April 2011 CE

Site code # 107200E-1211

The Patient With Heart Failure; CPAP as an Intervention

Prepared by:

Lt. Bill Hoover, Medical Officer Wauconda Fire District Reviewed/revised by Sharon Hopkins, RN, BSN, EMT-P

To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=352

Date of CE presentation: April 2011 Topic: Patient with CHF; Using CPAP Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to:

Define heart failure and congestive heart failure. Identify causes of heart failure. Identify symptoms of heart failure. Identify patterns of medical history related to the patient with heart failure. Identify current home medications typically taken by the patient with

congestive heat failure. Identify the difference between the patient with congestive heart failure

and pneumonia. Identify the assessment of the patient with congestive heart failure. Identify the proper procedure for assessing breath sounds. Identify treatment goals and options for congestive heart failure following

Region X SOP’s. Define CPAP as used by EMS for the patient with pulmonary edema. Describe how CPAP will benefit the patient with pulmonary edema. State indications, contraindications and medications used with CPAP. Describe the process of setting up the CPAP device. Describe the process of adding in-line Albuterol with CPAP. Describe patient assessment while delivery CPAP. State components to document when using CPAP. Demonstrate the set up of CPAP. Demonstrate the set-up of regular and in-line Albuterol. Demonstrate adding in-line Albuterol with CPAP. Actively participate in case scenario discussion. Successfully complete the post quiz with a score of 80% or better.

References:

2007 Condell Medical Center EMS System SOP’s

2008 Northwest Community EMSS SOP

www.WebMD.com

www.MayoClinic.com

www.eMedicineHealth.com

Advanced Medical Life Support, 3rd Ed., Brady

Flight for Life Pocketbook Guide, 2009 Ed.

Fluid build-up in CHF may be pulmonary, peripheral, sacral, or ascites

Right heart failure

Evaluation CHF/PE Pneumonia COPD

History HTN, heart

problems

n/a Lung problems

Dyspnea Orthopnea,

PND

Orthopnea possible Chronic; pursed

lips

Recent hx Acute weight

gain,

dependent

edema

Fever, malaise Gradual weight

loss

Cough Frothy sputum Productive thick

green

Chronic;

productive

Onset Rapid Gradual Gradual

B/P High Normal Normal

Meds Dig, anti-

HTN, diuretic

Antibiotic, cold prep Bronchodilators,

steroids

Tx O2, NTG,

lasix, MS

O2, neb, fluids O2, neb

Separating Signs and Symptoms

Symptom CHF/PE Pneumonia COPD

SOB Yes Yes Yes

Cough Maybe Yes Early a.m.

Sputum Frothy pink Yellow/green Thick brown

Fever No Yes No

Skin Cold/clammy Hot/dry Normal or dusky

Chest pain Possible Maybe No

Smoking hx Possible Possible Usually

Wheezing Maybe; bilateral Maybe; same side

as disease

Usually, bilateral

Crackles Yes; bilateral Maybe; same side

as disease

No

CPAP Set-up

Adding Albuterol In-line to CPAP

Cut the CPAP corrugated tubing as close to patient as possible in smooth

area of tubing

Splice Albuterol kit T piece in-line

Remove the mouthpiece and place the adaptor (used for

in-line Albuterol)

Connect adaptor to distal cut end of corrugated CPAP tubing

Remove Albuterol corrugated tubing and connect proximal end of

CPAP tubing to T piece of Albuterol

Keep Albuterol cup upright

Albuterol kit still needs to be hooked to O2

Case Scenarios

Small Group and Large Group Discussions

Read the presentation

Form a general impression

Discuss treatment options

Discuss what/how/when to reassess the patient

Decide what treatment to continue or what adjustments need to be made

Note: Additional questions are asked on power point that can be discussed

during group presentations.

Case 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

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

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

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

Case Scenario #3 – Documentation Review

Initial impression was acute pulmonary edema

Based on physical assessment; history; recent hospitalization for CHF

Treatment was routine medical care

IV – O2 non-rebreather- monitor

CPAP started after ordered by Medical Control

2 sets of vital signs and 2 cardiac rhythm interpretations documented

Initial vital signs (B/P 170/98 – 92 – 32); cardiac rhythm sinus

Second reading at the hospital; cardiac rhythm remained sinus

Upon arrival patient found sitting upright, agitated, complaining of chest pain and

difficulty breathing. Audible congested breathing standing next to patient. Unable to

complete a full sentence. Bilateral pedal edema noted. Began oxygen via nonrebreather.

IV started. Moved patient to ambulance. Medical Control contacted and ordered CPAP to

be started. Patient becoming more agitated. After 5 minutes, SaO2 increasing. Patient

stated breathing was becoming easier.

Patient transported sitting upright. Continued CPAP during entire call. Transported

patient into ED on portable O2 with CPAP continued.

Documentation noted:

Pt contact: 0954 Depart scene: 1025

“Drugs”

0959 - Oxygen - 15 l – non-rebreather

1001 – 0.9 NS 1000ml – TKO – IV

1005 – CPAP /oxygen – 15l – CPAP mask

Case Scenario #4 - Discussion

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

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

Case Scenario #5 – Documentation

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

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

Documentation Practice

Pre-Quiz Paramedic And Basic Level

From April 2011 CE Material

The Patient with Heart Failure; CPAP Name_________________________________Date___________ 1. List 3 contributing factors to heart failure. 2. What is the influence of Starling’s Law on myocardial function (think of a stretched rubber band)? 3. List at least 5 signs or symptoms of right heart failure. 4. List at least 5 signs or symptoms of left heart failure. 5. How can you tell the difference between CHF and pneumonia? 6. Describe the technique for listening to breath sounds? -Which side of the stethoscope is best – bell or diaphragm? - Where do you place the stethoscope? - Why would you ask the patient to cough before listening?

Prequiz April 2011

7. If you are first on the scene with only BLS emergency equipment available, how would you start caring for the patient in acute pulmonary edema? 8. What is the purpose of nitroglycerin given for the patient in acute pulmonary edema? 9. What is the purpose of CPAP and when should it be started in acute pulmonary edema? 10. How can you tell when CPAP and or medications are becoming effective in the setting of acute pulmonary edema? File: CE, EMS; CE Packets April 2011 Prequiz Heart Failure and CPAP