# Respiratory emergency question



## redbull (Jul 6, 2010)

If a patient has a normal respiratory rate and pulse but is CYANOTIC, would you give him positive pressure ventilation with supplemental oxygen or a nonrebreather mask via 15 lpm?


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## lampnyter (Jul 6, 2010)

i would do a NRB unless his RR is 8 or under or extremely fast.


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## MrBrown (Jul 6, 2010)

No, what does objective clinical evidence tell us? Does he have signs of hypoxaemia?

If so, then yes, he would recieve supplumental oxygen; if not, then no

SPO is an adjunct to a good thorough assessment and not a replacement


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## Aidey (Jul 7, 2010)

It would probably totally depend on the patient's underlying condition. If the patient is hypoxic with a normal respiratory rate and pulse that indicates that the patient's compensatory mechanisms are not working properly. I want to know why.


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## LondonMedic (Jul 7, 2010)

What does the gas show?


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## redbull (Jul 7, 2010)

Didn't say hypoxic, just cyanotic in CAPS on the quiz. I went back to the Brady text and i figured since the patient has normal breathing and pulse then it's a non-rebreather. But the Cyanotic part threw me off.


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## 18G (Jul 7, 2010)

When looking at a patient and determining if they are getting enough oxygen you have to look at more than just the respiratory rate. 

Think minute volume which is the amount of air in and out in a minute (very important). Respiratory rate is just one part of minute volume... the other part is tidal volume which is assessed in the field by looking at the depth of respiration. If they are breathing at 20min but very shallow than their tidal volume is decreased and they may not be ventilating with a minute volume high enough to meet the body's demands. 

If a patient is cyanotic, than they are also hypoxic for whatever reason.

To answer your question based on what info was provided... I would try a NRB at 15lpm and if no improvement quickly I would start positive-pressure ventilation. Since the patient has spontaneous resp at a normal rate, you would want to do overdrive ventilation..


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## sdadam (Jul 7, 2010)

As this is in the BLS section I'll assume the question is out of your BLS textbook.

The answer is 15lpm. NRB. In the DOT curriculum you are looking for less than 8 or greater than 24 respiratory rate for BVM.

(Yes everybody I know how much more to the decision to use PPV there is. And yes, I understand there is much more to discuss about the pt condition in this example, however if this is a question out of the EMT textbook, the answer is 15lpm. NRB, that's all I'm sayin')


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## Aidey (Jul 7, 2010)

redbull said:


> Didn't say hypoxic, just cyanotic in CAPS on the quiz.



Cyanosis is a sign of hypoxia. Either that, or your patient is a smurf. ^_^


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## WolfmanHarris (Jul 7, 2010)

How's my SAT? How's their effort of breathing and LOC/LOA? What are the rest of the vitals in context, are they the text book HR of 72 or their normal resting HR? A HR of 60, with a RR of 12 in an person w/ decreased LOA may be pre-arrest if they've been in severe repsiratory distress so far and are no longer able to compensate. What's my ETCO2 show? 

Depending on the entire clinical picture we may be looking at NRB, BVM or CPAP.


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## Sandog (Jul 7, 2010)

sdadam said:


> As this is in the BLS section I'll assume the question is out of your BLS textbook.
> 
> The answer is 15lpm. NRB. In the DOT curriculum you are looking for less than 8 or greater than 24 respiratory rate for BVM.
> 
> (Yes everybody I know how much more to the decision to use PPV there is. And yes, I understand there is much more to discuss about the pt condition in this example, however if this is a question out of the EMT textbook, the answer is 15lpm. NRB, that's all I'm sayin')




Are you my instructor?


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## sdadam (Jul 8, 2010)

Who knows!

What school are you attending, I just might be. ;-)


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## Sassafras (Jul 8, 2010)

I asked a question similar to this in class, and was told that it was dependant upon their level of conciousness.  If they are sitting up, concious albeit freaked out b/c they are in respiratory distress, good luck getting them to lie down to be bagged.  They get a nrb.  Unconcious or barely concious, laying down, bvm.


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## FLEMTP (Jul 8, 2010)

I say CPAP...or just intubate them all.. and ask questions later!


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## MrBrown (Jul 8, 2010)

FLEMTP said:


> I say.. just intubate them all.. and ask questions later!



Now now mate, that thinking might just land you a job as a helicopter doctor! 

I misread that in the first instance, if the patient is cyanosed and showing sings of hypoxameia then I would provide some supplumental oxygen.

Am I going to cram 15 litres down thier throat? No, simply because if thier FiO2 is normal then what good is massively increasing the amount of oxygen they are getting?

My guess is that thier SvO2 is not high enough which points to some sort of oxygenation problem rather than a ventialory issue.  Oyxgenation and ventilation are not the same thing.

And as for that ABG um .... who took my iStat machine? 

Oh, um ... and how do you read an ABG? Maybe knowing that is important hmm ...


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## PrincessAnika (Jul 15, 2010)

redbull said:


> If a patient has a normal respiratory rate and pulse but is CYANOTIC, would you give him positive pressure ventilation with supplemental oxygen or a nonrebreather mask via 15 lpm?



depends on the pt - why are they cyanotic?  are you sure it is hypoxic cyanosis?  (IOW, were they swimming in cool water for the last half hr and just cold?)  pt by pt, medical hx as a factor, on the street i would go supplemental O2 via NC or NRB; i would consider BVM for an unresponsive or severely AMS pt.  would also want to know depth of resps - if the pt is breathing normally but esp shallow that could be contributing.     on a test, as a test question, with no other information, i would give NRB @15lpm.



WolfmanHarris said:


> How's my SAT?



i hate pulse ox.  treat the pt not the machine/monitor/numbers.  pulse oximetry is not a reliable tool....


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## WolfmanHarris (Jul 15, 2010)

PrincessAnika said:


> i hate pulse ox.  treat the pt not the machine/monitor/numbers.  pulse oximetry is not a reliable tool....



Horse hockey. A good piece of advice on avoiding tunnel vision has become this weird pseudo-luddite mantra. A thorough understanding of your equipment, it's limitations and how it works tells you a great deal about the patient's condition, that cannot be gained through physical and history alone.

Pulmonary embolism are extremely atypical in their clinical presentation, but a 12 lead may detect it. (S1Q3T3 pattern)

An otherwise healthy young person may present with fairly classic ischemic CP w/o any Hx of drug use. Without a 12 lead you may not Dx percarditis. (Global ST elevation)

A simple lift assist of an extremely elderly person may get signed off, but a simple SPO2 clues you in to the underlying hypoxia as the cause of the weakness and you decide to transport despite no other significant clinical signs. Remember the elderly do not always present with clear S&S.

ETCO2 waveform can detect bronchospasm and the progress of it's resolution with treatment.

I could go on.

The fact is modern medicine relies on diagnostic equipment and labs as important tools in diagnosis and treatment plans. We need to embrace our equipment and it's limitations as important in forming proper, full assessments and treatment plans.


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## WolfmanHarris (Jul 15, 2010)

MrBrown said:


> And as for that ABG um .... who took my iStat machine?



I'm looking forward to the day in my career when we start doing on scene cardiac markers. Maybe even lactate for sepsis screening (is that 85 y/o generally unwell a failure to thrive or are they septic? Can they wait hours or be offloaded into subacute, or do they need aggressive treatment?)


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## Shishkabob (Jul 15, 2010)

PrincessAnika said:


> i hate pulse ox.  treat the pt not the machine/monitor/numbers.  pulse oximetry is not a reliable tool....



Actually, pulse ox is a VERY reliable tool, so long as you know how to interpret it and understand to not take it at face value.


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## PrincessAnika (Jul 15, 2010)

Linuss said:


> Actually, pulse ox is a VERY reliable tool, so long as you know how to interpret it and understand to not take it at face value.



IF.  that's a really big IF.  far too many people (in and out of hospital) look at the pulse ox and numbers, and fail to provide pts with proper care, bc "the number is 'normal' "  - example of this is the pt my husband had 2 wks ago - older fm, resp distress, tripoding, normal color, etc...  98% RA.   nurse in ER wants to know why pt is on oxygen "bc her sats are normal" - keep in mind pt is still tripoding....
yes, used properly, it can be great, but used at the expense of proper pt care....


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## jonpw52 (Jul 15, 2010)

If he is CYANOTIC then you have to bag him. That means his breathing no matter what the rate, is inadquate.


_______________________

I NEED MEDICS, MEDICS!!!


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## Shishkabob (Jul 15, 2010)

jonpw52 said:


> If he is CYANOTIC then *you have to bag him*.



No.


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## WolfmanHarris (Jul 15, 2010)

jonpw52 said:


> If he is CYANOTIC then you have to bag him. That means his breathing no matter what the rate, is inadquate.



Incorrect.


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## CAOX3 (Jul 15, 2010)

jonpw52 said:


> If he is CYANOTIC then you have to bag him. That means his breathing no matter what the rate, is inadquate.
> 
> 
> _______________________
> ...



Ventilation and oxygenation are two different animals.


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## jjesusfreak01 (Jul 16, 2010)

Ill try to make this as simple as possible. At a basic level, you are probably not going to be able to consider the CPAP. So, that leaves us with NRB and BVM.

If the patient is breathing adequately, regardless of all else, they get an NRB. If the patient is breathing inadequately, then they get the BVM.

Adequate breathing has 2 components, rate and volume. You have to have both adequate rate and volume to be breathing adequately. Adequate rate can be as low as ~10 breaths per minute and as high as ~20. Adequate volume is indicated by good chest rise and fall. 

Low rate (10) and good volume can be just fine, as can high rate(20) and moderate volume can be too. You should be able to simply look at a patient and very quickly know if their breathing is adequate or inadequate.

Note: If someone is breathing adequately and is cyanotic, how would hooking them up to a BVM help? They will be getting just as much oxygen as on an NRB.


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## clibb (Jul 16, 2010)

jonpw52 said:


> If he is CYANOTIC then you have to bag him. That means his breathing no matter what the rate, is inadquate.
> 
> 
> _______________________
> ...



Annnnd if he's unresponsive you begin CPR too right? 

Cyanotic just means give him oxygen. Sp02 lower then 90, then bag him. Patient could be Cyanotic due to a lot of different problems. But if it's due to lack of oxygen, then give him some! 




jjesusfreak01 said:


> Note: If someone is breathing adequately and is cyanotic, how would hooking them up to a BVM help? They will be getting just as much oxygen as on an NRB.



Wrong. With a BVM you fill the lungs (800cc but around 150cc of that is dead space) better and my sufficient then you would with a regular mask. Since you are pushing the air into the lungs. With a regular 15lpm mask, you're really not pushing any air into the patient's lungs. 

Now if you have a patient that is 10 bpm and is cyanotic, you have a problem. You'll be able to see if he's struggling with the use of his accessory muscles.  



PrincessAnika said:


> IF.  that's a really big IF.  far too many people (in and out of hospital) look at the pulse ox and numbers, and fail to provide pts with proper care, bc "the number is 'normal' "  - example of this is the pt my husband had 2 wks ago - older fm, resp distress, tripoding, normal color, etc...  98% RA.   nurse in ER wants to know why pt is on oxygen "bc her sats are normal" - keep in mind pt is still tripoding....
> yes, used properly, it can be great, but used at the expense of proper pt care....



The nurses asked why? Treat the patient not the machine. Since it's a female, if she had nail polish on it could misread the whole pulse ox. Also, oxygen is a courtesy


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## jjesusfreak01 (Jul 16, 2010)

clibb said:


> Wrong. With a BVM you fill the lungs (800cc but around 150cc of that is dead space) better and my sufficient then you would with a regular mask. Since you are pushing the air into the lungs. With a regular 15lpm mask, you're really not pushing any air into the patient's lungs.
> 
> Now if you have a patient that is 10 bpm and is cyanotic, you have a problem. You'll be able to see if he's struggling with the use of his accessory muscles.



And that there would be one of the perfect indicated uses of the CPAP (anytime a person is breathing adequately through a NRB but you think they could still use more air), which basics cannot use. Sure, if a person isn't breathing quickly or deeply enough you can assist with a BVM and match their respirations, but honestly if they are already breathing adequately (and this is the only situation I am talking about) are you going to be able to get much more air into them than they can get from their own respirations? They bag and reservoir on the BVM only holds so much, and a patient breathing normally will probably take in most --> all of that, right? This is kind of a silly argument though because the situation you list is a clear CPAP case. If they are cyanotic with a NRB mask at 15lpm then you need to be looking for other serious causes while ALS is on the way, not worried about forcing respirations through the BVM.


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## Shishkabob (Jul 16, 2010)

Erm... you don't use CPAP if they are "breathing adequately and just need more air"


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## jjesusfreak01 (Jul 16, 2010)

Linuss said:


> Erm... you don't use CPAP if they are "breathing adequately and just need more air"



You know what I mean. Respiratory distress where they may have ok tidal volume, good rate, but are a patient that could benefit from a higher volume. As well as of course the classic uses of CPAP prehospital like pulmonary edema.

When would you use the CPAP in a pre-hospital setting?


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## clibb (Jul 16, 2010)

jjesusfreak01 said:


> And that there would be one of the perfect indicated uses of the CPAP (anytime a person is breathing adequately through a NRB but you think they could still use more air), which basics cannot use. Sure, if a person isn't breathing quickly or deeply enough you can assist with a BVM and match their respirations, but honestly if they are already breathing adequately (and this is the only situation I am talking about) are you going to be able to get much more air into them than they can get from their own respirations? They bag and reservoir on the BVM only holds so much, and a patient breathing normally will probably take in most --> all of that, right? This is kind of a silly argument though because the situation you list is a clear CPAP case. If they are cyanotic with a NRB mask at 15lpm then you need to be looking for other serious causes while ALS is on the way, not worried about forcing respirations through the BVM.



To be honest with you I've heard that the CPAP aren't used that much anymore. Yeah, I've had a CPAP used on me just to try it out and it does force air into your lungs.
*If a person is breathing adequately, you should only be giving them oxygen through Nasal Cannula (2-6 LPM) or NRB (12-25 LPM)*
The BVM holds enough air to fill your lungs and to increase you Sp02 to 98% or above state. 
If the person is Cyanotic, breathing adequately, and CONSCIOUS. I am going to put them on 15-25 lpm NRB, if that doesn't work (which would be very weird) I will BVM then against their will . Now if they are Cyantic, inadequate breaths and unconscious I'll use my BVM hooked up to oxygen. 
With a CPAP it's easier to damage and/or hyperventilate a patient then it is with the BVM. Remember, machine determines pressure and rate while with the BVM you determine pressure and rate. At least with the CPAP I used in my class.


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## Shishkabob (Jul 16, 2010)

There is so much wrong with this thread it's starting to hurt. 

25lpm NRB? 

Holds enough air to increase spo2 to 98%? 

CPAP not used much anymore? 

Bvm against their will if nrb doesn't work? 


CPAP determines pressure and rate on it's own?


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## clibb (Jul 16, 2010)

Linuss said:


> There is so much wrong with this thread it's starting to hurt.
> 
> 25lpm NRB?
> 
> ...



We were taught we could do 12-25 lpm via nrb.
I've never see anyone do 25 lpm though, that would dry you out in no time.
With enough air to increase spo2 I meant that the BVM holds a close value of air that the lung does. I didn't mean like it was Miami Medical where you can increase spo2 from 88% to 98% with one puff.
CPAP is not used around here anymore is what I've been told. I've never seen it on any rigs  that I've been on around here. 
BVM against their will was a joke, hint the smiley face... I'm not a comedian, I know.


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## WolfmanHarris (Jul 16, 2010)

People it's time to expand the depth of your education. It's apparent that there's a great deal of rote learning being applied incorrectly based on experience and misunderstanding.

Here are some concepts worth learning about at any level of training:
- Oxy-hemoglobin dissociation curve
- Acid-base balances
- FIO2 of various breathing devices (for example, what increase in approximate FIO2 can one expect by increasing flow rate from 10lpm to 25 lpm?)
- Positive End Expiratory Pressure (especially in regards to CPAP)
-Ventilation vs. oxygenation vs. perfusion

I am by no means an expert on respiratory care, but these concepts are absolutely vital to understanding how oxygen does and doesn't benefit patients.


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## jjesusfreak01 (Jul 16, 2010)

My instructor has gone on and on about how much he loves the CPAP for respiratory patients. I think primarily CHF and COPD patients, but also for pneumonia and asthma patients in my county. Can you think of a faster way to help a CHF patient suffering from pulmonary edema than nitro and a CPAP?


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## CAOX3 (Jul 16, 2010)

Linuss said:


> *There is so much wrong with this thread it's starting to hurt. *
> 25lpm NRB?
> 
> Holds enough air to increase spo2 to 98%?
> ...



That could be the understatement of the year!


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## Cawolf86 (Jul 16, 2010)

We should rename this thread - how _not_ to handle a respiratory emergency.


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## MrBrown (Jul 16, 2010)

WolfmanHarris said:


> People it's time to expand the depth of your education. It's apparent that there's a great deal of rote learning being applied incorrectly based on experience and misunderstanding.
> 
> Here are some concepts worth learning about at any level of training:
> - Oxy-hemoglobin dissociation curve
> ...



+10 my Canadian friend!


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## iamajammer (Jul 25, 2010)

jjesusfreak01 said:


> My instructor has gone on and on about how much he loves the CPAP for respiratory patients. I think primarily CHF and COPD patients, but also for pneumonia and asthma patients in my county. Can you think of a faster way to help a CHF patient suffering from pulmonary edema than nitro and a CPAP?



I could maybe understand the cpap for a CHF patient, but for COPD, probably not. Typically you would use a Bipap or no more than 28% O2 for your copd patient. The reason is, most COPD's have an obstructive component (emphysema), which basically causes you to air trap and retain high CO2 levels. A CPAP may help slightly, but you really want to ventilate these patients, not better oxygenate them. 

As for a faster way to help a CHF patient, you would want to consider also giving lasix.


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## MrBrown (Jul 25, 2010)

iamajammer said:


> As for a faster way to help a CHF patient, you would want to consider also giving lasix.



*Brown taps his foot for twenty minutes waiting for the frusemide to work while watching the electrolyte numbers get worse

I think it'd be a safe bet that it will be withdrawn here next year


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## jjesusfreak01 (Jul 25, 2010)

MrBrown said:


> *Brown taps his foot for twenty minutes waiting for the frusemide to work while watching the electrolyte numbers get worse
> 
> I think it'd be a safe bet that it will be withdrawn here next year



I have been told they no longer carry Lasix in my area for these reasons. 

Also, we don't carry BIPAP machines, I have been told, due to the size. I guess they are probably getting small enough now, but at $2000 a pop, that's a lot for a 30 ambulance system. A BIPAP can replace the CPAP on the truck, right? I assume they can work in a CPAP like mode.


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## MasterIntubator (Jul 25, 2010)

Maybe its just me.... but if a  patient of mine presented like that, and the pt was like.... "Hey dude.... wassup.. I feel kinda sick, but I am not short of breath"....  I would be thinking cardiac and circulatory issues as my next step after assessing his resp status.
I would offer additional oxygen PRN, but not to oversaturate them.  After they reach 100% sats by nasal cannula, all a mask is gonna do is muffle the answers I need to hear and waste oxygen.  ( of course, I am assuming that their ambient sats were like... 94% or so.... as some pts I have had before.  

But... thats just me.


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## Aidey (Jul 25, 2010)

iamajammer said:


> A CPAP may help slightly, but you really want to ventilate these patients, not better oxygenate them.
> 
> As for a faster way to help a CHF patient, you would want to consider also giving lasix.




CPAP affects both ventilation and oxygenation. It provides positive pressure, and a higher concentration of oxygen. 

Lasix is a last resort med in my system, and I've given it once that I can remember. Lasix increases mortality in patient's with lung infections, and EMS in general tends to be bad at telling lung sounds apart, and differentiating CHF from an infection.


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## Shishkabob (Jul 25, 2010)

Not to mention for most urban / suburban EMS systems, Lasix won't really kick in until after you deliver them to the ER.





Maybe I'm confusing abbreviations here, but isn't RRT "Registered Respiratory Therapist"?  I'm starting to think he isn't THAT kind of RRT and is another kind of RRT...  WHat kind of "RRT" are you jammer?


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## WolfmanHarris (Jul 25, 2010)

iamajammer said:


> As for a faster way to help a CHF patient, you would want to consider also giving lasix.



Ummm... what?

I don't follow. How would lasix be better in acute pulmonary edema than increasing airway pressure via CPAP? 

Given the length of time until lasix reaches therapeutic levels and the time it stays in the system, lasix was removed from the EMS tool box awhile ago.


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## sir.shocksalot (Jul 26, 2010)

WolfmanHarris said:


> Ummm... what?
> 
> I don't follow. How would lasix be better in acute pulmonary edema than increasing airway pressure via CPAP?
> 
> Given the length of time until lasix reaches therapeutic levels and the time it stays in the system, lasix was removed from the EMS tool box awhile ago.


We still have lasix here in CO. I use it mostly to practice my mad juggling skills and as a trash can filler.
Does anyone else's system use NTG for CHF pt's? We use it often and I have gotten excellent results.


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## WolfmanHarris (Jul 26, 2010)

sir.shocksalot said:


> We still have lasix here in CO. I use it mostly to practice my mad juggling skills and as a trash can filler.
> Does anyone else's system use NTG for CHF pt's? We use it often and I have gotten excellent results.



SL NTG at 0.8 mg or 0.4 mg is our front line treatment, backed-up by CPAP.


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## jjesusfreak01 (Jul 26, 2010)

sir.shocksalot said:


> We still have lasix here in CO. I use it mostly to practice my mad juggling skills and as a trash can filler.
> Does anyone else's system use NTG for CHF pt's? We use it often and I have gotten excellent results.



They do that in my area, though I can't speak to results. Nitro has a fairly quick half life, right, and Lasix takes a little while to get going, so why not give a kick start with nitro while you are waiting to lower the load?


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