# Big Heart



## MrBrown (Dec 30, 2009)

You're send down to the local doc in a box (urgent care) for a shortness of breath.

O/A 86 yom with chest discomfort for 5 days had sob for 6-8 hours, is pale and anxious, increased wob incl acc muscle use but no cyanosis pt states has felt fluey and unwell for about a week, no pmhx, nka

O/E GCS 14 (4/5/5) BP 98/68 RR 16 laboured HR 65 SPO2 90% on 3lpm NC temp 38.5° BS mid and basalar crackles, 12 lead ECG negative for MI but does show new onset 1° AVB and multifocal PVCs 

Chest x-ray shows enlarged right heart 

What are you going to do ..... and more importantly what are you *not* going to do, and why?


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## DV_EMT (Dec 30, 2009)

High flow O2, blankets, rapid transport... maybe use bolus fluids (NS most likely) just to be safe.


I'd avoid any nitro because the BP is so low.


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## MrBrown (Dec 30, 2009)

I can't edit it but let me put in another question:

- If the BP was say, 140/100 how would that change your treatment modality?


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## DV_EMT (Dec 30, 2009)

MrBrown said:


> I can't edit it but let me put in another question:
> 
> - If the BP was say, 140/100 how would that change your treatment modality?



I'd still be gun shy bout giving nitro... since there is no signs of an MI/STEMI, i'd be more likely to give a low dose aspirin as opposed to the nitro. do you have a pt list of meds as well? that might help for any ALS personnel (not so much for us BLS folk)?


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## MrBrown (Dec 30, 2009)

no meds


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## reaper (Dec 30, 2009)

Think preload!


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## MrBrown (Dec 30, 2009)

reaper said:


> Think preload!



Meaning what exactly?


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## Scott33 (Dec 30, 2009)

Sounds like CHF.

Any pedal edema, ascites, JVD? Productive cough? Skin turgor?

No meds - possible new onset. 
Right-sided EKG?
Usual diet?
General appearance?

No Pmhx - When did he last see his doctor? How often does he see his doctor? What for? Family medical history? Surgical history? Daily Routine? Smoker? Drinker? Any change in sleeping habits?

Do you have CPAP over there?


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## Scott33 (Dec 30, 2009)

DV_EMT said:


> High flow O2, blankets, rapid transport... maybe use bolus fluids (NS most likely) just to be safe.



In someone who has fluid halfway up their lungs?


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## NomadicMedic (Dec 30, 2009)

CPAP and access. No fluid, but a saline lock.

Depending on the length of transport, I'd consider some SL nitro.


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## rescue99 (Dec 30, 2009)

n7lxi said:


> CPAP and access. No fluid, but a saline lock.
> 
> Depending on the length of transport, I'd consider some SL nitro.



I second this!


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## MrBrown (Dec 30, 2009)

Scott33 said:


> Sounds like CHF.
> 
> Any pedal edema, ascites, JVD? Productive cough? Skin turgor?
> 
> ...





n7lxi said:


> Depending on the length of transport, I'd consider some SL nitro. !



Why do you want to give this patient GTN?


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## rhan101277 (Dec 30, 2009)

MrBrown said:


> You're send down to the local doc in a box (urgent care) for a shortness of breath.
> 
> O/A 86 yom with chest discomfort for 5 days had sob for 6-8 hours, is pale and anxious, increased wob incl acc muscle use but no cyanosis pt states has felt fluey and unwell for about a week, no pmhx, nka
> 
> ...



I'm worried about pulmonary perfusion as well as him not getting enough gas exchange due to fluid.  I am going to stick him on NRB @ 15L, 40mg furosemide pushed SLOWLY.  If he has to potty, he has to potty.  This fluid needs gone and this problem needs to be fixed to see if perhaps once it clears up his vitals clear up.  An SPO2 of 90% is roughly equivalent to 60% PaO2 which isn't good.

Now he will need monitored very closely, I would be concerned about his blood pressure dropping as the effects of furosemide kick in, but I think he would be at hospital before any worries.  I would consider nitro if he continued to deteriorate but it wouldn't be my first thought.  Mid-clavicular and basalar crackles must be fixed.  It doesn't matter how much blood his heart is getting, if he isn't getting enough gas exchange.

I will also stick him on waveform capnography to see if treatment is working.

P.S. this a good scenario


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## Shishkabob (Dec 30, 2009)

With a bp in the 90/60's, the problem isn't excess fluid, so giving him Lasix will only compound the bad juju of a lowering blood pressure.


It depends on your specific protocols, but many places won't allow you to push Nitro, Lasix OR morphine if Bp is below 100 (or 90, depending). 





I'd skip the nitro, lasix and morphine all together, if we're making 100mmHg the cutoff, and go CPAP while preparing to intubate / RSI, depending on how the CPAP improves him or not.


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## MrBrown (Dec 30, 2009)

rhan101277 said:


> I'm worried about pulmonary perfusion as well as him not getting enough gas exchange due to fluid.  I am going to stick him on NRB @ 15L, 40mg furosemide pushed SLOWLY ... I would be concerned about his blood pressure dropping as the effects of furosemide kick in, but I think he would be at hospital before any worries.



I would shy away from fruseomide personally, if you bum his pressure out we can't pump it back up and we run the risk of depleting his K or Na and causing more stress on his buggered conduction system.

Now I need a cardiac arrest, but i'm not into making them!

You may not have meant it this way but the "we will be at ED before any problems" could sound like "it wont be my problem anymore", I'm not into handing ED a patient I made worse! 





rhan101277 said:


> I would consider nitro if he continued to deteriorate but it wouldn't be my first thought.  Mid-clavicular and basalar crackles must be fixed.  It doesn't matter how much blood his heart is getting, if he isn't getting enough gas exchange.
> 
> I will also stick him on waveform capnography to see if treatment is working.



I would be very judicious with GTN, if we lower his pressure much and decrease preload it's going to worsen his edema and .... the only thing we could do to pump him back up would be fluid but he is already overloaded so I'm leaning away from any nitrates


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## MrBrown (Dec 30, 2009)

Linuss said:


> I'd skip the nitro, lasix and morphine all together, if we're making 100mmHg the cutoff, and go CPAP while preparing to intubate / RSI, depending on how the CPAP improves him or not.



CPAP is good stuff


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## rhan101277 (Dec 30, 2009)

MrBrown said:


> I can't edit it but let me put in another question:
> 
> - If the BP was say, 140/100 how would that change your treatment modality?



So what BP are we going with, I thought it was 140/100?


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## rhan101277 (Dec 30, 2009)

Linuss said:


> With a bp in the 90/60's, the problem isn't excess fluid, so giving him Lasix will only compound the bad juju of a lowering blood pressure.
> 
> 
> It depends on your specific protocols, but many places won't allow you to push Nitro, Lasix OR morphine if Bp is below 100 (or 90, depending).
> ...



You can still have excess fluid with low pressure.  You have the osmotic pressure not being high enough to move the fluid where it needs to go.


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## MrBrown (Dec 30, 2009)

The actual BP was 96/68 

However, theoretically, *if* the BP was 140/100, would that change your treatment?

Two part question


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## DV_EMT (Dec 31, 2009)

MrBrown said:


> The actual BP was 96/68
> 
> However, theoretically, *if* the BP was 140/100, would that change your treatment?
> 
> Two part question



with low BP like that... i'd still go the bolus NS route... did we determine pedal edema?


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## rhan101277 (Dec 31, 2009)

MrBrown said:


> The actual BP was 96/68
> 
> However, theoretically, *if* the BP was 140/100, would that change your treatment?
> 
> Two part question



Oh I see, yeah no lasix with systolic BP under 100mmHg


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## MrBrown (Dec 31, 2009)

rhan101277 said:


> Oh I see, yeah no lasix with systolic BP under 100mmHg



What about GTN?



DV_EMT said:


> with low BP like that... i'd still go the bolus NS route... did we determine pedal edema?



Would you give fluid with mid & baslar crackles? 

Is this patient hypovolemic or third spaced?


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## LondonMedic (Jan 2, 2010)

DV_EMT said:


> with low BP like that... i'd still go the bolus NS route... did we determine pedal edema?


You'll drown him before you pull his BP up to 'normal'. The cause of low BP in this case is unlikely to be low volume (although of course CCF punters can bleed or get dehydrated just like any other) and although you _could_ force the BP up with colloid you'll ultimately be making the cardiogenic problem worse.


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## LondonMedic (Jan 2, 2010)

MrBrown said:


> Would you give fluid with mid & baslar crackles?


Sometimes. But more judiciously.


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## 18G (Jan 2, 2010)

With a description of being "fluey", has the patient had any cough, chills or generalized weakness? What is the quality of the chest discomfort? How frequent are the PVCs?

Given the chest discomfort for 5 days, dyspnea, crackles, and presence of fever (101.5F), poor skin turgor, decreased SpO2, and productive cough, all combined with this patients age... I'm thinking pneumonia. 

Now with the slight JVD and pedal edema along with the EKG changes we also have obviously some cardiac involvement. Usually, CHF patients do not present with a fever. Could there be a myocarditis? Pericarditis usually presents with ST elevation in all the leads which none was reported. 

With the presence of fever, Im looking for an infectious process as the culprit to the patients problem. Although, perhaps the pt. has more than one problem going on as well. I've had a patient with severe bilateral pneumonia who was filled with fluid who presented similar to this patient. 

What is the doctor thinking at the clinic? His input would be helpful in developing a treatment plan. This patient could very well be dehydrated as well. 

As far as treatment...
Given this patient is having obvious issues with gas exchange with the crackles, I would place the pt. on CPAP to improve ventilation and recruit atelectatic areas of the lung (alveoli that collapsed due to being filled with fluid) to participate in gas exchange. With the low B/P, there is a small risk of further reducing it so a watchful eye on the B/P will also be had. Although at a PEEP of less than 10cm/H2O, this should not be a problem. 

If pt. does not respond or tolerate CPAP, pt. will need to be nasally intubated.

IV at KVO... if pressure drops I would give a 250mL bolus (perfectly okay for CHF) and see what that does. If pressure continues to drop, than dopamine. 

As long as the pressure maintains less than a 100, NTG and captopril are both out. 

I think as long as we can improve this patients ventilation and oxygenation and reduce the workload of the heart with CPAP, we can stabilize and improve patients conditions until arrival at the hospital. 

Quite possibly, this patient may need antibiotics to treat the underlying cause.


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## LondonMedic (Jan 2, 2010)

18G said:


> Given this patient is having obvious issues with gas exchange with the crackles, I would place the pt. on CPAP to improve ventilation and recruit atelectatic areas of the lung (alveoli that collapsed due to being filled with fluid) to participate in gas exchange. With the low B/P, there is a small risk of further reducing it so a watchful eye on the B/P will also be had. Although at a PEEP of less than 10cm/H2O, this should not be a problem.


Would you prone him?


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## 18G (Jan 2, 2010)

Prone? As in lay the patient face down?


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## exodus (Jan 2, 2010)

LondonMedic said:


> Would you prone him?



So with the lungs sounding the way they do, you want to lay him face down flat so any blood or fluid building in in the lungs can move all over the rest of the alveoli! Awesome... He's staying fowlers.


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## LondonMedic (Jan 2, 2010)

exodus said:


> So with the lungs sounding the way they do, you want to lay him face down flat so any blood or fluid building in in the lungs can move all over the rest of the alveoli! Awesome... He's staying fowlers.


Blood? What do you think is going on with this chap?

(And the lungs will already be doing a good job of moving the fluid up and down)


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## 18G (Jan 2, 2010)

Anymore info on this scenerio? I'm interested in knowing the diagnosis.


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## MrBrown (Jan 2, 2010)

It was myocarditis.

The big issues here was differentiating between left and right ventricular failure as there are obvious contraindications to GTN, fluid and possibly frusemide in the setting of RVF.

I posed this scenario with two possible BPs as the actual BP (98/68) contraindicates GTN whereas say, 150/110 does not while if we look at what is happening I wouldn't be the first to use it.  The lower BP may in the minds of some providers indicate fluid however if we take the large clinical picture of pump insufficency causing the pedal edema, JVD and crackles fluid would be contraindicated.  

Some also have problems differentiating between hypovolemic (low volume) and third spacing (such as in cardiogenic edema, the volume is not "low" but rather in the wrong place and if we pump him full of fluids its not ging to help).


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## 18G (Jan 2, 2010)

Thanks for posting the diagnosis. Good scenario.

Was this a real patient? If so, how did the providers manage them in the field?


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## MrBrown (Jan 2, 2010)

lots of o2 and transport


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## Jeffrey_169 (Jan 9, 2010)

For the patient I would not be giving IV fluids. It seems fairly obvious to me he is experiencing Right Sided Heart Failure, and although I would state and IV it would be a hep lock/ Saline lock. I wold position the patient in POC (probably Fowler's position) and off the hospital we would go Lots of O's for this patient as well. While in route I would certainly consider the administration of an diuretic to get some fluid off his lungs.


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