The Patient with Heart
Failure
CPAP as an Intervention
April 2011 CE
Condell Medical Center
EMS System
Site Code #107200E -1211
Prepared by: Lt. William Hoover, Medical Officer
Wauconda Fire District
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
1
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.
2
Objectives cont’d





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.
3
Objectives cont’d






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.
4
Objectives cont’d
 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.
5
What is Heart Failure?
 A clinical
syndrome
 Heart’s mechanical performance (ie:
pumping action) is compromised

Cardiac output unable to meet the demands
of the body’s needs
 Generally
divided into backward
ventricular failure (right heart failure) and
forward ventricular failure (left heart
failure)
 Can be of a chronic or acute nature
6
Heart Failure
 Variety


of causes
Valve disease
Heart disease
 Contributing





factors to heart failure
Diet - excess fluid or salt intake
Hypertension
Pulmonary embolism
Excessive alcohol or drug usage
Progression of an underlying disease
7
What is CHF?
 Congestive


heart failure = CHF
Condition of excess build-up of fluid in the
lungs and/or other body parts/organs
Fluid build-up causes congestion in the
organs seen as edema
 May
be brought on by diseased heart
valves, hypertension, or some form of
obstructive pulmonary disease
 Often a complication of AMI
8
Fluid build-up in CHF may be
pulmonary, peripheral, sacral, or ascites
9
Understanding CHF
 A failure
of the pumping action of the heart
 Heart


is a 2 sided pump
Right side of heart is a low pressure
system
Left side of heart is a high pressure
system
10
Heart as a Pump
 Left


side of heart muscular
Needs to overcome pressure in the arteries to
push/pump blood
Pumps blood flow to the body
 Right

side of heart less muscular
Pumps blood to the lungs
• Does not need to be a very aggressive
pump with a lot of force
11
Starling’s Law
 The
more the myocardial muscle is
stretched, the greater the force of
contraction (the greater the recoil)

Greater the preload (amount of blood
returned to the right heart), the farther the
myocardium is stretched and the more
forceful a contraction that results leading to
an increased cardiac output
 When
Starling’s Law fails, the patient is
no longer able to compensate
12
Hypertension
 B/P
is a measurement
of force against the wall of the arteries
 When vessels stiffen due to calcium buildup (arteriosclerosis) and plaque develops
(atherosclerosis), vessels are less
compliant
 Higher pressures are needed to pump
blood through stiffer vessels
13
Right Ventricular Failure
 Failure
of right ventricle as a forward
pump
 Back pressure of blood into systemic
venous circulation system
 Common causes




Left ventricular failure (AMI)
Systemic hypertension
Pulmonary hypertension
Cor pulmonale – heart
disease due to pulmonary
disease
(ie; effects of COPD)
14
Progression of Right Heart Failure
 Right
ventricle cannot eject all of the blood
out
 Fluid/pressure builds up
• In right atrium
Backs up into the venous system
Results in pedal/dependent
edema
 Visible as JVD
15
Right
Sided
Heart
Failure A
Systemic
Picture
16
Left Ventricular Failure

Failure of left ventricle to function as a forward
pump
 Back pressure of blood into pulmonary circulation


Often causes pulmonary edema
Common causes

Various types of heart disease
• Ischemia / acute MI
• Coronary artery disease (CAD)arteriosclerosis/atherosclerosis
• Valve disease
• Chronic hypertension -  afterload
• Dysrhythmias
17
Progression of
Left Ventricular Failure
 Left
ventricle cannot eject all the blood
delivered from the right heart via the
lungs
 Left atrial pressure rises and transmitted
to pulmonary veins and capillaries
 These high pressures force blood plasma
into alveoli (ie: pulmonary edema)
 Oxygen capacity of lungs reduced


Hypoxia develops
Acidosis develops
18
Pulmonary
Edema
 Severest
form
of congestive
heart failure

Left ventricular forward failure
 Think


left/lungs
Patient develops respiratory distress due to
fluid in the lungs
Note: extremely rare to have unilateral pulmonary
edema; then related to unusual pathology/med hx
19
Pathophysiological Changes in
Pulmonary Edema

Left ventricle cannot empty effectively
 Fluid moves from capillary beds into
surrounding interstitial tissue  alveoli


Surfactant lining alveoli washes out



Fluid in alveoli impedes oxygen exchange
Alveoli stiffen
Alveoli collapse after each breath and are harder to
open
Lungs develop  compliance,
airflow obstruction, hyperinflation
  to workload of breathing
20
Symptoms of CHF
 In
the more chronic setting of right heart
failure, symptoms usually related to
excess fluids in organs and other body
parts
 In the more acute left heart failure,
symptoms usually related to excess fluid in
the lungs and therefore respiratory
distress
21
Signs and Symptoms
Right Heart Failure







Dependent edema
Peripheral edema
Hepatomegaly
Splenomegaly
Jugular vein
distension (JVD)
Ascites
Weight gain






Dysrhythmias
Nausea/vomiting
Fatigue
Dizziness
Syncopal episodes
Weakness
22
Signs and Symptoms
Left Heart Failure








Shortness of breath
Dyspnea
Orthopnea
Crackles
Wheezing
Hypoxia
Respiratory acidosis
Chest pain








Sweating
Productive cough
Blood tinged sputum
Cyanosis
Palpitations
Dysrhythmias
Hypertension
Anxiety/restlessness
23
Typical medical history pattern of
patient with CHF

Hypertension
 Cardiovascular
disease (CVD)
 Myocardial infarction
(MI)
 Coronary artery
disease (CAD)

Arteriosclerosis
Atherosclerosis



Smoker
 Excessive alcohol or
drug use




Cocaine
Methamphetamine
Inhaled solvents
PCP
Dietary intake excess
fluids, excess salt
 High cholesterol
24
Typical home medication history
pattern of patient with CHF




Diuretic
Digoxin
  contractility force of
the heart (inotropic)
Home oxygen therapy
Anti-hypertensive


ACE inhibitors (end in “pril”)
Beta blockers
•  heart rate & force
of contractions  B/P
• Often end in “olol”

Calcium channel
inhibitors
• Slows movement of
calcium into small
muscles wrapped
around blood
vessels relaxing
blood vessels
•  peripheral
vascular resistance
relaxing blood
vessels
25
Herbal remedies that may be harmful
when mixed with heart failure







St. John’s wort
Ephedra
Gingko biloba
Kava
Licorice
Ginseng
Aconite






Alisma plantago
Bearberry buchu
Couch grass
Dandelion
Horsetail rush
Juniper
26
Evaluation CHF/PE
HTN, heart
History
problems
Pneumonia
COPD
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
Rapid
Productive thick
green
Gradual
Chronic;
productive
Gradual
B/P
Meds
High
Normal
Normal
Dig, anti-HTN,
diuretic
Antibiotic, cold prep
Bronchodilators,
Tx
O2, NTG,
lasix, MS
O2, neb, fluids
Onset
steroids
O2, neb
27
Separating Signs/Symptoms
Symptom
SOB
Cough
Sputum
Fever
Skin
Chest pain
Smoking hx
Wheezing
Crackles
CHF/PE
Yes
Maybe
Frothy pink
No
Cold/clammy
Possible
Possible
Maybe;
bilateral
Yes; bilateral
Pneumonia
Yes
Yes
Yellow/green
Yes
Hot/dry
Maybe
Possible
Maybe; same
side as disease
Maybe; same
side as disease
COPD
Yes
Early a.m.
Thick brown
No
Normal or dusky
No
Usually
Usually,
bilateral
No
28
A Note…
“Old geezers don’t become new
wheezers!”

COPD develops over a long period of time. If
an elderly person does not have a history of
COPD and they are suddenly wheezing, think
a cardiac problem or pulmonary edema.
Assume the worst,
hope for the best
29
Patient Assessment - CHF
 Acute

findings
Recent trouble sleeping
•  trips to the bathroom at night
• Orthopnea with  number of pillows
• Sleeping in the recliner
• New episodes of paroxysmal nocturnal
dyspnea (PND)
•  use of nitroglycerin to stop chest pain
•  use of oxygen
30
Patient Assessment - CHF

General impression










Labored respirations
Audible noisy respirations
Tripod positioning
Frothy sputum production
 work of breathing – retractions, tachypnea
Wheezing/crackles bilaterally
Diaphoretic
Change in skin color from norm
Severe anxiety/restlessness
Severe hypertension may be present
31
Patient Assessment - CHF
 Signs








and symptoms pulmonary edema
Tachypnea
Orthopnea
PND
Noisy labored respirations
Fine crackles/rales
Wheezing – “cardiac asthma”
Coarse crackles/rhonchi larger airways
Coughing with frothy blood tinged sputum
32
Obtaining Breath Sounds
 Use
flat diaphragm surface of stethoscope
 Rub stethoscope head between hands to
warm it up before placing on patient’s skin
 If audible sounds are heard, ask patient to
cough gently to clear upper airway
 Auscultate side to side and top to bottom
 Anterior:
Posterior:
33
Adventitious (Extra) Breath
Sounds
 Check
for asymmetry
 Crackles: high pitched, continuous sounds
like rubbing hair between fingers
 Wheezes: generally high pitched, of musical
quality
 Stridor: Harsh inspiratory wheeze indicating
upper airway obstruction
 Rhonchi: snoring or gurgling quality
 Any extra sound not a crackle or wheeze
34
is usually rhonchi
Decision Making –What to Do?





Use critical thinking skills
Decide if patient is sick or not
Obtain current and past history
Obtain vital signs
Look





Skin (wet/dry; color; temp)
JVD present or not
Peripheral / dependent edema present
Subtle signs
Listen

Breath sounds
35
Making the Right Decision
 Does
the medical history include
cardiovascular disease?
 Does the physical examination/patient
assessment paint a picture of CHF?
 Use critical thinking skills
 Not treating pulmonary edema means the
body becomes more hypoxic and acidotic


Miss diagnosis (ie: pneumonia) could prove
lethal
This patient will arrest
36
Treatment Goals for CHF
 Decrease
myocardial workload
 Decrease oxygen demand
 Decrease fluid retention
 Correct hypoxia
 Correct acidosis
37
Treating CHF/Pulmonary
Edema
 Decrease





myocardial workload
No physical activity (they don’t walk to the
rig)
Sitting the patient upright; dangle feet
Administering oxygen – non-rebreather
CPAP to increase oxygen absorption surface
of lungs
Medications to  preload and afterload
Nitroglycerin
Morphine
Lasix – additionally works as diuretic
38
Treatment Goals for Pneumonia
 Supply
supplemental oxygen as needed
 Treat the bacterial infection
 Hydrate the patient
•
•
•
Usually found in the elderly
Often vague symptoms; use to feeling ill
Immune system often already weakened
so mortality rate is high with this diagnosis
39
Region X SOP- Acute
Pulmonary Edema
 Begin



Routine Medical Care
Take standard precautions
Perform assessments
Identify priority patient and make transport
decisions
• Stay and play?
• Load N go?

Perform routine tasks
• IV-O2-monitor
40
What About the IV and
Nitroglycerin?
 Region



X Medical Directors discussion:
Majority of patients in pulmonary edema will be
hypertensive
Nitroglycerin will help reduce preload which will
lower blood pressure (beneficial)
Do not delay NTG dose, if no contraindications,
to start the IV
• If patient deteriorates before IV established,
can always place an IO
41
Region X SOP- Acute
Pulmonary Edema
 Determine
if the patient is stable or
unstable

Stability guided by status of perfusion
B/P and level of consciousness


If stable, the patient can receive more
aggressive care including medications and
procedures (ie: CPAP)
If unstable, Medical Control needs to
coordinate degree of care provided in the
field (ie: meds and CPAP)
42
Region X SOP- Acute
Pulmonary Edema - Stable
 Nitroglycerin


Nitrate vasodilator
Decreases myocardial workload
• Dilates arterial and venous systems
•  preload
•  afterload


Carefully monitor blood pressure
Screen for concomitant use of sexual
enhancement drug
• Viagra or Levitra in last 24 hours
• Cialis in past 48 hours
43
Stable Pulmonary Edema SOP
 Lasix





Loop diuretic
Moves sodium (NA+) out of blood vessels
• Water follows sodium
• Potassium (K+) also pulled out
Vasodilation effects within 5 minutes
• Decreases preload
Diuresis within 20-30 minutes
Peaks within 30 minutes
44
Stable Pulmonary Edema SOP
 Morphine




sulfate
Narcotic analgesic
• Reduces anxiety
Dilates venous and arterial systems
•  preload
•  afterload
•  blood pressure
Stimulates nausea center in the brain
Slows respiratory rate in medulla
45
Region X SOP – Pulmonary Edema
Medication Regimen
 Stable

patient
Nitroglycerin 0.4 mg sl
• One every 3-5 minutes to max dose of 3



Begin CPAP
Lasix 40 mg IVP (80 mg if taken at home)
Morphine 2 mg IVP slow over 2 minutes
• May repeat 2 mg every 2 minutes to max of 10mg

If wheezing, contact Medical Control for
possible Albuterol neb treatment
46
CPAP
 Continuous

positive airway pressure
Delivered throughout the respiratory cycle
 Noninvasive
ventilatory support
 Most beneficial when initiated early
 Maintains airway in open position
  intrathoracic pressure which  venous
return to the heart

Preload and afterload both decrease
47
Benefits of CPAP
 Increases
amount of inspired oxygen
 Decreases work load of breathing
 Reduces need for intubation
 Intubation requires ICCU stay
• Increased exposure to risks associated
with complications due to intubation
• Increases overall hospital length of stay 48
Redistribution of extravascular lung
water during use of CPAP
Without CPAP
With CPAP
49
50
Indications for CPAP
 Patient
in acute pulmonary edema with
stable blood pressure

Stable B/P = >100mmHg systolic
– with revised 2011 SOP’s, blood
pressure levels will be shifting to systolic
of 90 as a consistent guideline throughout
the SOP’s
 FYI
51
Contraindications for CPAP





Decreased or altered level of consciousness
Inability of patient to protect their airway from
aspiration
Persistent nausea/vomiting
Need for immediate intubation
Hemodynamic instability (B/P<100)


Note: B/P guideline will be changing to <90 with
revised 2011 SOP
Penetrating chest trauma
52
Medications Simultaneous With
CPAP
 Medications
should be started
NTG sl
 Then begin CPAP
 Then continue medication administration as
indicated
 Lasix – 40mg or 80mg IVP
 Morphine – 2 mg IVP repeated every 2 min

CPAP will buy time for the medications to work
53
Did you know…
It is not either / or
(CPAP or meds)
CPAP works WITH medications
in tandem
Lift the mask to continue administration of
more NTG
54
CPAP Equipment
 Fixed
whisper
flow

Connects to
your oxygen
source
55
O2 Tank Duration
 Approximate
time at 30% FIO2
D tank
E tank
M tank
H tank
30 min.
50 min.
253 min.
508 min.
*based on 50 psi output
56
CPAP
Circuit
Set-up
Package
includes:
Mask
Tubing
Head
strap
CPAP
valve
Air
entrainment
filter
CPAP
valve
Filter
57
Most patients need a lot of coaching to
initially tolerate the tight fitting mask
58
If The Patient is Wheezing
 Contact
Medical Control to consider an
order for Albuterol via nebulizer



Medical Control needs to give this
physician’s order
Contact ECRN on radio
• Needs to give the ED MD a report
• Obtains MD’s order
• Relays the response to EMS
If Albuterol is given, monitor for cardiac
side effects (ie: tachycardia)
59
In-line Albuterol Set-up with
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
60
CPAP With In-line Albuterol Set-up
61
Criteria to Discontinue CPAP
 Development

of hemodynamic instability
B/P drops below 100 systolic
• Revised 2011 SOP B/P level will be 90 systolic
 Inability
of patient to tolerate tight fitting
mask
 Emergent need to intubate the patient
62
Patient Monitoring During Use
of CPAP
 Constant
reassessment required:
Patient tolerance
Mental status
Respiratory pattern
Rate, depth, subjective feeling of
improvement
Blood pressure, pulse, SaO2, EKG rhythm
Complications
Gastric distension, nausea, vomiting
63
Monitoring Improvement With
CPAP
 It’s






working when:
Level of distress decreases
Respiratory rate is returning toward normal
Pulse oximetry (SaO2) increasing
Pulse rate decreasing toward normal
Decrease in use of accessory muscles
Ability to speak in fuller sentences returning
64
Contacting Medical Control
 Remember:


Early communication with receiving
hospital
Hospital needs to get their regulator for
oxygen source connection
• Usually not kept in each room
65
Documentation With CPAP
 Assessment
leading your general
impression to a diagnosis of pulmonary
edema
 CPAP level provided (10cmH2O)
 FiO2 provided (100%)
 SaO2 serial levels
 Vital signs over time
 Response to treatment
 Any adverse reactions noted
66
So, What’s Different About BiPAP?
 Bi-level
positive airway pressure
 Uses 2 levels of pressure

Helps move more air into lungs without need
to exhale against higher pressures
 CPAP

is a larger & noisier machine
Uses extra effort to exhale and can be tiring
 Both
can be used for sleep apnea
 BiPAP easier on those with COPD and
neuromuscular diseases
67
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 ppt that can be
discussed during group presentations.
68
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
69
Case 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
70
Case Scenario #1
 What

is your general impression?
Are assessment findings stronger for
exacerbation of COPD or for acute
pulmonary edema?
 COPD



supported
History
Appearance
Lung sounds
 What
treatment is indicated?
71
Case 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
72
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
73
Case 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
74
Case Scenario #2

What is your general impression?
 Are assessment findings stronger for
exacerbation of COPD or for acute pulmonary
edema?
 Pulmonary edema supported
 History
 Appearance
 Lung sounds
 What treatment is indicated?
75
Case Scenario #2

Need to move rapidly


IV-O2-monitor



Minimize scene time as much as possible
Start nonrebreather until switched to CPAP
Consider AMI so obtain 12 lead EKG
Any contraindications to treatment?




Nitroglycerin?
CPAP?
Lasix?
Morphine?
NO
NO
NO
NO
76
Case 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
77
Case Scenario #2
 What

Patient is deteriorating
 What


is your general impression now?
is your treatment now?
CPAP needs to be discontinued
Patient needs to be bagged and intubated
• One breath every 5-6 seconds before intubation
• One breath every 6-8 seconds after intubation


Hold further repeats of medications used
Consider need for dopamine infusion
78
Case Scenario #3 Documentation

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 documented
 Initial vital signs (B/P 170/98 – 92 – 32)
79
 Second reading at the hospital
Case Scenario #3 Comments
Documented

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.
80
Case Scenario #3 Documentation
cont’d
 Patient
transported sitting upright.
Continued CPAP during entire call.
Transported patient into ED on portable O2
with CPAP continued.
81
Case Scenario #3 Documentation
cont’d
 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
 “`Cardiac


rhythm”
0958 – sinus
1035 - sinus
82
Case Scenario #3 Documentation
Discussion
What went well?


Recognized pulmonary edema
CPAP used with positive patient response
83
Case Scenario #3 Documentation
Discussion
 What



could be improved upon?
Long on-scene time (0954 – 1025 -31 mins)
Delay in initiating O2 therapy – 5 minutes
Waited for MC to order CPAP – 11 min delay
• No Medical Control direction needed to initiate


No other meds given for pulmonary edema
Only 2 sets of vital signs taken on a critical
patient
84
Case 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
85
Case 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
86
Case Scenario #4
 What
is your general impression?
 Are assessment findings stronger for
acute pulmonary edema or pneumonia?
 Pneumonia supported?



History
Appearance
Lung sounds not so helpful
 What
treatment is indicated?
87
Case Scenario #4
 What
is your treatment now?
 IV-O2-monitor
 Fluids
• Faster than keep open but not a fluid
challenge
 Diagnosis confirmed at the hospital with
chest x-ray and labs
88
Case Scenario #4
 Patients
with pneumonia need fluids
 Patients with congestive heart failure need
fluid restrictions
 A wrong diagnosis and therefore wrong
treatment approach could be harmful for
both patients
89
Case 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
90
Case 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
91
Case Scenario #5
 What
is your general impression?
 What is your treatment plan?
 Write a run report



Include initial assessment
Document treatment interventions indicated
Document reassessment performed
 Discuss
as a group what needs to be
included
92
93
94
Bibliography






Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care: Principles and Practices. Brady. 2009.
Limmer, D., O’Keefe, M. Emergency Care, 10th
Edition. Brady. 2005.
Region X SOP’s March 2007; Amended
January 1, 2008.
http://whisperflow.respironics.com/
www.emsworld.com
Variety internet websites for CPAP and
pulmonary edema
95