# 82 y/o female respiratory distress



## rhan101277 (Apr 20, 2014)

You are dispatched for the above call, when you arrive at the house you find the fire department is arriving the same time as you.  Upon entering the house and making patient contact you find the patient sitting up in the bed in severe respiratory distress.  You quickly place the patient on 15L NRB and assess lung sounds.  Diffuse coarse crackles are noted, no pedal edema, really no stethoscope is needed to hear these crackles.  pt aaox3, gcs 15, difficulty speaking due to the distress.

PmHx: HTN
Medications: Metoprolol

After further questioning this is an acute onset of breathing difficulty with no previous lung or heart problems. No recent n/v/d, skin p/w/clammy. Vitals are obtained.

BP: 103/90
HR: 133 (wide complex) no pacemaker
SP02: 92% on 15L NRB

Pt is loaded on a stair chair for extrication and re-vitalized

BP: 80/40 (still has good mentation)
HR: 140
SP02: 93% on 15L NRB

You have a 2 mile ride to the hospital, as you wonder what is going on with this patient.

What is going on and how would you proceed?


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## Imacho (Apr 20, 2014)

Sound like a possibility of  a PE.


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## mycrofft (Apr 20, 2014)

_No habla_ "Crackles". Inspiratory or exhalatory or both? (I'm guess "both").
A bilat lung auscultation enroute would be wise just in case. Nasty uncompensated drop in BP there, automated or manual? Pulse regularity ( EKG good for that)? Was a different sized cuff used on the pt between measurements? (I've seen a small cuff used from a jump bag on an emaciated little old lady get a higher BP than the larger one mounted to the vehicle's installed aneroid BP cuff).
Yeah, PE needs to be entertained. Usually get some sort of ℅ pain in those early on.


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## Handsome Robb (Apr 20, 2014)

Can we have a 12-lead? Wide complex at 140 could be a lot of different things and could potentially cause her pulmonary edema. 

I'm assuming diffuse coarse crackles is going to be bilateral rales.

Sounds like APE, probably secondary to an AMI. Seems like she's in cardiogenic shock and about to decompensate. She needs PPV but I'm hesitant to do it with her vitals. Inotropes would be nice, a small fluid bolus (yay frank starling), position her as upright as you can. Consider intubation if she starts to lose her mentation or airway. She also needs a cath lab I'm betting so let's go to a hospital that's capable. 

Without more information it's tough to say, this is moving towards a lets boogy scenario though.


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## mycrofft (Apr 20, 2014)

2 miles ride. How many minutes?


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## Imacho (Apr 20, 2014)

Missed that part. Then ya  flash edema would be primary impression. Pressure is too low for CPAP. Titrate dopamine to achieve 90 systolic.


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## FLdoc2011 (Apr 20, 2014)

Not sure what protocols would say but I wouldn't let an iffy BP stop me from using BiPAP/CPAP in a patient in resp distress which it appears this pt is in.


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## Angel (Apr 20, 2014)

is she still wide complex @140? 

2 miles isn't time to do a lot but id take another person and give her PPV, due to her BP cant use CPAP here. 

Id get an IV and get base order for dopamine while assessing. 

12 lead.


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## NightShiftMedic (Apr 20, 2014)

I would want to get a good quality 12 lead ECG with a quickness, especially before resorting to dopamine or another vasoactive medication.  We also need more history.  Was she recently sick?  Any recent infections, cough, cold, etc?  My thoughts on treatment based on the given information are:

Continue the current oxygen therapy
12-lead ECG ASAP
be ready to intubate her should her GCS drop < 8
two (at least) well functioning IV's/IO's
small (IE 250 mL and no more!) fluid bolus
get her to the ER, preferably one that has a cath lab and is equipped to handle her

Currently my guess is that she's had a MI and is in cardiogenic shock.  I would also guess that her wide complex rhythm is a bundle branch block due to the MI, however if we were to find VT or something like that on the 12 lead I would want to correct that before I would start dopamine, which can cause lots of ventricular ectopy.

Regarding CPAP or BiPAP, she may very well be preload dependent.  With a pressure of 80 systolic, I wouldn't want put her on CPAP and reduce her preload even further.

I like this case!


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## Angel (Apr 20, 2014)

For my own curiosity...why are so many people thinking MI?


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## rmabrey (Apr 20, 2014)

Angel said:


> For my own curiosity...why are so many people thinking MI?



MI sometimes cause APE. When ive seen It, its usually a sign of imminent death. Results may vary.


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## NightShiftMedic (Apr 20, 2014)

Angel said:


> For my own curiosity...why are so many people thinking MI?



Given what little info we have at the moment, it's a good place to start.


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## jrm818 (Apr 20, 2014)

Angel said:


> For my own curiosity...why are so many people thinking MI?



It's an easy way to explain how a recently healthyish patient can suddenly have a miserable blood pressure and pulmonary edema.  There aren't that many ways that happens quickly, and MI is probably the most common.  

When we think about ACS or evaluating an MI, there are "anginal equivalents" that put your antennae up...sudden SOB/pulmonary edema is one, so that alone would make me wonder.

Arrythmias can obviously cause some of the same problems, and I don't really think any of us have a clear idea what is going on with the ECG in this scenario, seeing a 12 lead would help with that.


as rmabrey said, pulmonary edema + low BP is a very bad thing; much worse than the more typical acute pulmoary edema with hypertension.
For your listening pleasure: 

http://emcrit.org/podcasts/cardiogenic-shock/


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## Angel (Apr 20, 2014)

awesome site! thanks, and for the feed back too, guys.


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## Handsome Robb (Apr 20, 2014)

Redacted


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## FLdoc2011 (Apr 20, 2014)

Whatever is going on here it's bad.  

Acute Pulm edema is a good thought on what's currently happening, but the question would be from what?  Acute MI/CHF/cardiogenic shock, viral illness/sepsis, alveolar hemorrhage, aspiration are all possibilities.  Lots of other causes as well but they don't fit this scenario. 

PE:  also a possibility.... Tachycardic, hypoxic, hypotensive.

PNA:  didn't say if she had a fever or not and shouldn't really be a completely acute onset but still a consideration.  Would have to ask further questions on the days leading up to this and how she felt.  

Arrhythmia:  I'm still worried about that rate in an 82yr old.  Don't have an ECG yet but would think about rapid afib/flutter causing hemodynamic instability or even vtach given wide complex noted, but a monitor/ECG should let us know there and after some supportive oxygen one of the first things that should be done and would probably dictate further management.   

Clinically looking at her I would get an idea if she appeared fluid overloaded or dry.   If not overtly overloaded and verified to be hypotensive could try a conservative bolus.   

Without knowing more it's hard to agree it disagree with dopamine.  On the surface I would be hesitant with that heart rate and note knowing what the rhythm was, though if truly in shock and that's the only pressor you have then I guess not much choice, but rarely is dopamine my first choice of pressor.   

If work of breathing is increased where she is struggling and/or continued to be hypoxic would put on bipap/CPAP.    Was ETCO2 done?  

Could try some fluid,  if pulm or mental status worsens then intubate.


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## Handsome Robb (Apr 20, 2014)

Now that I'm on a computer I can be a bit more detailed. I think it's been pretty well covered why MI is on the ddx list. Another thought I had is VT could cause APE correct secondary to the poor cardiac output. It doesn't seem fast enough though unless left ventricular function was already compromised. 

If it isn't VT It seems like dobutamine would be a good option if you have it. 

I'd be pretty hesitant to ventilate her unless I absolutely had to. Any sort of PPV is going to cause an increase in intrathoracic pressure especially with PEEP. She's mentating, 92% on the mask and if the pleth form is good and she's not about to tucker out I'd like to let her ventilate herself until we can get her hemodynamically stable but if her airway starts to go I want to try and stay ahead of the game. 

Can I add a question for discussion? If you had to RSI her what meds would you use? I'm thinking fentanyl, ketamine and sux. Ketamine has a good hemodynimic profile and can actually cause transient increases in BP, fentanyl has a good hemodynamic profile as well.


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## NightShiftMedic (Apr 20, 2014)

Robb said:


> Can I add a question for discussion? If you had to RSI her what meds would you use? I'm thinking fentanyl, ketamine and sux. Ketamine has a good hemodynimic profile and can actually cause transient increases in BP, fentanyl has a good hemodynamic profile as well.



I like your ideas of fentanyl and ketamine.  I would probably use roc instead of sux so long as there's no predictors of a difficult airway.  When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.

If this patient gets RSI'd then likely we would need a pressor to support her BP.


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## NightShiftMedic (Apr 20, 2014)

Although, I do understand that a lot of protocols only allow sux as the first paralytic unless it's a dialysis patient or something like that.

With my current protocols it would be etomidate and roc for the initial intubation then fentanyl and midazolam for continued sedation.


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## NightShiftMedic (Apr 20, 2014)

Robb said:


> If it isn't VT It seems like dobutamine would be a good option if you have it.



Or norepinephrine.  I was just reading about this last night.  Apparently there's less mortality with norepinephrine in cardiogenic shock.



Robb said:


> I'd be pretty hesitant to ventilate her unless I absolutely had to. Any sort of PPV is going to cause an increase in intrathoracic pressure especially with PEEP. She's mentating, 92% on the mask and if the pleth form is good and she's not about to tucker out I'd like to let her ventilate herself until we can get her hemodynamically stable but if her airway starts to go I want to try and stay ahead of the game.



I'd definitely say this is the way to go.


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## mycrofft (Apr 24, 2014)

rhan101277 said:


> You are dispatched for the above call, when you arrive at the house you find the fire department is arriving the same time as you.  Upon entering the house and making patient contact you find the patient sitting up in the bed in severe respiratory distress.  You quickly place the patient on 15L NRB and assess lung sounds.  Diffuse coarse crackles are noted, no pedal edema, really no stethoscope is needed to hear these crackles.  pt aaox3, gcs 15, difficulty speaking due to the distress.
> 
> PmHx: HTN
> Medications: Metoprolol
> ...



1. Dying
2. With a quickness.

OP, where are you?


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## alabamatriathlete (Apr 25, 2014)

lmfao to above


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## mycrofft (Apr 25, 2014)

NightShiftMedic said:


> I like your ideas of fentanyl and ketamine.  I would probably use roc instead of sux so long as there's no predictors of a difficult airway.  When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.
> 
> If this patient gets RSI'd then likely we would need a pressor to support her BP.



You are 11,000 feet from the hospital.


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## Handsome Robb (Apr 25, 2014)

mycrofft said:


> You are 11,000 feet from the hospital.



I added the RSI question just to spark discussion. With that said even distance to the hospital isn't a good argument if the patient needs an airway right now. I'm a firm believer of providing care necessary to situate the patient for a successful transport in place. If that means spending a couple extra minutes establishing a patent airway and optimizing ventilation and oxygenation I don't see a problem with it but that's just me. More of the bring the ER to the patient rather than scoop 'em and run. Now if you're in the park across the street I might agree just to take them across the street.

Also, we're only 10, 560 ft from the hospital


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## Handsome Robb (Apr 25, 2014)

NightShiftMedic said:


> I like your ideas of fentanyl and ketamine.  I would probably use roc instead of sux so long as there's no predictors of a difficult airway.  When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.
> 
> If this patient gets RSI'd then likely we would need a pressor to support her BP.



I agree with that. I think it's going to come down to protocol and paralytic of choice at this point. I don't see any contraindications to any paralytics thus far, only reason I said succs was rapid onset in an emergent situation but this is also borderline elective since she is maintaining her own airway at this point.


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## NightShiftMedic (Apr 26, 2014)

Robb said:


> I agree with that. I think it's going to come down to protocol and paralytic of choice at this point. I don't see any contraindications to any paralytics thus far, only reason I said succs was rapid onset in an emergent situation but this is also borderline elective since she is maintaining her own airway at this point.



That makes sense.  I think you could make good arguments either way.


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## mycrofft (Apr 26, 2014)

Robb said:


> I added the RSI question just to spark discussion. With that said even distance to the hospital isn't a good argument if the patient needs an airway right now. I'm a firm believer of providing care necessary to situate the patient for a successful transport in place. If that means spending a couple extra minutes establishing a patent airway and optimizing ventilation and oxygenation I don't see a problem with it but that's just me. More of the bring the ER to the patient rather than scoop 'em and run. Now if you're in the park across the street I might agree just to take them across the street.
> 
> Also, we're only 10, 560 ft from the hospital



I'm a pessimist. And if they're nautical miles, its 12,000 ft. :wacko:

Oxygenation is good, but delay due to placement of difficult case's airways (or unexperienced practitioners) isn't. I repeatedly wish that more can be done "on the move" (in the vehicle and enroute).

Isn't this a ripe scenario for the "I can do anything for you that an ER can" crowd?


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## Handsome Robb (Apr 26, 2014)

mycrofft said:


> I'm a pessimist. And if they're nautical miles, its 12,000 ft. :wacko:
> 
> Oxygenation is good, but delay due to placement of difficult case's airways (or unexperienced practitioners) isn't. I repeatedly wish that more can be done "on the move" (in the vehicle and enroute).
> 
> Isn't this a ripe scenario for the "I can do anything for you that an ER can" crowd?




It'd be cool if we could do these things safely and effectively on the move but we can't. I'm not sticking a laryngoscope blade in someone's mouth going code or non code down the street, that's just asking for trouble. If she's going to arrest before we get to the ER and I can correct the airway and breathing problem that's leading towards the arrest and support their circulation rather than end up doing CPR on them why wouldn't I? 

The snatch and grab culture is really frustrating to me


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## FLdoc2011 (Apr 26, 2014)

I think it's a judgement call.   Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.

In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.

The peri-intubation period is an extremely dangerous time for the patient with a LOT that can go wrong and a lot of potential for decompensation immediately after intubation.  

So if they can be supported for a short trip to a hospital I think that serves the patient better.


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## Handsome Robb (Apr 26, 2014)

FLdoc2011 said:


> I think it's a judgement call.   Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.
> 
> In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.
> 
> ...




I agree. But like you said there are situations where we need to 'stay and play.' This particular patient I do agree that she'd be better served by a quick trip rather than mucking around on scene. Just asked the RSI question to spark some more discussion.


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## Carlos Danger (Apr 26, 2014)

NightShiftMedic said:


> I like your ideas of fentanyl and ketamine.  I would probably use roc instead of sux so long as there's no predictors of a difficult airway.  When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.
> 
> If this patient gets RSI'd then likely we would need a pressor to support her BP.



Why fentanyl and ketamine? Why roc instead of sux? How likely is sux-induced hyperkalemia in this patient, given what was presented by the OP? What do predictors of a  difficult airway have to do with anything? Which pressor would you use and how would you use it?

What do you need to be concerned about with using ketamine in a patient like this? What else could you use and what would your considerations be with those meds? 



FLdoc2011 said:


> I think it's a judgement call.   Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.
> 
> In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly *they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.
> 
> ...



This.


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## mycrofft (Apr 27, 2014)

*"Snatch and run culture" versus "stay and pay" culture.*

Yes, I understand some stuff just isn't safely done on the roll and there are case where "stay and play" pays off in a stabilized pt. But it is frustrating when a case is a tossup as to whether running for definitive care or digging in and struggling to initiate stabilization will yield the better outcome.

We read about case after case where patients tossed into cop cars and raced to ER's survive and their peers expire at the scene in a pile of bloody 4X4's and discarded tubes and sharps. Sometimes it really is a coin toss. (And I know there are cop car expedites who arrive dead too, for sure). 

I don't believe in these as "cultures" (no more than I believe in "hip-hop culture….urp), just two approaches which any practitioner needs to know how to weigh. When we don't either love or hate approaches, we greatly broaden our armamentarium.


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## rhan101277 (Apr 27, 2014)

I need to follow up on this patient but when we arrived she was placed on BiPAP and immediately began improving.  Our protocols state that cpap is contraindicated due to increased intrathoracic pressure for bp's below 90.  I did learn from this call though.  I did not perform a 12 lead because I thought that time would be better used trying to get an IV in.  If it was a STEMI there would be nothing I could do BUT it would be good to inform the hospital and it saves time.  This patient was critical and I wanted to go.  It was wide complex which made me pause, but p waves were present so I figure it was a block.  Next time im going to do the 12 lead, I always do but with this call I didn't and opted just to get to the hospital faster.


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## Handsome Robb (Apr 27, 2014)

What kind of settings did you use for the BiPAP if you don't mind me asking? 

Always learn something every day. I had 12-leads on patients like this drilled into my head, I'd bet it was ugly.


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## rhan101277 (Apr 27, 2014)

Robb said:


> What kind of settings did you use for the BiPAP if you don't mind me asking?
> 
> Always learn something every day. I had 12-leads on patients like this drilled into my head, I'd bet it was ugly.



Don't know about the BiPAP settings this was done at the ER.  We only have CPAP, we need to get BiPAP prehospital though.


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## mycrofft (Apr 27, 2014)

rhan101277 said:


> I need to follow up on this patient but when we arrived she was placed on BiPAP and immediately began improving.  Our protocols state that cpap is contraindicated due to increased intrathoracic pressure for bp's below 90.  I did learn from this call though.  I did not perform a 12 lead because I thought that time would be better used trying to get an IV in.  If it was a STEMI there would be nothing I could do BUT it would be good to inform the hospital and it saves time.  This patient was critical and I wanted to go.  It was wide complex which made me pause, but p waves were present so I figure it was a block.  Next time im going to do the 12 lead, I always do but with this call I didn't and opted just to get to the hospital faster.



In this sort of case where decision is demanded quickly, would it help to try to ask yourself what would the receiving hospital prefer to see coming in the door, a patient along with an IV *or* an EKG *or* ???* I don't know in this case, just asking for thoughts on process .


*Yes, "OR a pulse". Assume that.


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## Handsome Robb (Apr 27, 2014)

mycrofft said:


> In this sort of case where decision is demanded quickly, would it help to try to ask yourself what would the receiving hospital prefer to see coming in the door, a patient along with an IV *or* an EKG *or* ???* I don't know in this case, just asking for thoughts on process .
> 
> 
> *Yes, "OR a pulse". Assume that.



It's going to depend on the situation. If they need an emergent airway and you come in with a  12-lead but no line you're gonna get whomped on but say they're doing decently probably want a 12-lead.


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## mycrofft (Apr 27, 2014)

And then some nurse will yell at you. 
I hate it when we have to yell at innocent EMTs.


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## Handsome Robb (Apr 27, 2014)

mycrofft said:


> And then some nurse will yell at you.
> I hate it when we have to yell at innocent EMTs.



It's pretty rare that we get hollered at by nurses here. We've got a pretty tight knit team and they know if they're rude to us we can make their lives a living hell and visa versa so we all get along pretty well. 

Helps when it's a small enough region that you're on a first name basis with nearly every ERRN and ERP.


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## mycrofft (Apr 28, 2014)

Robb said:


> It's pretty rare that we get hollered at by nurses here. We've got a pretty tight knit team and they know if they're rude to us we can make their lives a living hell and visa versa so we all get along pretty well.
> 
> Helps when it's a small enough region that you're on a first name basis with nearly every ERRN and ERP.



Roger that!


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