# Cardiac asthma



## DrankTheKoolaid (May 4, 2009)

uggg..... missed one tonight. 0130 called to male short of breath.  Get on scene to find patient well know to myself and and my partner sitting upright in his bed a bit pale, warm and dry speaking 8 - 10 word sentences stating increased SOB began at 1500 with no cp/discomfort or nausea vomiting.  Pt denies fever or cough.  Lungs diminished all fields with wheezing everywhere despite his 3 self administered neb's through out hey day.  Patient with long history of prenisone dependent COPD among about a half dozen other respiratory med's, CHF, HTN other conditions.  Patient also on 40 lasix bid.  

PX  - CAOX4, skin pale warm dry, Heent unremarkable with oral mucosa moist and no circumoral cyanosis, JVD not noted, chest bilat equal rise/fall with diminished lung sounds with expiratory wheezing and base line O2 of 89 on 2 L/min via his home O2. Distal CSM intact X 4 with noted 2+ pitting edema to midca
lf which patient stated was his baseline.  VS 172/80, 20 labored, 116 paced without ectopy 98.9 tympanic.  Patient literally lived 1.5 minutes from hospital.  

TX - Loaded and went and started a albuterol en route which bumped his sat to 100.  Arrive ER and he was opened up enough that the doc could hear some fine rales in the bases.  Then treated with another 80 of lasix, and NTG and MS and produced 800 of urine between then and 0430 when we got called to transfer him to another facility at the patients request. 

Im just really disappointed with myself for missing this one.  Any of you guys have a particular trick for sorting this out VS COPD?

Obviously with a longer transport time i would hopefully had been able to hear the fine basilar rales after the treatment, but for the future i want a stronger tool set to seperate these



Corky


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## MSDeltaFlt (May 4, 2009)

Corky said:


> uggg..... missed one tonight. 0130 called to male *short of breath*. Get on scene to find patient well know to myself and and my partner sitting upright in his bed a bit pale, warm and dry speaking *8 - 10 word sentences stating increased SOB began at 1500 with no cp/discomfort or nausea vomiting*. Pt denies fever or cough. *Lungs diminished all fields with wheezing everywhere despite his 3 self administered neb's through out hey day*. Patient with *long history of prenisone dependent COPD* among about a half dozen other respiratory med's, CHF, HTN other conditions. Patient also on 40 lasix bid.
> 
> PX - CAOX4, skin pale warm dry, Heent unremarkable with oral mucosa moist and no circumoral cyanosis, *JVD not noted*, *chest bilat equal rise/fall with diminished lung sounds with expiratory wheezing and base line O2 of 89 on 2 L/min via his home O2. Distal CSM intact X 4 with noted 2+ pitting edema to midca*
> *lf which patient stated was his baseline*. VS 172/80, 20 labored, 116 paced without ectopy 98.9 tympanic. Patient literally lived *1.5 minutes from hospital*.
> ...


 
Over 10hrs of being SOB and he only gave himself 3 nebs?!?  Med/O2 dependent COPD'ers with increased SOB will not get better like this; especially with the liter flow of most home neb machines.

Plus there was no way you could differentiate due to decrased breath sounds.  Your neb in the truck actually helped the ER MD make a definitive Dx.

The only thing that changed, according to your ALS assessment, was breathing difficulty.  There appeared to be no cardiac involvement, so why treat it?

Remember your ABC's.  Pt c/o SOB *without* CP, and you could not hear any Rales.  You, my friend, were stuck on "B".  If you would have had CP, then you would have been stuck on "B" and "C".  Then you could have used a bit of NTG and/or lasix (NTG's faster).  Add to that the less than 2 min trip, I'd have missed that, too.

Don't sweat it, dude.  You did fine.


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## bonedog (May 4, 2009)

Short transport times make these calls hard.

I look at SOBOE, PND, orthopnea, productive cough, Rx compliance, diet, bowel habits any changes in recent health, helps point me which way I will proceed.

Often rales are absent in old COPD patients due to the changes in elasticity of the small airways.

Sometimes beta agonists will reveal this, one must also be cognizant of the increased work load in the failing heart also. Often CPAP is a good alternative till a definite differential is decided on.

These are some of our toughest calls, like MSD alludes to, don't sweat it.


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## vquintessence (May 5, 2009)

Wonder why the EMD jumped into giving the MS04?


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## TomB (May 5, 2009)

Differential diagnosis of shortness of breath is difficult, especially for patients with comorbidities. The fact that you recognize that it's difficult bodes well for your career in the emergency services. There is no "trick" that is 100%.


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## Onceamedic (May 5, 2009)

How old was your patient?  Did you put them on the cardiac monitor?  Do you have 12 lead capabilities?


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## DrankTheKoolaid (May 5, 2009)

*re*

56 male,  fully paced at 116, no 12 lead nor would i have taken the time with such a short eta.  Bu yeah anything longer and a 12 lead would have been in order.  Just waiting on a funding source before we get em.


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## triemal04 (May 5, 2009)

Not much to add that hasn't been said already.  Unfortunately, if you don't have 12lead capabilities then I'm guessing you also don't have the ability to measure ETCO2 levels and capnography.  This would have been the perfect time to use them and would have helped with a diagnosis...might bring that up with your supe and push for it...


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## 46Young (May 7, 2009)

I'm assuming that with an increase in pulse ox, and an increase in air exchange post neb, the pt was feeling more comfortable. A more prudent approach would be to attach an in-line neb to CPAP. You were right around the corner from the hospital. Your actions were wholly justifiable due to his Hx and comorbidities. He was tight, with wheezing, no JVD, and no discernable rales at the moment. I would have leaned toward COPD exac. vs APE, as you did. The pitting edema is likely chronic, and we treat rales, not peripheral edama, anyway. The albuterol likely opened up surface area for air exchange, is what the pt needed most. If you had a longer txp, and the pt flashed, you have the tools to battle that, anyway. That's why an in-line neb would be indicated, to help mitigate any increase in pulmonary edema, as well as ease the pt's effort in breathing. Bottom line, your actions resulted in an improvement in the pt's condition. The pt felt better. You didn't do anything(or not do anything) that another competent medic wouldn't do.


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## VentMedic (May 7, 2009)

Corky said:


> TX - Loaded and went and started a albuterol en *route which bumped his sat to 100.*


 


46Young said:


> I'm *assuming that with an increase in pulse ox,* and an increase in air exchange post neb, the pt was feeling more comfortable.


 
Was the nebulizer powered by 6 L of oxygen? 

Rarely will this type of  patient have just one component to treat.   The whole disease process of COPD, Cor Pulmonale and hypoxic pulmonary vasoconstriction may need to be considered.


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## DrankTheKoolaid (May 8, 2009)

*re*

Yeah we dont run our treatments on anything other then 6-8 L/min, though i know in the ER i use room air concentrators to run nebs quite often per MD preference


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## 46Young (May 8, 2009)

I said "assuming" because no mention of the pt's appearance, positioning, or perceived effort of breathing was mentioned post neb. Of course Cor Pulmonale(RVH) and hypoxic pulmonary vasoconstriction will impair Rt ventricular function.


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## DrankTheKoolaid (May 8, 2009)

*re*

yeah he was still in the middle of the neb when i transfered care over, didnt see him after.  Well at least not until hours later when he was transfered out


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## VentMedic (May 8, 2009)

Corky said:


> yeah he was still in the middle of the neb when i transfered care over, didnt see him after. Well at least not until hours later when he was transfered out


 
That would explain the SpO2 of 100%.   If I could just go one day without hearing "give him a neb, it raises his SpO2" which is great except I hear the same thing 20 minutes later after the 6  L of O2 has been removed for a few minutes.


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## DrankTheKoolaid (May 8, 2009)

*re*

yeah i really love rural EMS for just this reason.  99.9% of my calls are NOT short ETA and i get to actually see the effects of my treatments and get down to the second and third line medications and see there effects.  This one just really sucked being so close to the ED


Corky


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## zzyzx (May 8, 2009)

Corky, you didn't do anything wrong. The only "mistake" I see you making is in trying to put this patient into only one category: CHF vs COPD. This guy has both, so why not consider that he's got two things going on at the same time? I wouldn't call this "cardiac asthma."

Wouldn't it be nice if all our patients read the same textbooks we do?


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## 46Young (May 8, 2009)

VentMedic said:


> That would explain the SpO2 of 100%.   If I could just go one day without hearing "give him a neb, it raises his SpO2" which is great except I hear the same thing 20 minutes later after the 6  L of O2 has been removed for a few minutes.



When I assumed that the pt improved with the neb, in addition to the SpO2 increase, the pt's lungs opened enough to hear the rales. I attributed this to the albuterol admin. I would think that the 4lpm increase in supplemental O2 contributing to the improvement in pt condition goes without saying.


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## VentMedic (May 8, 2009)

46Young said:


> When I assumed that the pt improved with the neb, in addition to the SpO2 increase, the pt's lungs opened enough to hear the rales. I attributed this to the albuterol admin. I would think that the 4lpm increase in supplemental O2 contributing to the improvement in pt condition goes without saying.


 
You will also hear different breath sounds at the patient changes positions which is why we study lung segments and not just the lobes.   There are also many other disease processes that present with crackles or rales.   Pts can also have many of the 'osis disease processes in combination with COPD as well as PNA.   Thus the reason only a BNP and CXR will make the definitive diagnosis.


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## DrankTheKoolaid (May 8, 2009)

*re*

aye agreed Vent, he bumped his bnp that evening more then his his baseline elevation


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