# 71yoM c/o difficulty breathing



## Epi-do (Feb 28, 2011)

Just wanted to get some input on this run.  It was one we had a few days ago, and I can't help but feel as if I was missing something.

We were dispatched around 0500 for difficulty breathing, and showed up at the address to find our pt, a 71yoM, sitting in the back seat of a car.  His wife and daughter are with him.  The daughter states that she was going to take him to the ER herself, but he just looked really bad to her and she wasn't comfortable doing it.  This mornings episode woke him from his sleep.  He felt completely fine before going to bed last night and worked yesterday.

The gentleman is sitting in the car and appears to be in moderate distress.  He is using accessory muscles to breath, and is speaking in aprox 4 word phrases.  His color is still good, and he has no cyanosis anywhere.  He also has a very weak, but productive, cough.  He is coughing up thick mucus that is almost orange in color.  He denies having any pain at all and also states he hasn't had a fever or NVD with this.

The wife states that he is completely healthy, and that "he still works 6 days a week."  His daughter hands you his medications.  When asked, he provides a medical history consistent with the medications he is on.

Rx:  simvistatin, lisinopril, actos, ASA
Hx:  hypertension, high cholesterol, NIDDM.  He was also shot 4 times in the abdomen & leg in 1995.
alg:  an antibiotic, although I can't recall which one it was now

We get him out of the car and into the back of the truck.  BBS=extremely diminished in all lobes, to the point I can't hear any air movement.  SpO2 is 80% on room air.  I immediately started an albuterol nebulizer (5 mg).  He is A&Ox3 and continues to maintain his own airway.  His skin is still pink and his cap refill is amazingly <2 sec. His vital signs remained pretty consistent throughout the transport.

HR: 100-110 throughout transport
BP: 160's/95-105 throughout transport
RR:  20-24 throughout transport

He states he feels as if the albuterol may be helping some, but there is no change in his breath sounds or his general appearance.  His SpO2 has only marginally improved, so I also put him on a nasal cannula at 4 lpm.  That brings his SpO2 up to 87%.  It never gets any better than that the entire time I have him.  I do give him a second 5 mg dose of albuterol.

The cardiac monitor shows sinus tach with a very occasional PVC.  (Sorry, I don't have a strip to post.)  The 12-lead is unremarkable.  I notice he appears to have a small amount of swelling in his ankles, but he insists that is something he "always" has and that it is not new.  He denies ever having any sort of cardiac or respiratory problems in the past & states he is "healthy as a horse."

We were close enough to the ER that I didn't get a chance to get an IV.  Also, I did consider heart failure but based upon the story, I just didn't think it added up.  I know his pressure was a bit high, but it wasn't through the roof like we typically see with pts in failure, and he did have a history of htn.  That, coupled with his anxiety, could explain his current BP.  Because of all that, I opted to not give nitro.  

We do have CPAP available to us, and I really wanted to give it a try.  However, that is one of the few things our medical director is a real stickler about us strictly following our protocol for.  It states that we must get the complete second 5 mg dose of albuterol in before we can use it and although I was able to give the second dose, we were to close to the ER to get it even halfway in the pt, so that wasn't an option at the time.

When we got to the ER, the doc listened to his lungs, and he had just barely started to open up at all.  The doc thought he "might" hear some crackles in the upper lobes, but didn't hear anything at all in the lower lobes.  He had respiratory immediately put the pt on BiPAP.  He then was able to pull up the pt's history on the hospital's computer system and found that the pt had actually had an episode a couple years ago that ended up being a COPD/heart failure episode - something the pt and his family never mentioned.  While talking to me, he said he thinks the guy is in heart failure.

The doc told me that given the info I had, I didn't do anything to mishandle the pt, but I just can't help but feel that I should have done more.  So, what do you guys think?  Was I completely wrong for treating this as a respiratory patient as opposed to a heart failure patient?  I mean, I did consider it, but decided it was more important to try and get him opened up enough so I could hear what was going on with his lungs.  

So go ahead and let me have it.  What would you have done?  I can try to fill in any other info you want that I may have left out.


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## truetiger (Feb 28, 2011)

Given what you found, I think you treated appropriately. I'll agree with the blood pressure too, especially if you found the lungs to be tight and not wet. You mention the sats never rose above 87%, was that on a NRB?


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## Epi-do (Feb 28, 2011)

That was with a neb going and on a cannula.


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## Bon-Tech (Feb 28, 2011)

Thanks for sharing the scenario. I'm just an I/85 student but had a couple questions: With an SpO2 that low, could it have been advantageous to put him on an NRB on high flow right away? 

Around here the first neb is always Albuterol and Atrovent for its longer term effect.


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## MrBrown (Feb 28, 2011)

Does not sound like there is any objective evidence of cardiac insufficency or fresh infarct and no crackles so Brown would have been thinking this was a respiratory event.

Given the limited history you got from this guy and the nonspecific physical findings Brown wouldn't worry about it.


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## MrBrown (Feb 28, 2011)

Bon-Tech said:


> With an SpO2 that low, could it have been advantageous to put him on an NRB on high flow right away?



No, oxygenation and ventilation are different physiologic processes, you can cram tons of oxygen down somebodies throat and it will not change anything if the process of gas exchange or transport is impaired.

There is nothing magic about oxygen and its often given when not required or in excissevely supratherapeutic doses.


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## Veneficus (Feb 28, 2011)

Epi-do said:


> We were dispatched around 0500 for difficulty breathing, and showed up at the address to find our pt, a 71yoM, sitting in the back seat of a car.  His wife and daughter are with him.  The daughter states that she was going to take him to the ER herself, but he just looked really bad to her and she wasn't comfortable doing it.  This mornings episode woke him from his sleep.  *He felt completely fine before going to bed last night* and worked yesterday.



I am sure you recall people with heart failure have difficulty breathing when laying flat. If he was sleeping propped up (and on how many pillows) or laying flat would be a question that would lead your findings in a different route.



Epi-do said:


> He is coughing up thick mucus that is almost orange in color.



Orange body fluids like somebody on rifamycins?




Epi-do said:


> He denies having any pain at all and also states he hasn't had a fever or NVD with this.



All important findings.



Epi-do said:


> The wife states that he is completely healthy, and that "he still works 6 days a week."



BS. I cannot even recall how many codes I worked on people who were "perfectly healthy." Anytime a pt. or family says this it is a lie and the pt. is a trainwreck of multiple undiagnosed/untreated pathologies.

Do not be influenced by this report. It always prompts me to do a detailed assessment system by system. (Which in his distress and your proximity to the hospital would have been an uncalled for prolongation of scene time)



Epi-do said:


> Rx:  simvistatin, lisinopril, actos, ASA
> Hx:  hypertension, high cholesterol, NIDDM.



Plenty of suspicion for cardiovascular or cardiopulmonary diseases both acute and chronic.



Epi-do said:


> alg:  an antibiotic, although I can't recall which one it was now



Rifampin, rifapentine or rifabutin perhaps?



Epi-do said:


> We get him out of the car and into the back of the truck.  BBS=extremely diminished in all lobes, to the point I can't hear any air movement.  SpO2 is 80% on room air.



DId he have any findings of COPD? Barrel chest? History of chronic or repeated caughing? Clubbing? Pursed lips? Distal cyanosis?

No history of Asthma?

(not looking like COPD without them)



Epi-do said:


> HR: 100-110 throughout transport
> BP: 160's/95-105 throughout transport
> RR:  20-24 throughout transport



Compensating. Like in shock?



Epi-do said:


> He states he feels as if the albuterol may be helping some, but there is no change in his breath sounds or his general appearance.  His SpO2 has only marginally improved, so I also put him on a nasal cannula at 4 lpm.  That brings his SpO2 up to 87%.  It never gets any better than that the entire time I have him.  I do give him a second 5 mg dose of albuterol.



Sounds perfectly reasonable.



Epi-do said:


> The cardiac monitor shows sinus tach with a very occasional PVC.  (Sorry, I don't have a strip to post.).



Like in Shock.



Epi-do said:


> I notice he appears to have a small amount of swelling in his ankles, but he insists that is something he "always" has and that it is not new.



See, they lied, he has heart failure, insufficent circulation, or bilateral lymphedema. Given what was stated above, I'll pick heart failure.



Epi-do said:


> He denies ever having any sort of cardiac or respiratory problems in the past & states he is "healthy as a horse."



Liar. (ok, he may be in denial or just refuses to go to the doctor who will tell him he is not healthy as a horse)



Epi-do said:


> We were close enough to the ER that I didn't get a chance to get an IV.  Also, I did consider heart failure but based upon the story, I just didn't think it added up.



Wouldn't have changed anything with such a short transport time. Perhaps some nitro, but no harm, no foul.



Epi-do said:


> I know his pressure was a bit high, but it wasn't through the roof like we typically see with pts in failure, and he did have a history of htn.  That, coupled with his anxiety, could explain his current BP.  Because of all that, I opted to not give nitro.



There is both high and low output failure as well as valvular insuficency, You cannot decide heartfailure on BP, it has to correlate with other findings.  



Epi-do said:


> We do have CPAP available to us, and I really wanted to give it a try.  However, that is one of the few things our medical director is a real stickler about us strictly following our protocol for.  It states that we must get the complete second 5 mg dose of albuterol in before we can use it and although I was able to give the second dose, we were to close to the ER to get it even halfway in the pt, so that wasn't an option at the time.



Like I said above, little would have changed.



Epi-do said:


> He then was able to pull up the pt's history on the hospital's computer system and found that the pt had actually had an episode a couple years ago that ended up being a COPD/heart failure episode - something the pt and his family never mentioned.



Because they lied to you.



Epi-do said:


> While talking to me, he said he thinks the guy is in heart failure.



Sounds reasonable.



Epi-do said:


> The doc told me that given the info I had, I didn't do anything to mishandle the pt, but I just can't help but feel that I should have done more.  So, what do you guys think?  Was I completely wrong for treating this as a respiratory patient as opposed to a heart failure patient?  I mean, I did consider it, but decided it was more important to try and get him opened up enough so I could hear what was going on with his lungs.


 
Doesn't look bad to me, I added some stuff you may find useful in the future but given what you were presented with, I don't think you could have asked any more of yourself and nor could anyone else.


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## NomadicMedic (Feb 28, 2011)

Based on the PT's history and presentation, I think you acted and treated appropriately. You had no idea of his cardiac history. Obviously, if you had known of his CHF, you would have held off the neb and started the SL nitro and CPAP.

If he was normothermic, hypertensive and had adventitious or diminished breath sounds and the noted lower extremity edema and productive cough, I would have been leaning toward CHF as a rule out, even if they tell me the edema is "normal". 

Actos is a drug that can exacerbate CHF through increased sodium retention. I'm surprised that he was on this drug if he had a past diagnosis of CHF. However, he didn't seem to be very forthcoming about his past history, so perhaps his PCP wasn't aware...

I think he was been a good candidate for CPAP. Unless you can appreciate wheezing, the efficacy of Albuterol is questionable. 

Also, while Albuterol wasn't really appropriate for _this_ patient, we're able to inline a SVN for albuterol with CPAP for COPD and Asthma patients. This may be something you can discuss with your doc.

Do you regularly use capnography? A true respiratory patient would display the "shark fin" waveform, while the CHF pt would present as hypoxic with hypercarbia.


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## Outbac1 (Feb 28, 2011)

With the info you had I think you made good choices. However as Vene said pts lie or at least don't tell the whole truth. (and it pi$$es me off). An albuterol tx is unlikely to cause harm and often opens up the chest enough to hear crackles or wheezes that couldn't be heard before. I suspect this is what you were hoping for. Pedal edema, even slight and has been there for years, is almost guarranteed to be from a "heart issue". The pt may truely not be aware of this. The sudden awaking with sob when the pt has been fine with no indications of sickness is another indicator of "heart issues".  I think I would have been leaning towards heart failure and not respiratory. But that doesn't mean I would have been right. I've been wrong before. 
 The orange colored phlegm, could the color have come from a tint of blood from coughing?  Usually I find a green or yellow color to be from infection not an orange. 
 Bottom line the pt got to hosp no worse than when you got them and slightly better. It's nice to try for more but thats often as good as it gets.


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## Epi-do (Feb 28, 2011)

Thanks so much for all of the input!

*n7lxi*- No, we do not have capnography.  I really wish we did.  It can be such a useful tool.  We also can do inline neb treatments with CPAP.  As for the albuterol, since I couldn't hear anything when listening, our medical director actually encourages us to give the albuterol a try.  He has told us that if we can open them up enough to hear _anything_, then it will help point us in the right direction.  Also, while I truly am not a "but the protocol says..." type of medic, we are allowed to give albuterol to pts in pulmonary edema.

*vene*- Thank you so much for all the input.  You helped me remember some things that I should have considered, and also provided some info that I wasn't aware of.  I have always been taught that "most" patients who have heart failure will typically have very elevated BPs.  In fact, I have had docs tell me that if I am trying to decide between COPD and heart failure, that it can be a very good indicator that it is the latter.  I also did not know that rifamycins cause orange body fluids.*

Bon-Tech*- Although his SpO2 was in the 80's, his breath sounds, for all intents and purposes, were nonexistent.  If he isn't able to move any air, for whatever reason, it doesn't matter how much oxygen you pump into him.  That's why I ended up going with a neb + a cannula.


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## Epi-do (Feb 28, 2011)

*outbac1*- I only wish I could have thought that the orange mucus was slightly blood tinged.  I have never seen anything like it before though.  It was almost the color of a pumpkin - a definate orange tinge, and not red or brown.


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## Petey0397 (Feb 28, 2011)

Seems as though you treated effectively. Just as a suggestion, you might have thought about End Tidal monitoring if you have that capability. Not sure it would have changed tx all that much, but might have been good to know... i.e. if he had by chance had high Co2 he was probably acidic and might have made you think twice about CPAP. Might have taken a temp too to screen for pneumnonia. And I don't know what your protocols are, but as previously stated by others ours call for a duo-neb in a situation such as this one.


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## vquintessence (Feb 28, 2011)

Acute onset nocturnal dyspnea, increased WOB w/ a tinged sputum, poor spO2 despite supplemental oxygenation, pedal/sacral edema, extremely constricted lung sounds, (borderline) htn, and a preexisting cardiac condition (vaguely supportive, but pertinent w/ all the other symptoms).  APE/CHF is screamingly high on the list of differentials.

Curious though, your agency required the administration of Albuterol 5 mg prior to ANY initiation of CPAP?  Are you able to administer any NTG prior to the "full" neb treatments?

I'm not saying there's anything wrong w/ giving a bronchodilator in conjunction w/ CPAP for certain APE/CHF pts, but I'm having trouble wrapping my pea brain on the mandatory bronchodilator pre-req.


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## firetender (Mar 1, 2011)

*A Simpleton's read...*

If you didn't have time to start an IV from where you were to the hospital and the patient was NOT exhibiting anything other than "wait and see" then you really did NOT have enough time to screw anything up more than it was, so I'm glad you didn't!

Why must you feel so obligated to do something other than doing what's appropriate for the actual time that you're with your patient? This call was not momentous, it was moments.


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## MrBrown (Mar 1, 2011)

firetender said:


> Why must you feel so obligated to do something other than doing what's appropriate for the actual time that you're with your patient? This call was not momentous, it was moments.



Because there is benefit to thinking on a higher level than just "treat symptoms and take to hospital" -- it may not be about what you do for a patient right then and there but considering the larger clinical picture.

Ambulance does not operate in its own little silo'd universe where all is honky dory when the patient gets to the hospital.


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## abckidsmom (Mar 1, 2011)

firetender said:


> If you didn't have time to start an IV from where you were to the hospital and the patient was NOT exhibiting anything other than "wait and see" then you really did NOT have enough time to screw anything up more than it was, so I'm glad you didn't!
> 
> Why must you feel so obligated to do something other than doing what's appropriate for the actual time that you're with your patient? This call was not momentous, it was moments.





MrBrown said:


> Because there is benefit to thinking on a higher level than just "treat symptoms and take to hospital" -- it may not be about what you do for a patient right then and there but considering the larger clinical picture.
> 
> Ambulance does not operate in its own little silo'd universe where all is honky dory when the patient gets to the hospital.



Not to mention the fact that given this discussion, Epi and whoever's read this thread have had the opportunity to review what the physical exam and detective work looks like in the face of a poor historian.  If I was to see this guy tomorrow, I'd have an hour's drive to the hospital, which is potentially plenty of time to kill him.

There is never, never any harm in evaluating an interaction for what could have been done better.


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## johnrsemt (Mar 1, 2011)

The only thing that I can think to add is that  yes alot of CHF patients in trouble _usually_ have HTN;  remember that the fact he is on anti-HTN meds can and will keep the bp down.  Hard to remember, but sometimes the meds work to well.

other than that, you did great.  Wish we had CPAP,  for our long transports that would help alot


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## firetender (Mar 2, 2011)

MrBrown said:


> Ambulance does not operate in its own little silo'd universe where all is honky dory when the patient gets to the hospital.



Perhaps it's different over there but here, to the best of my knowledge, we get the cap guns and the hospitals have the 44 Magnums. 

If for nothing else than that they have the personnel and resources, wouldn't logic dictate that any decisions made for the long-term good of the patient are made in the hospital; NOT in the back of the rig? Who REALLY gets to see the Big Picture?

My experience is that ER's are in the same business as we are, but with more personnel and more sophisticated tools; but even most of them are diagnostic to help lift the veil of what the true problem is so the next level of care can be provided AFTER the ER has done its work.

At our best, in the field we only get a partial picture, largely having to do with our primary focus being on the immediate crisis and really not having the time or instrumentation to go deeper. Perhaps our job is to deal with the disrupted, life-threatening parts and stabilize them one at a time, setting our priorities on those most dangerous.

(Isn't what we do all about stabilization for transport?)

I don't know that I'd want to be held accountable for "missing" something that's likely tangential to the crisis at hand. 

Accurately identifying the immediate crisis and responding appropriately so that the patient can get to the next level of treatment seems to me to be an adequate description of what we're called on to do.

Sure, we can educate ourselves about many more details in disease entities but when it comes down to the money, I want to know those ambulance guys/gals are focused on the problem at hand.


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## MrBrown (Mar 2, 2011)

What is done in the back of an ambulance can have a significant impact on patient outcomes; for example hyperventilation in a brain injured patient, excessive fluid resuscitation in trauma with physiologic abormality, an amp of 50% dextrose given to a stroke who the ambos think is hypoglycaemic, an incorrectly fitted hard collar causing juglar venous compression .... 

A small part of the work of an Ambulance Officer is to deal with critically unwell and time dependant patients, most of the jobs Brown has been to are not such.  To simply focus on those, as America seems to do almost exclusively, is rather short sighted, even moreso than Brown!

The problem at hand may not be an emergent time critical life threat but rather something completely different, to look at a patient and say "oh there is no symptoms or obvious signs of massive time critical physiologic abnormality so they are a 'BLS' (clinically insignificant) patient" is again, rather short sighed and ignores 95% of Ambulance workload.

If the US is to have any success at the end goal of having its Ambos actually being taken seriously as a health professional then you need to get away from the silod, emergent, take everybody to the hospital on the back of a one year course and never look beyond mentality.


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## abckidsmom (Mar 2, 2011)

Like Brown said, you can focus on the "emergency" (or lack thereof) or you can focus on the myriad of other details that you get by virtue of being present in the patient's home and work on getting the patient the right help.  

I get 45 minutes or more of one on one time with my patients.  Yesterday, I we had an autistic kid with asthma that was out of control.  He couldn't go in the ambulance without his guardian, and she couldn't get him home without her car.  He was dramatically improved with the treatment he received in the ambulance, and the guardian was reassured that this wasn't looking like the PICU admission they had a month ago.  I included the tranportation problem in my report, and the nurse called the social worker immediately upon admission to the ER.  

That was the difference between an entire night spent in the ER and getting the kid home before midnight, and letting him go to school the next day.  I don't believe the guardian would have brought up her transportation issue with the staff until it was time for discharge, potentially adding hours to their stay.

It's the little things.  If you go around looking for ways to reach beyond a couple of nebs and a ride to the ER, you will do so.  

I also believe that my long-term reach happens through educating the patients.  I am continually astonished with how ignorant people are about simple physiology.  I include some teaching on every patient interaction.  I think that makes a long-term difference, too.

Firetender, I think you can choose to be a band-aid box, or you can choose to be a member of the healthcare team.  You are completely in control of whether you are going to make a difference in the patients' days.


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## OCCPR (Mar 3, 2011)

*Resp difficulty*

Treatment Plan seemed pretty solid. Do you have the ability for ETc02 monitoring? I use it all the time out here in So Cal. SPo2% has a bit of delayed response and skin signs may take a while to give you a clear picture depending on what is truly going on with this guy. If he was febrile I would treat aggressively with O2 and Albuterol also. 

Watch out for Flash-Pulmonary edema after that breathing treatment though!

occpr


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## MrBrown (Mar 3, 2011)

OCCPR said:


> Watch out for Flash-Pulmonary edema after that breathing treatment though!



Or lets do a thorough physical assessment and perhaps not give him salbutamol in the first place if we suspect he is in any decent stage of CHF?


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## Rykielz (Mar 3, 2011)

Epi-do said:


> 1) He is using accessory muscles to breath, and is speaking in aprox 4 word phrases.
> 
> 2) He also has a very weak, but productive, cough.  He is coughing up thick mucus that is almost orange in color.
> 
> ...



I highlighted 6 things in your assessment that to me screamed CHF. You were right to get the guy going on O2, get the ECG on him/12-lead, and start an albuterol treatment. However, the next thing I would've done before anything else, is establish an IV and start with the nitro. My reasoning is that you said his lung sounds were diminished in all fields but you couldn't hear any crackles. Sometimes a pt's lungs can become so filled with fluid that the crackles can't be heard. His BP was high as was his HR. You also had CPAP available which works wonders for CHF, but for some reason your protocol is anal about using it so that's not your fault. In the end, you treated him based off what you obtained in your assessment which nobody can fault you for. I however, would've given the nitro.


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## Veneficus (Mar 3, 2011)

I would like to again point out.

The op stated: "He is coughing up thick mucus that is almost orange in color"

Rifamycins cause body fluids to become orange. It is characteristic of them.

That should not be confused with pink or red sputum.

The patient is demonstrated an unreliable historian, making his med list and allergies suspect as well.

Rust colored sputum (which also may be "orange") and is associated with blood, has a handful of differentials like pneumonia.

Coupled with the finding of his inability to breath, this can be the primary or concurrent pathology. I would strongly caution against using this finding as the basis for deciding upon CHF.


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## Rykielz (Mar 3, 2011)

Veneficus said:


> I would like to again point out.
> 
> The op stated: "He is coughing up thick mucus that is almost orange in color"
> 
> ...



In the same sense couldn't the rifamycin's also distort the color of pink/red frothy sputum to orange? Yes the patient's an unreliable historian, but you can also look at the actual findings: pedal edema, tachycardia, hypertension,
low SPO2 (Assuming it's working correctly), and diminished lung sounds which can possibly be disguising crackles. I don't think anyone would fault you for giving the guy a spray of NTG to see if he improves.


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## Veneficus (Mar 3, 2011)

Rykielz said:


> but you can also look at the actual findings: pedal edema, tachycardia, hypertension,
> low SPO2 (Assuming it's working correctly), and diminished lung sounds which can possibly be disguising crackles. I don't think anyone would fault you for giving the guy a spray of NTG to see if he improves.



I am not discounting the other findings or their use. I am pointing out that there are other things that can give the finding of orange sputum and you cannot just call it a sign of CHF. 

In many EMS systems, and in all EDs, furosimide is still given for acute CHF crisis. It is also relatively contraindicated in pneumonia, which may exist alone or concurrently with CHF, which is indistinguishable in the field at 0 dark 30.

My point is that using that specific finding as evidence for CHF is not a good idea.


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## Rykielz (Mar 3, 2011)

Veneficus said:


> I am not discounting the other findings or their use. I am pointing out that there are other things that can give the finding of orange sputum and you cannot just call it a sign of CHF.
> 
> In many EMS systems, and in all EDs, furosimide is still given for acute CHF crisis. It is also relatively contraindicated in pneumonia, which may exist alone or concurrently with CHF, which is indistinguishable in the field at 0 dark 30.
> 
> My point is that using that specific finding as evidence for CHF is not a good idea.



I'll agree with you on that


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