needs to give the ED MD a report • Obtains MD’s order Obtains MD’s order • Relays the response to EMSRelays the response to EMS
If Albuterol is given, monitor for cardiac If Albuterol is given, monitor for cardiac side effects (ie: tachycardia)side effects (ie: tachycardia)
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In-line Albuterol Set-up with In-line Albuterol Set-up with CPAPCPAP
Cut the CPAP corrugated tubing as close to patient Cut the CPAP corrugated tubing as close to patient as possible in smooth area of tubingas possible in smooth area of tubing
Splice Albuterol kit T piece in-lineSplice Albuterol kit T piece in-line Remove the mouthpiece and place the adaptor (used for Remove the mouthpiece and place the adaptor (used for
in-line Albuterol)in-line Albuterol) Connect adaptor to distal cut end of corrugated CPAP Connect adaptor to distal cut end of corrugated CPAP
tubingtubing Remove Albuterol corrugated tubing and connect Remove Albuterol corrugated tubing and connect
proximal end of CPAP tubing to T piece of Albuterolproximal end of CPAP tubing to T piece of Albuterol Keep Albuterol cup uprightKeep Albuterol cup upright Albuterol kit still needs to be hooked to OAlbuterol kit still needs to be hooked to O22
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CPAP With In-line Albuterol Set-upCPAP With In-line Albuterol Set-up
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Criteria to Discontinue CPAPCriteria to Discontinue CPAP
Development of hemodynamic instabilityDevelopment of hemodynamic instability B/P drops below 100 systolicB/P drops below 100 systolic
• Revised 2011 SOP B/P level will be 90 systolicRevised 2011 SOP B/P level will be 90 systolic
Inability of patient to tolerate tight fitting Inability of patient to tolerate tight fitting maskmask
Emergent need to intubate the patientEmergent need to intubate the patient
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Patient Monitoring During Use Patient Monitoring During Use of CPAPof CPAP
Constant reassessment required:Constant reassessment required: Patient tolerancePatient tolerance Mental statusMental status Respiratory patternRespiratory pattern
Rate, depth, subjective feeling of Rate, depth, subjective feeling of improvementimprovement
Blood pressure, pulse, SaOBlood pressure, pulse, SaO22, EKG rhythm, EKG rhythm ComplicationsComplications
Gastric distension, nausea, vomitingGastric distension, nausea, vomiting
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Monitoring Improvement With Monitoring Improvement With CPAPCPAP
It’s working when:It’s working when: Level of distress decreasesLevel of distress decreases Respiratory rate is returning toward normalRespiratory rate is returning toward normal Pulse oximetry (SaOPulse oximetry (SaO22) increasing) increasing Pulse rate decreasing toward normalPulse rate decreasing toward normal Decrease in use of accessory musclesDecrease in use of accessory muscles Ability to speak in fuller sentences returningAbility to speak in fuller sentences returning
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Contacting Medical ControlContacting Medical Control
Remember:Remember: Early communication with receiving Early communication with receiving
hospitalhospital Hospital needs to get their regulator for Hospital needs to get their regulator for
oxygen source connectionoxygen source connection
• Usually not kept in each roomUsually not kept in each room
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Documentation With CPAPDocumentation With CPAP
Assessment leading your general Assessment leading your general impression to a diagnosis of pulmonary impression to a diagnosis of pulmonary edemaedema
CPAP level provided (10cmHCPAP level provided (10cmH22O)O) FiOFiO22 provided (100%) provided (100%) SaOSaO22 serial levels serial levels Vital signs over timeVital signs over time Response to treatmentResponse to treatment Any adverse reactions notedAny adverse reactions noted
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So, What’s Different About BiPAP?So, What’s Different About BiPAP?
BiBi-level -level ppositive ositive aairway irway ppressureressure Uses 2 levels of pressureUses 2 levels of pressure
Helps move more air into lungs without need Helps move more air into lungs without need to exhale against higher pressuresto exhale against higher pressures
CPAP is a larger & noisier machineCPAP is a larger & noisier machine Uses extra effort to exhale and can be tiringUses extra effort to exhale and can be tiring
Both can be used for sleep apneaBoth can be used for sleep apnea BiPAP easier on those with COPD and BiPAP easier on those with COPD and
neuromuscular diseasesneuromuscular diseases
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Case ScenariosCase ScenariosSmall Group and Large Group Small Group and Large Group
DiscussionsDiscussions Read the presentationRead the presentation Form a general impressionForm a general impression Discuss treatment optionsDiscuss treatment options Discuss what/how/when to reassess the Discuss what/how/when to reassess the
patientpatient Decide what treatment to continue or what Decide what treatment to continue or what
adjustments need to be madeadjustments need to be made Note: Additional questions are asked on ppt that can be Note: Additional questions are asked on ppt that can be
discussed during group presentations.discussed during group presentations.
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Case Scenario #1Case Scenario #1
Dispatch: You are called to a 70 y/o man c/o breathing problems
HPI: Increasing shortness of breath for 1 day despite the use of inhalers
PmHx: COPD, Hypertension, and Diabetes Medications: Albuterol Inhaler, Lasix, and
Aspirin Allergies: Penicillin
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Case Scenario #1Case Scenario #1
Physical Exam: Thin white man on home oxygen breathing through pursed lips sitting in a tripod position
Vital Signs: B/P 180/90; HR 120 sinus tachycardia; RR 30; SaO2 88%; LOC alert; airway patent
Head & neck: Perioral cyanosis, no JVD Pulmonary: Lung auscultation reveals
inspiratory and expiratory wheezes Extremities: Cyanotic, no pedal edema
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Case Scenario #1Case Scenario #1
What is your general impression?What is your general impression? Are assessment findings stronger for Are assessment findings stronger for
exacerbation of COPD or for acute exacerbation of COPD or for acute pulmonary edema?pulmonary edema?
COPD supportedCOPD supported HistoryHistory AppearanceAppearance Lung soundsLung sounds
What treatment is indicated?What treatment is indicated?
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Case Scenario #1Case Scenario #1
IV – O2, monitor
Albuterol nebulizer started:
• 5 min Vital Signs: B/P 160/90; HR 130; RR 24; SaO2 92%, LOC Alert; lung sounds unchanged
• 10 min Vital Signs: B/P 120/90; HR 120, RR, 24, SaO2 92%, LOC Alert; lung sounds less prominent wheezing; subjectively patient breathing easier
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Case Scenario #2 Case Scenario #2
Dispatch: 65 y/o woman c/o of shortness of breath
HPI: 1 week history of progressive dyspnea with exertion. Unable to lay down flat without shortness of breath, no chest pain or cough
PmHx: Hypertension, Diabetes Medications: Lasix, Atenolol, and
Glucaphage
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Case Scenario #2Case Scenario #2
Physical Exam: 260 lb woman sitting in recliner.
Vital Signs: B/P 160/80; HR 140 sinus tachycardia; RR 30; SaO2 78%, LOC follows commands; airway patent
Head & neck: Cyanosis, JVD present Pulmonary: Crackles in all lung fields Extremities: Cyanotic, 3+ pedal edema
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Case Scenario #2Case Scenario #2
What is your general impression?What is your general impression? Are assessment findings stronger for Are assessment findings stronger for
exacerbation of COPD or for acute pulmonary exacerbation of COPD or for acute pulmonary edema?edema?
Pulmonary edema supportedPulmonary edema supported HistoryHistory AppearanceAppearance Lung soundsLung sounds
What treatment is indicated?What treatment is indicated?
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Case Scenario #2Case Scenario #2
Need to move rapidlyNeed to move rapidly Minimize scene time as much as possibleMinimize scene time as much as possible
IV-OIV-O22-monitor-monitor Start nonrebreather until switched to CPAPStart nonrebreather until switched to CPAP Consider AMI so obtain 12 lead EKGConsider AMI so obtain 12 lead EKG
Any contraindications to treatment?Any contraindications to treatment? Nitroglycerin?Nitroglycerin? CPAP?CPAP? Lasix?Lasix? Morphine?Morphine?
NO
NO
NO
NO
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Case Scenario #2Case Scenario #2
After CPAP started:
5 min Vital Signs: B/P 100/60; HR 100; RR 24; SaO2 84%; LOC: responds to verbal stimuli
10 min Vital Signs: B/P 60/40; HR 30; RR 6; SaO2 60%; LOC unresponsive
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Case Scenario #2Case Scenario #2
What is your general impression now?What is your general impression now? Patient is deterioratingPatient is deteriorating
What is your treatment now?What is your treatment now? CPAP needs to be discontinuedCPAP needs to be discontinued Patient needs to be bagged and intubatedPatient needs to be bagged and intubated
• One breath every 5-6 seconds before intubationOne breath every 5-6 seconds before intubation• One breath every 6-8 seconds after intubationOne breath every 6-8 seconds after intubation
Hold further repeats of medications usedHold further repeats of medications used Consider need for dopamine infusionConsider need for dopamine infusion
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Case Scenario #3 DocumentationCase Scenario #3 Documentation
Initial impression was acute pulmonary edemaInitial impression was acute pulmonary edema Based on physical assessment; history; Based on physical assessment; history;
recent hospitalization for CHFrecent hospitalization for CHF Treatment was routine medical careTreatment was routine medical care
IV – OIV – O22 non-rebreather- monitor non-rebreather- monitor CPAP started after ordered by Medical CPAP started after ordered by Medical
ControlControl 2 sets of vital signs documented2 sets of vital signs documented
Initial vital signs (B/P 170/98 – 92 – 32)Initial vital signs (B/P 170/98 – 92 – 32) Second reading at the hospital Second reading at the hospital
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Case Scenario #3 Comments Case Scenario #3 Comments DocumentedDocumented
Upon arrival patient found sitting upright, Upon arrival patient found sitting upright, agitated, complaining of chest pain and agitated, complaining of chest pain and difficulty breathing. Audible congested difficulty breathing. Audible congested breathing standing next to patient. Unable to breathing standing next to patient. Unable to complete a full sentence. Bilateral pedal edema complete a full sentence. Bilateral pedal edema noted. Began oxygen via nonrebreather. IV noted. Began oxygen via nonrebreather. IV started. Moved patient to ambulance. Medical started. Moved patient to ambulance. Medical Control contacted and ordered CPAP to be Control contacted and ordered CPAP to be started. Patient becoming more agitated. After started. Patient becoming more agitated. After 5 minutes, SaO5 minutes, SaO22 increasing. Patient stated increasing. Patient stated breathing was becoming easier.breathing was becoming easier.
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Case Scenario #3 Documentation Case Scenario #3 Documentation cont’dcont’d
Patient transported sitting upright. Patient transported sitting upright. Continued CPAP during entire call. Continued CPAP during entire call. Transported patient into ED on portable OTransported patient into ED on portable O22
with CPAP continued.with CPAP continued.
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Case Scenario #3 Documentation Case Scenario #3 Documentation cont’dcont’d
Pt contact: 0954Pt contact: 0954 Depart scene: 1025Depart scene: 1025 ““Drugs”Drugs”
0959 - Oxygen - 15 l – non-rebreather0959 - Oxygen - 15 l – non-rebreather 1001 – 0.9 NS 1000ml – TKO – IV1001 – 0.9 NS 1000ml – TKO – IV 1005 – CPAP /oxygen – 15l – CPAP mask1005 – CPAP /oxygen – 15l – CPAP mask
““`Cardiac rhythm”`Cardiac rhythm” 0958 – sinus0958 – sinus 1035 - sinus 1035 - sinus
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Case Scenario #3 Documentation Case Scenario #3 Documentation DiscussionDiscussion
What went well?What went well? Recognized pulmonary edemaRecognized pulmonary edema CPAP used with positive patient CPAP used with positive patient
responseresponse
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Case Scenario #3 Documentation Case Scenario #3 Documentation DiscussionDiscussion
What could be improved upon?What could be improved upon? Long on-scene time (0954 – 1025 -31 mins)Long on-scene time (0954 – 1025 -31 mins) Delay in initiating ODelay in initiating O22 therapy – 5 minutes therapy – 5 minutes Waited for MC to order CPAP – 11 min delayWaited for MC to order CPAP – 11 min delay
• No Medical Control direction needed to initiateNo Medical Control direction needed to initiate No other meds given for pulmonary edemaNo other meds given for pulmonary edema Only 2 sets of vital signs taken on a critical Only 2 sets of vital signs taken on a critical
patientpatient
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Case Scenario #4Case Scenario #4
Dispatch: You are called to a 84 year-old female c/o breathing problems
HPI: Running low grade fevers, not feeling well for 4 days
PmHx: MI, Hypertension, TIA’s Medications: Plavix, Lasix, Lisinopril Allergies: Iodine, shellfish
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Case Scenario #4Case Scenario #4
Physical Exam: Vital Signs: B/P 142/80; HR 96 sinus
rhythm; RR 28; SaO2 92%, LOC follows commands; airway patent
Head & neck: Pale, no JVD Pulmonary: Crackles in right lower lung
field Extremities: Pale, pedal pulses palpable
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Case Scenario #4Case Scenario #4
What is your general impression?What is your general impression? Are assessment findings stronger for Are assessment findings stronger for
acute pulmonary edema or pneumonia?acute pulmonary edema or pneumonia? Pneumonia supported?Pneumonia supported?
HistoryHistory AppearanceAppearance Lung sounds not so helpfulLung sounds not so helpful
What treatment is indicated?What treatment is indicated?
8888
Case Scenario #4Case Scenario #4
What is your treatment now?What is your treatment now? IV-O2-monitorIV-O2-monitor Fluids Fluids
• Faster than keep open but not a fluid Faster than keep open but not a fluid challengechallenge
Diagnosis confirmed at the hospital with Diagnosis confirmed at the hospital with chest x-ray and labschest x-ray and labs
8989
Case Scenario #4Case Scenario #4
Patients with pneumonia need fluidsPatients with pneumonia need fluids Patients with congestive heart failure need Patients with congestive heart failure need
fluid restrictionsfluid restrictions A wrong diagnosis and therefore wrong A wrong diagnosis and therefore wrong
treatment approach could be harmful for treatment approach could be harmful for both patientsboth patients
9090
Case Scenario #5Case Scenario #5
Dispatch: You are called to a home for a 78 year-old male with severe SOB
HPI: Has been getting progressively SOB past 2 days; slept in recliner last night
PmHx: MI x3; hypertension, diverticulitis, seizures
Medications: Aspirin, Hydrodiuril, Verapamil, NTG PRN, Coumadin, Phenobarbital
Allergies: none
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Case Scenario #5Case Scenario #5
Physical Exam: Vital Signs: B/P 172/96; HR 110 sinus
tachycardia; RR 36; SaO2 88%, LOC follows commands; extremely anxious; airway patent
Head & neck: JVD Pulmonary: Crackles mid way up lung fields
bilaterally Extremities: Cyanotic, pedal edema palpable
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Case Scenario #5Case Scenario #5
What is your general impression?What is your general impression? What is your treatment plan?What is your treatment plan? Write a run report Write a run report
Include initial assessmentInclude initial assessment Document treatment interventions indicatedDocument treatment interventions indicated Document reassessment performedDocument reassessment performed
Discuss as a group what needs to be Discuss as a group what needs to be includedincluded
9393
9494
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BibliographyBibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care: Principles and Practices. Brady. 2009.Care: Principles and Practices. Brady. 2009. Limmer, D., O’Keefe, M. Emergency Care, 10Limmer, D., O’Keefe, M. Emergency Care, 10 thth
Edition. Brady. 2005.Edition. Brady. 2005. Region X SOP’s March 2007; Amended Region X SOP’s March 2007; Amended
January 1, 2008.January 1, 2008. http://whisperflow.respironics.com/http://whisperflow.respironics.com/ www.emsworld.comwww.emsworld.com Variety internet websites for CPAP and Variety internet websites for CPAP and
pulmonary edemapulmonary edema