# Renal Failure/CHF/Pulmonary Edema/Cardiogenic shock



## fma08 (Aug 31, 2009)

I'd like to hear some thoughts on treatments for a pt. who has renal failure, CHF, and "fluid overloaded" to the point of pulmonary edema exhibiting signs of cardiogenic shock from the CHF. The scenario would be a pt. transfer, about an hour long to the receiving facility.

This came up from a transfer I did with a renal failure/ CHF pt. who did have some SOB and lowered SpO2. The nurse said on the phone when we were on our way over that the pt. had "fluid overload" and sounded like the pt. was nearing her time, however the pt. managed more than fine on a nasal cannula at 4L/min. The rest of the trip was pretty much a "keep an eye" on her sort of thing. But, on the way over my partner and I got to talking about some what if scenarios that could arise from this pt.

Sorry for the long spiel, have at it! ^_^


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## MSDeltaFlt (Aug 31, 2009)

Speaking from a ground medic's point of view.  My ALS service does not have CPAP or even bi-level ventilation for that matter.  Wish we did, but we don't.  So I'm speaking from a very limited ALS service.

The vast majority of RF'ers with CHF, Pulm. Ed., and Cardiogenic Shock in my area are our hemodialysis pts who do not urinate at all and are about to crap out on us.

When they are in cardiogenic shock, their BP's either dropping or just about gone.  Your pt is also getting into Respiratory Failure as well, not just Respiratory Distress.  Their SpO2's are dropping as is their GCS.  By a "dropping GCS" I mean 8 or less.  

This is where you need to be very aggressive.  What do you do?  If they're making any kind of audible words, they still have an airway.  So you're stuck on Breathing, or "B".  Though they may have an airway, you'll still need to secure one so you can better assist their breathing as best as you can.  It may mean ETI with RSI, BNTI, Combitube/King LT (if that's all you got), or even assisting their respirations with BVM.  If you can't then you can't.  You do what you gotta do following your protocols.  If your pt falls outside of your protocols, then call OMC.

For renal failure pts Lasix is pretty much a no-go, if it worked at all it'd be slow, so all you got is NTG.  If their lungs are full and their BP's low, you can't just give them Lasix or NTG.  Iatragenic medicine is bad joojoo.  You'll need to get a dopamine drip if they're hypotensive.  For the Pulm. Ed. refer to the above paragragh.

If this is not what you were wondering, then scratch this post.


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## fma08 (Aug 31, 2009)

Just as kind of a relate side topic, does anyone's protocols allow the use of morphine along with lasix?


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## Shishkabob (Aug 31, 2009)

Yes. 

Nitro and Lasix. Once nitro is maxed out, you can give morphine.


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## Akulahawk (Aug 31, 2009)

Sacramento protocol has  Albuterol (if wheezing), NTG, CPAP (if available), Morphine/Lasix. Goes like this:



 Mild: Albuterol (if wheezing), NTG (SBP >90)
 Moderate: Albuterol (if wheezing), NTG (SBP >90), consider CPAP @ 7.5 cm H2O
 Severe: Albuterol (if wheezing), NTG (SBP >90), CPAP @ 7.5 cm H2O, Morphine, Lasix (if the patient already takes it).... BHO: Dopamine if SBP consistently <90.
Lasix is only given if the patient already takes it... and it's 80mg. Other systems I've been in state: 40 mg, or match the patient's dose, if above 40 mg.


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## medicdan (Sep 1, 2009)

fma08 said:


> I'd like to hear some thoughts on treatments for a pt. who has renal failure, CHF, and "fluid overloaded" to the point of pulmonary edema exhibiting signs of cardiogenic shock from the CHF. The scenario would be a pt. transfer, about an hour long to the receiving facility.
> 
> This came up from a transfer I did with a renal failure/ CHF pt. who did have some SOB and lowered SpO2. The nurse said on the phone when we were on our way over that the pt. had "fluid overload" and sounded like the pt. was nearing her time, however the pt. managed more than fine on a nasal cannula at 4L/min. The rest of the trip was pretty much a "keep an eye" on her sort of thing. But, on the way over my partner and I got to talking about some what if scenarios that could arise from this pt.
> 
> Sorry for the long spiel, have at it! ^_^


I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.


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## TransportJockey (Sep 1, 2009)

Linuss said:


> Yes.
> 
> Nitro and Lasix. Once nitro is maxed out, you can give morphine.



Same protocol here. We also have CPAP in some areas as well (my county area being one of them). Wound up running that as my first call last internship cycle. Got through the Lasix (40mg), NTG (1.2mg), and had 2mg of MS on board before we got to the hospital.


Our state guidelines for Lasix are usually double what the pt takes PO, but here in county we are maxed out at 40mg regardless or what the pt takes.


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## MrBrown (Sep 1, 2009)

GTN and lasix


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## TransportJockey (Sep 1, 2009)

MrBrown said:


> GTN and lasix



GTN=NTG? Just wondering...


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## Shishkabob (Sep 1, 2009)

Glycerin the nitro?

^_^




I've noticed all our people from down under say GTN.


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## VentMedic (Sep 1, 2009)

emt.dan said:


> I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.


 
Why? Is this the only service available?

GTN - Glyceryl trinitrate


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## Smash (Sep 1, 2009)

CPAP, nitrates (SL) with no upper limit, plus transdermal nitrate patch. This is interim measure until we get the systems and logistics sorted for IV nitrates. 

Lasix, match daily dose to max of 80mg, otherwise 40 (or less at discretion of medic). 

Morphine only if patient agitated and not tolerating CPAP or if they have pain. 

Sedation and intubation if necessary.

Albuterol ONLY if patient has a history of reactive airways disease/COPD as increasing myocardial workload is the last thing we want.

Lasix is not really flavour of the month anymore, although I suspect it still has a place in some settings, particularly where CPAP is used, however more research is needed in the prehospital field.


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## fma08 (Sep 1, 2009)

emt.dan said:


> I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.



I would want them on the monitor... The renal failure part alone gives potential for cardiac problems.


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## medicdan (Sep 1, 2009)

VentMedic said:


> Why? Is this the only service available?


We certainly do have ALS available, but the distinction is based on "skills" not necesssarily the condition of the patient. I may, and probably have taken a patient very similar to this to dialysis from an SNF. None of the outpatient dialysis clinics in our region have monitors, so if a patient in this condition needs dialysis, they need it in an acute setting (hospital). 

I know I just contradicted myself, but what I am trying to say is that, fairly often, when encountered wth a patient like this, the SNF doesnt know what else to do other then send them for dialysis.

When the above situation is met with a brand new EMT in the back of the truck, possibly an EMT who has no real understanding of dialysis, and has been told, "Oh, you dont need a blood pressure on these patients, we see them all the time!", we often have a problem. 

[/soapbox, hijack]


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## Smash (Sep 1, 2009)

Sorry, forgot the inotrope. Epi infusion if shocked.


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## medic417 (Sep 1, 2009)

emt.dan said:


> I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.



Read the scenario!!!!!!!!!!  THIS PATIENT NEEDS THE MONITOR.  If you BLS a patient as described you need to lose your certification and if your service allows it they need out of business.


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## emtjack02 (Sep 1, 2009)

Wow, Epi gtt. That seems like going straight to the "big guns".


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## Shishkabob (Sep 1, 2009)

Lasix .5-1mg/kg

0.5 mg for people not on it.

1 mg for people on it already.


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## medic417 (Sep 1, 2009)

So everyone is talking about Lasix are you intending to give it to the OP's patient?  If so explain your reasoning.


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## ResTech (Sep 1, 2009)

Smash... why the Epi infusion over Dopamine or Dobutamine for cardiogenic shock?


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## emtbill (Sep 1, 2009)

Let's talk about the pathophysiology of this patient's treatment for a minute...

I understand how CPAP works in terms of adding PEEP, increasing inspiratory volumes which decreases work of breathing, stenting open alveoli that are under pressure from fluid which helps improve gas exchange, etc, but how does it work on a cardiovascular level? Also, NTG and morphine are indicated as vasodilators and to reduce preload which will reduce the amount of fluid being pumped through the pulmonary vein correct? Lastly, would pressors be a better choice if this patient became hyoptensive since they are in cardiogenic shock (and we wouldn't want to exacerbate the problem by giving more fluids) or is this going to be counterproductive to giving morphine and NTG?

Also, why is CPAP generaly not indicated in COPD and asthma? It seems like bronchospasm could be treated in the same way as pulmonary edema.


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## ResTech (Sep 1, 2009)

It's my understanding that CPAP does not "increase inspiratory volume". CPAP is about airway pressure, and not volume. For example, the device we use for CPAP is called the Oxy-PEEP which on inspiration it provides no pressure increase on the inspiratory phase... it is the same as a NRB during the inspiratory phase... its magic occurs during expiration where it forces a positive pressure in the chest which prevents alveolar collapse and increases the surface area available for diffusion. If I am wrong in my understanding someone please correct me. 

CPAP works on the cardiovascular level by means of the positive pressure. The positive pressure created in the chest causes a pinching down of the vena cava which reduces preload. As you know (and in case others dont), when you decrease preload (blood return to the heart) you decrease the overall workload and myocardial oxygen demand of the heart. I remember it this way... think of hypoventilation induced hypotension and why that is detrimental during a cardiac arrest. The frequent ventilations (hyperventilation) keeps a positive pressure in the chest and does not allow for the negative pressure to come into play which is where blood return to the heart comes from.  

So not only does the decreased preload help to take workload off the heart, it also helps to reduce pulmonary pressures which helps keep the fluid from crossing cell membranes and entering the alveoli.

In Maryland protocol, CPAP is indicated for Asthma and COPD... it has been found to work and be very effective in these conditions as well.

Since were talking a bit about CHF.... I haven't heard anyone mention using ACE inhibitors. Does ne one use SL captopril in the field for afterload reduction?


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## VentMedic (Sep 1, 2009)

> but how does it work on a cardiovascular level?


CPAP reduces the left ventricular preload and afterload by increasing intrathoracic pressure and lowering left ventricular transmural pressure.




> Also, why is CPAP generaly not indicated in COPD and asthma? It seems like bronchospasm could be treated in the same way as pulmonary edema.


 
Bronchospasm is often causes by an inflammation. Sometimes you can splint the airways and sometimes you will just cause more air trapping. The same for certain types of COPD as there are more than emphysema which also comes with various phases and etiologies. The FRC may be extended to where it becomes most of the TLC which makes each VT ineffective. Also, if their muscles are fatiqued, without access to bilevel ventilation, you may increase the work of breathing. Secretions might also be an issue where you would not want to utilize CPAP unless you could clear the airway appropriately. In the hospital and for some CCT, we do use CPAP and Bilevel (BiPAP, BIPAP) to rescue some patients with asthma and COPD. But, we vary the pressures and flows by CXR and hemodynamic monitoring as well as having the ability to support BP if needed. 

*Mechanical Ventilation of Patients with COPD and Asthma* (this includes NIPPV)

http://www.slideshare.net/scribeofegypt/copd-asthma


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## VentMedic (Sep 1, 2009)

ResTech said:


> CPAP works on the cardiovascular level by means of the positive pressure. The positive pressure created in the chest causes a pinching down of the vena cava which reduces preload.


 
No, it does not "pinch" the vena cava.

Also:
CPAP doesn't push the lung water and lidocaine does not numb the heart.


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## Shishkabob (Sep 1, 2009)

ResTech said:


> For example, the device we use for CPAP is called the Oxy-PEEP which on inspiration it provides no pressure increase on the inspiratory phase...



I think you're describing PEEPing instead of a CPAP device.

PEEP-- Positive End Expiratory pressure, keeps all the air from being exhaled thereby keeping the pressure up in the lungs, while CPAP, Continuous Positive Air Pressure, continually forces air into the lungs at a certain pressure, during inhalation and exhalation.

BiPAP is where it switches between 2 pressures for inhalation and exhalation.


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## ResTech (Sep 1, 2009)

> No, it does not "pinch" the vena cava.



"PEEP elevates the upstream pressure driving venous return, increases venous resistance, *and directly compresses the inferior vena cava.*"

compress is synonymous with "pinch".

LINK: http://www3.interscience.wiley.com/journal/121644471/abstract?CRETRY=1&SRETRY=0


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## Shishkabob (Sep 1, 2009)

VentMedic said:


> Also:
> CPAP doesn't push the lung water



Now this is where I am of no clue.

Yes, I know it reduces preload.


But I have had a physician, and NOT my paramedic instructor like some people think, tell me that an increase in lung pressure will keep more fluid out of the interstitial space, to which the fluid goes to because of the increased pressure in the vessels and decreased pressure in the lungs.


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## VentMedic (Sep 1, 2009)

Linuss said:


> I think you're describing PEEPing instead of a CPAP device.
> 
> PEEP-- Positive End Expiratory pressure, keeps all the air from being exhaled thereby keeping the pressure up in the lungs, while CPAP, Continuous Positive Air Pressure, continually forces air into the lungs at a certain pressure, during inhalation and exhalation.


 
It depends on how the PEEP is delivered. The Oxy-PEEP is a mask with a resistive valve. CPAP that is generated continuously is generally more effective and less likely to fatique the patient. 

If you go into CCT and use various ventilators you will notice the difference. Vents with an external resistive valve for PEEP are not as effective as those with internal continuous flow for CPAP/PEEP. 




Linuss said:


> BiPAP is where it switches between 2 pressures for inhalation and exhalation.


 
The baseline or EPAP flow may be continuous and the 2nd level can augment inspiratory effort.  However, the differences comes again with how the CPAP/PEEP is delivered as to if the inspiratory effort is from EPAP baseline or Zero.


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## ResTech (Sep 1, 2009)

The Oxy-Peep (http://www2.mooremedical.com/index.cfm?CS=HOM&FN=ProductDetail&PG=CTL&PID=14860) is what is approved for CPAP in the county I am affiliated and does not force pressure during inspiration. I have used it a few times and achieved good results. 

CPAP and PEEP are really one in the same in terms of desired effect.


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## VentMedic (Sep 1, 2009)

Linuss said:


> But I have had a physician, and NOT my paramedic instructor like some people think, tell me that an increase in lung pressure will keep more fluid out of the interstitial space, to which the fluid goes to because of the increased pressure in the vessels and decreased pressure in the lungs.


 
Yes it will move the fluid by making the lymphatic system more effective with the pressure changes.


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## VentMedic (Sep 1, 2009)

ResTech said:


> The Oxy-Peep CPAP and PEEP are really one in the same in terms of desired effect.


 
Again that will depend on how each is delivered as the names state:

CPAP: Continuous Positive Airway Pressure

PEEP: Positive End Expiratory Pressure

Some believe all technology is the same and fail to understand how each device works to appreciate the differences.  Thus, we hear various comments about the effectiveness without actually analyzing "why".

The Ford Escort and the Ferrari are both cars but are not the same.


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## VentMedic (Sep 1, 2009)

A brief description of the CPAP devices available in the field:

http://www.ems1.com/ems-products/me...967-New-Devices-Delivering-CPAP-in-the-Field/


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## VentMedic (Sep 1, 2009)

ResTech said:


> I remember it this way... think of hypoventilation induced hypotension and why that is detrimental during a cardiac arrest. The frequent ventilations (hyperventilation) keeps a positive pressure in the chest and does not allow for the negative pressure to come into play which is where blood return to the heart comes from.


 
Hyperventilation is a reduction of PaCO2. If the patient is tachyneic (high respiratory rate) allowing little time for expiration or there is air trapping caused by the tachypnea the patient may present with Auto-PEEP and hyperINFLATION which will cause hypotension. As well, when the FRC is extended, the PaCO2 may increase.


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## ResTech (Sep 1, 2009)

I noticed a typo in my post... I meant HYPERventilation induced, not hypo.

I might be lost... I always thought hyperventilation meant as the name implies... a faster than normal rate of breathing (or over breathing) and not the level of PaCO2. Hyperventilation is a cause of low PaCO2... where a low PaCO2 is known as hypocapnia and not termed hyperventilation since you can have brief hyperventilation without hypocapnia or respiratory alkalosis.


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## VentMedic (Sep 1, 2009)

ResTech said:


> I noticed a typo in my post... I meant HYPERventilation induced, not hypo.
> 
> I might be lost... I always thought hyperventilation meant as the name implies... a faster than normal rate of breathing (or over breathing) and not the level of PaCO2. Hyperventilation is a cause of low PaCO2... where a low PaCO2 is known as hypocapnia and not termed hyperventilation since you can have brief hyperventilation without hypocapnia or respiratory alkalosis.


 
Fast breathing is tachypnea.

Hyperventilation is ONLY confirmed by the presence of a low PaCO2.

Babies, as are adults, with impending respiratory failure are tachypneic as the PaCO2 rises. They are NOT hyperventilating.

Hypocapnia is a term used for many states in which the PaCO2 is reduced either pharmacologically, mechanically or in the face of various disease processses.  For TBIs, in some cases we will use the term "hyperventilate" ONLY if we have actually lowered the PaCO2 as confirmed by analysis of blood. 

Hypoventilation can refer to various syndromes including those that are congenital which may being on a chronic increase in PaCO2 unless mechanically or pharmacologically controlled. If you get into analyzing respiratory patterns you will learn more about hyponea.


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## medic417 (Sep 1, 2009)

medic417 said:


> So everyone is talking about Lasix are you intending to give it to the OP's patient?  If so explain your reasoning.



Anyone?  Anyone?


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## Shishkabob (Sep 1, 2009)

I was going to say "Yes" just to elicit the correct answer from you, but I already know why it's a no.




Renal failure = lasix is pretty useless.


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## medic417 (Sep 1, 2009)

Linuss said:


> I was going to say "Yes" just to elicit the correct answer from you, but I already know why it's a no.
> 
> 
> 
> ...



Or is it?


Here do some research young man and come give the class the correct answer.


http://www.aafp.org/afp/20000401/2077.html


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## Shishkabob (Sep 1, 2009)

Darn you and your non-answering ways!


I'm going to go out on a limb and say it has to do with getting rid of excess potassium, and since potassium follows sodium, using a loop diuretic to get rid of the sodium should also get rid of the excess potassium.


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## Smash (Sep 1, 2009)

ResTech said:


> Smash... why the Epi infusion over Dopamine or Dobutamine for cardiogenic shock?



Well, there are a number of reasons, but the most simple is 'because it's there'.

There is scant (or no) evidence that inotropes in cardiogenic shock improve outcomes. In fact the opposite is true. Inotropes are merely a temporizing measure until interventional cardiologists can get their hands on the patient.

There is also little to suggest that any particular flavor of inotrope is better than any other. Given this it was decided that epi has at least one advantage over dobutamine/dopamine in that it has been used for decades so medics are familiar with it and it is cheap. 

Ms Hochman has written a large number of papers on cardiogenic shock of various etiologies and is well worth a read regarding inotropes.


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## artman17847 (Sep 1, 2009)

Pennsylvania Department of Health Cardiac 5002 – ALS – Adult
Effective 11/01/08 5002-1 of 2
CONGESTIVE HEART FAILURE
STATEWIDE ALS PROTOCOL
Treat any Dysrhythmias according to appropriate Cardiac Protocol or as Medical Command orders
Initial Patient Contact - see Protocol #201
Manage Airway/Ventilate, if indicated
SpO2 < 90% on High-flow Oxygen
Monitor ECG & Pulse Oximetry
Proceed to Appropriate
Dysrhythmia Protocol
Contact Medical Command
Initiate IV/IO NSS
SBP > 90 mmHg 1
If not using Viagra-type drugs 2,
Nitroglycerin 0.4 mg SL
(1-3 doses every 3-5 minutes 3,4 )
If patient already takes a diuretic, administer Furosemide 40-100 mg IV 5
YES
NO
Consider Cardiogenic Shock
Contact Medical Command
Apply CPAP (if available)
Unstable tachycardia / bradycardia present
If SBP = 70-90, Consider Dobutamine Drip (if available) 6
OR
If SBP < 90
Dopamine Drip 7
If wheezing or if possibility of reactive airway disease, consider Nebulized Bronchodilator
(using options in Asthma protocol #4022)
Systolic Blood Pressure
SBP > 100mmHg 1
SBP 90-100 mmHg 1
SBP < 90 mmHg 1
YES
High-flow Oxygen
CPAP/BiPAP (if available – CPAP/BiPAP required for ALS by 7/1/09) if respiratory distress


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## Shishkabob (Sep 2, 2009)

So do I get a cookie, medic416?


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