# Treat My Patient



## MedicPrincess (Mar 13, 2007)

82 y/o M, called 911 for respiratory difficutly. ALS FD on scene for approximatley 2 minutes before we arrive. They have managed to put him on O2 NRB 15LPM and where standing there watching him breath.

Patient is extremely pale, dripping wet all over, using all his accessory muscles to breath even on the O2. 

RR = 42, Pulse (from pulse ox) = 166

Patient was released from a local hospital x9 days ago with "a lung infection." He also has a pacemaker/defibrilator. Pitting edema to feet at a +3 present. Patients caregiver denies CHF, however states he has just recently been put on Lasix for his "lung infection."

BBS- clear, equal, all fields.

Patient loaded onto stretcher and taken to ambulance. Monitor is applied in the ambulance with BP obtained.

BP= 136/54
RR= 48
O2 sat = 96% on 15LPM NRB - CPAP put in place my medic on truck.
IV - 22g R forearm (20 in L AC blew, really crap for peripheal veins_

Monitor show this....









12- lead obtained-








Patient is still very pale, even more diaphoretic now. However his is still conscious and can answer yes and no questions.

Where would you have gone from here?


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## Ridryder911 (Mar 13, 2007)

First place the pulse ox away.. it is incorrect and does not matter anyway. Chances this patients maybe septic .. with acceberated CHF and possible AMI on top. 

Now, I do question why the why the CPAP if the lung sounds were clear ? Indication of CPAP is for pulmonary edema.. I question the lung sounds, since the recent HX of lasix and pitting edema. 

I would need more information.. skin color, temp, JVD,etc... 

R/r 911


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## DT4EMS (Mar 13, 2007)

I agree with Rid.........

"Who" listened to the lungs?

It does look lik elevation in II,III and F. There is depression in I and L as well.
(I wonder which QRS the machine is reading for V1 to be a RBBB, it could have a LBBB too)
If the LBBB is present everything else is pretty much out the window..........

But that is just one piece of the puzzle.

 Remember...... sometimes when people are "air hungry" it can be from more than just one source. If there is a VQ mismatch or a bleed, people can be in respiratory distress while the lungs are clear.


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## MedicPrincess (Mar 13, 2007)

Patient was very pale, cool, diaphoretic.  I didn't notice any JVD.

BBS were reported by FD to be clear.  My medic checked them and said they sound clear to her.

CPAP was put in place d/t RR and it not improving with just O2.  He had began to have the resp difficutly 2 hrs prior to calling, and seemed to be getting tired.  CPAP in an effort to get it under control, before taking him down to intubate.

The only pitting edema was in his feet.  It didn't extend into his legs or anywhere else, like I have seen with others.

I am thinking his respiratory difficulty was directly related to his cardiac status.....


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## Stevo (Mar 14, 2007)

so we have a diff breather w/bad vitals ?

O2, line, load and report to med con, and ask what thier drug of choice may be

S~


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## oldschoolmedic (Mar 14, 2007)

Just a question, but does anyone believe he is taking adequate breaths to assess his lung sounds at 42/min? It sounds as if this poor guy is panting. Need a better exam, no offense intended. Sounds like this guy was sent home with pneumonia and his "caregiver" hasn't followed the doctor's instructions well leading to his getting worse. CPAP is not a bad choice, lasix might be beneficial, consider MONA (okay O is already there) for the possible AMI developing. All things considered his vitals are pretty good except his resp rate, which I think the CPAP might help. Write this date down... because I agree with Stevo, turn it over to the doctors. They paid that much to become doctors, let them show what they know.


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## Stevo (Mar 14, 2007)

> Write this date down... because I agree with Stevo



gawd, feels like we should buy lotta tickets there OldSchool 

don't get me wrong,i think it's great practice to try and put the pieces of the puzzle together

but sometimes simple works too...

i end a lot of my patches asking what else i can relay, or what else can be done btw. i get my best feedback (and ultimately best patient care) _asking_ 

~S~


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## HorseHauler (Mar 14, 2007)

Always involve someone with deeper pockets!!!


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## Sophie (Apr 15, 2007)

Speaking of MONA, you're going to start seeing protocols change in the near future.  Morphine is going by the wayside, especially in CHF patients.  Evidenced based research is showing it's doing more damage then good.


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## Strike3 (Apr 24, 2007)

CPAP is not indicated with clear lung sounds. Lasix should not be given to pneumonia PT's due to the fact that it will dry the mucus secretions in the lungs into concrete and created a bigger problem. Lasix isn't going to clear them up.

The RR needs to be managed, whether it's by assisted ventilations or whatnot. Good tidal volume, and slowing the rate down is key.

As far as the AMI issue....I'd probably shoot another 12 lead and look for changes. You didn't mention any chest pain complaints from the patient. Med control is probably the ideal answer once the respiratory status is controlled.



On a side note, to the above post, they just released a big study in my area showing how MSO4 is beneficial in an ACS case... It's funny to hear you say that.


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## Sophie (May 2, 2007)

Read this month's edition of JEMS.  The same author was at the National EMS Expo in Baltimore and presented on the exact same thing and it is evidenced based.  Morphine increased the mortality of the patient by 13%. 

They want Bipap and Cpap used prehospital (which some medical directors do not in the midwest) and instead of Morphine they are requesting we start looking at benzodiazepines for the patient to relax them.  Lasix may also go to the wayside for prehospital according to literature I have been reading.


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## Sophie (May 2, 2007)

Strike3, could you share that study that you're talking about because we have a rather large controversy here regarding this.


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## Bongy (May 2, 2007)

Tachypnea with clear lung sounds.... 
Sounds like pulmonary embolism... 
Sedation,intubation,heparin IV and VERY fast to hospital...
Someone that breath 40 b/min will not hold for long...


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## TKO (May 3, 2007)

you've got time for coffee at Timmies.  It's when they drop down to 6 RR/min with profound bradycardia that you better G-L-H to the big H.


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## Ridryder911 (May 3, 2007)

Sophie said:


> Read this month's edition of JEMS.  The same author was at the National EMS Expo in Baltimore and presented on the exact same thing and it is evidenced based.  Morphine increased the mortality of the patient by 13%.
> 
> They want Bipap and Cpap used prehospital (which some medical directors do not in the midwest) and instead of Morphine they are requesting we start looking at benzodiazepines for the patient to relax them.  Lasix may also go to the wayside for prehospital according to literature I have been reading.



On CHF with associated Frank Pulmonary edema, research is demonstrating that CPAP is one of the few treatments that is actually reducing admissions, admissions to ICU, etc. The contradiction to Morphine is debated, but studies have demonstrated that there is a possibility of increasing infarct size on right or inferior wall AMI with Morphine administration. 

The second recommended medication in Frank CHF is the use of nitrates. Then followed bu diuretics, with caution. The reason diuretics is heavily debated is due to poor assessment and history taking making a false diagnosis. Nitrates is now being more and more administered in proper dosage as per IV route in the field setting. 

We are developing protocol the use of NTG IV in the field. Fortunately we already have infusion pumps. Most services do not explore the possibilities due to one has to have IV infusion pumps for administration of NTG. Of course with this one can start using other medications such as Levophed, Sodium Nitroprusside, etc. which we are exploring as well. 

With CHF being one of the largest percentage medical disorder of our elderly we will see more and more advance treatment. 

R/r 911


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## dtermnd (May 23, 2007)

I like all the comments but, did anyone think that this pt is in unstable v-tach?  in witch case instead of treating with mona, or treating for ami, consider 5 of valume and cardiovert starting at 100 joules...


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## Ridryder911 (May 23, 2007)

dtermnd said:


> I like all the comments but, did anyone think that this pt is in unstable v-tach?  in *witch* case instead of treating with mona, or treating for ami, consider 5 of *valume* and cardiovert starting at 100 joules...





A couple of things... First welcome to the site!

Now, please don't tell me that you actually thought that was V-tach, when it is a paced rhythm! You can't see the pacer spikes? ... Now you tell me you are going to shock them ?.. WOW!!! See ya in court!

What does it matter she is a witch or any faith for that matters ?  I don't know what Valume is... I do know what Valium is and personally rather not give it because of the duration and time of onset, but much rather give Versed instead, since it is faster acting and has amnesic effects as well.

R/r 911


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## mdymes (May 27, 2007)

Hello to all. 
Like a few others here I would like a little more information about this case as well as a better 12 lead to suggest a different treatment. One question I have is did the C-PAP work? Understanding that IV access was poor and only a 22 gauge was placed I would hesitate to begin Ntg. until I was more sure of what I was dealing with, an extremely high BP might warrant it but not this one. I have to agree with some that suggest that breath sound evaluation might not have been accurate due to RR as well as the seriousness of the patient condition and the rush to "do something" If there was no indication of bronchospasm or other air retention issue I can't think of any harm of the CPAP if no improvement or worsening noted remove it. I agree that we need to assist in some way before the patient crashes and CPAP is non-invasive and can be changed quickly if needed. This is a difficult call to handle, when in doubt call med control. 
Ridryder911 I am a little disappointed at the sarcasm you demonstrated. This was a good opportunity for you to educate the less informed about the finer points of reading 12 leads as well as encourage the new folks to continue posting without fear of ridicule. I believe we can all help each other and continue to improve the professional standing of EMS as a credible healthcare profession. Mike


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## Ridryder911 (May 27, 2007)

Sorry your offended, rather you should be quite offended that a "quote" medical trained person is actually out there that could actually * kill* someone, by cardioverting a paced rhythm! Sorry, this is not a "feel good" profession and in fact that is part of the problem, we have coddled so many and allowed  such to continue... Either get with the education or get out before you * kill* someone... yes, it can and does happen!

Do you not realize, what discountability this disproves to our so called * profession*, especially when one cannot interpret such a simple rhythm with obvious pacer spikes? Then not to even know how to spell common words and knowledge of the differential spelling as which and witch, and Valium?  Sorry, I just spent a week as an expert witness in court and I can attest, the attorneys would have a field day ! Yes, you are based upon your education level both professional and in general knowledge.

We continue to discredit our profession as long as we "sugar coat" and continue to be politically correct, thus allowing anyone into and allow continuation representing our profession. Yes, forums can be a learning tool and yes, even awaken one to take action in simple things such as to start studying the basics of English, spelling, and understanding of cardiac care, which not only individuals are judged upon, but our whole profession is as well. 

R/r 911


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## mdymes (May 28, 2007)

I'm sorry that I wasn't clear with my last post. I agree with you completely that we must not coddle folks and that they can and do kill people with their lack of knowledge or critical thinking skills. I am suggesting that if we look to the root of the problem we may find that we are very destructive to ourselves as a profession when we don't take "teaching moments" and use them to help the patients that they will treat. I have been in EMS since the early 80s when the classes were tough and failure rates were high. The first ACLS class I took only had RN's and MD'S teaching it and mega-code was a bear. Now with the "kinder gentler" AHA everybody should pass. I currently run an EMS training program at a local community college full time and work in the street on average of  48 hrs/wk. So I have an insight into some of the problems we have. First let’s think of the "training" that many folks get. The average student will complete an EMS program that includes a little "ride time" at the ALS level a little more. After that they will sit for a local or national exam and receive a credential. Many systems will place that newly credentialed medic on a truck to begin treating patients often times with bls partner. Other students will test and receive their credential and then be precepted for a period of time. Problem is who are the preceptors? Often times they don't want newbie’s, are burned out, have little more experience than the new person, or have no idea of how to teach. Students and new medics that ride with these folks often times do just that, ride! Evaluations consist of the simplest route with the least resistance "average" Management is often aware but they need a "patch and a pulse" to fill a spot in the least amount of time and least amount of money. When a mistake is made by this untrained individual his career is finished and he is dumped. Is this a fair thing to do to our young? Now, how does that fit in here? When we have the opportunity to educate those of us that can must do that. If we help those that are "misguided" then we help their patients. I certainly don't want to come off as a bleeding heart that believes everybody should succeed but we must try to help those that want to succeed. If education doesn't work it is time for a career change. As far as the spelling issue remember that most of these folks are the product of government schools that are only interested in teaching the lowest common denominator to pass the standardized tests. Many, if not most of these 12th grade graduates can't place out of 10th grade English in college testing. Now that’s quality education!! (remember: no idiot oops child left behind) I hope that I cleared up my statement and that we can use this forum to help not intimidate. If we intimidate then we lose the opportunity to teach. BTW I failed my first mega code in "84" when I forgot to turn back the Isuprell after the HR increased. Mike


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## Ridryder911 (May 28, 2007)

I as well agree with most of your thoughts. However; we continue to make excuses than to address the problems. Typical EMS solutions. 

I am far from being an English teacher however; poor and sloppy grammar and spelling is non-tolerable. Period. One of the ways a profession is judged upon on is how well they are able to communicate. 

When I first entered EMS forums, it was almost disgraceful on the poor writing skills most EMT's presented. Fortunately, most other posters have became non-tolerable on grossly presentations. Can one imagine the opinion one would have reading a physician or nurse forum and reading poorly written statements and misspelling of common medications? 

Part of the problem is that we in EMS do not expect anything better and will tolerate such. We do not even require EMS instructors to have formal education, even though we require kindergartners to have an instructor with a degree. Why should we expect much better from the current education level? 

Do we really eat our young? I have seen both sides. Yes, I believe it goes back to the educational system again. Most graduates are not properly educated and definitely not prepared for the workforce. Expectations and the reality is far from what they expected. 

We push and ingrain memory tricks to pass skill trauma skill stations, yet we never discuss the majority of calls are not ALS or trauma rather mundane and medical. Ever read the posts here on this forum? Congrat's and salutations on passing the EMT class/ tests, then later only to read where they were discouraged or already "burned out" in a such a short period of time 

You are right many EMS administrators (whom themselves are usually poorly educated) sometimes only care if their personnel have a "pulse and a patch".  Yet, again did we as educators really prepare the students for the workforce or just the ability to treat patients? 

I do believe we need to "toughen" up our students. Intimidation is subjective. If one becomes easily intimidated over a forum, then I can assure you they will be very intimidated the first time they get their arse chewed out by a physician. Preparing and educating the student that this job is no rose garden, and one needs to mentally prepare and be prepared to grow with such occurrences. Review the way medical students and even nursing students are demanded to present information and perform under scrutiny, as well as they are expected to "bounce back" and improve one self. 

We need to be sure that EMS students realize that they are only taught the minimal level. This allows them to obtain a license, certification to then to grow and improve upon. Although, I do not believe in total intimidation for teaching, but rather EMS and medicine is very intimidating in itself. It can be from peers, family, and the scene itself. As you can recall from your ACLS event you probably never forgot to monitor your Isuprel again thus the purpose of it all. 

It is the responsibility of the Field Training Officer to make sure that they are able to operate and function at their designated level within the system. It again has both sides. New graduates need to recognize that they have an obligation to learn and preceptors have an obligation to "mentor" and guide newbies. Excessive pressure is undo and not warranted. Yes, I have seen too many "egos" get in the way, not remembering what it was like when they first started out. 

Part of this job is persistence. Being able to justify your treatment or lack of, presenting a professional image, and supporting increased and improved education through out your career. 

R/r 911


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## VinBin (May 28, 2007)

I agree Rid, but it appears that dtermnd is stated to be a "student" and his level is not stated. I think he is far from being a lone practitionar and could just be reciting a common algorithm for an unstable rhythm.


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## mdymes (May 29, 2007)

The comment about the schools was not intended to excuse but my obviously poor attempt at sarcasm toward the government schools. Mike


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## Aileana (Jul 28, 2007)

to be honest, I have no idea as to what I would do in this case. Septic shock from the infection pt had is the only thing I can come up with with my current level of education in this field. Out of curiousity, how _did_ you treat this patient, and what was the diagnosis?


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## medic5740 (Aug 5, 2007)

*AMI? CHF? or Infection?*

I was wondering if nitro wouldn't be a good test for what is going on with this patient.  If a SL nitro did any good, perhaps repeat administration of SL nitro or a nitro drip might help this patient.  It's hard to imagine this patient with good breath sounds with all the other descriptions.  What was his temperature?  What other drugs was he taking?  Anything for the infection?  Did you attempt another IV?  How far from the hospital?
In our rural area, we would continue to attempt to establish an IV.  With your description, our med control docs would probably go with a nitro drip if that helped improve the respirations.  Our protocol would require assisting ventilations via BVM with respirations much above 40 by our basic EMTs as well as medics.

What was the final diagnosis?


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## KEVD18 (Aug 5, 2007)

airway airway airway. with that resp rate he is circling the drain. knock him down and tube him. manage everything else after you have his breathing controlled.

_EDIT TO REMOVE PERSONAL ATTACK_


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## Ridryder911 (Aug 5, 2007)

KEVD18 said:


> _
> Edit to remove personal attack_



Sorry, you feel this way. As a so proclaimed student, I would think you particularly would be the first to want everyone to know the current and correct therapy. While also supporting the knowledge to not defib a non-shockable rhythm (possibly causing a fatality) in this case, and to at least know the correct spelling of the medication(s) when discussing treatment(s). Endorsing such, even on forum sites only support ignorance and poor knowledge. If we can not even correct ourselves, would we prefer to have another professional do it for us later? What does that say about our demeanor? 

Airway is correct, however many * current literature* is NOT recommending RSI and intubation, unless it cannot be controlled by any other measures. This is definitely a difficult case in determining that it is pneumonia/URI versus CHF or even both. Recent literature as well has demonstrated that medics may misdiagnose CHF up to 80%. Thus the reason so many is pulling RSI, Lasix, etc. I support RSI treatment , in certain situation(s) it is a progressive treatment and definitely has its role, one should be sure all other methods have been exhausted before even considering such procedure. Placing a patient on a ventilator has more detrimental effects than most medics are aware of and should be again a last measure. 

Truthfully, I just don't sit around and shoot off from an emotional thought. As well feel like others, get tired of having to explain that I prefer that my profession be such.. a profession staffed by professionals. I do want EMS to be what it can be and should be, rather than just a vocation and hobby. There are many alike me that have worked, and attended more a than few months of trade school or junior college, and wish EMS to be respected, and treated as such. This of course only comes from us demonstrating as educated and knowledgeable professionals. 

The difference between me and many others EMS professionals, is that many others never do participate in EMS forums, many have explained per IM's to me it is due to the type of similar postings and ideology. There are a few other Paramedics on here such as Vent, Flight, DT4EMS, AK, etc (to name a few, there are others.. )that attempt to bring professional and current medical and clinical knowledge to this site. Many of other professional medics describe being amused or worse yet, scared of some of the postings in many of the EMS forums. 

Does it not seem strange from the thousands and thousands of Paramedics only a few handful ever participate in EMS forums? ... Have you not wondered why? 

R/r 911


R/r 911


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## DwayneW (Aug 10, 2007)

I'm confused as to the use of CPAP and intubation here, though I'm a student with no street experience, so I'm just airing my logic to see how it flies...

Elderly pt, respiratory distress @ 44 (or so), stamina failing, SPO2 94% on 15L, clear lungs, possible eschemia or worse on the monitor...it seems like we need the most immediate, decent chance to ventilate this man, no?

Why would CPAP even be considered before assisted vents were used to attempt to control his rate and volume?

And why intubate at this point? I'm guessing he's not been eating or drinking much in the last several hours, he seems able to protect his airway (has been doing it for at least the last two hours), what is to be gained with intubation?

Those that haven't read my posts before will soon find I'm not the brightest bulb on the tree...so I'm not attempting to disrespect anyone's opinions, only trying to see if my thinking is off in the ditch somewhere...

Have a great day all!

Dwayne


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## Ridryder911 (Aug 10, 2007)

Dwayne, as usual you bring out some very interesting points. This scenario is a confusing one, and as of yet have not been clear of the final diagnosis. Of course like in real life, there were probably multiple diagnosis, just like most of our patients. 

You are correct, I too would not had suggested CPAP as this patient lung sounds and other symptamology was not indicative of CHF. Side note; we do need to remember though, the shift from right to left side CHF, patients may compensate and actually clear up for a short period of time. Until the left side is unable to compensate, then one will be in trouble. In this case though, it appear to have an URI (upper respiratory infection) or pneumonia, with the pedal edema being probably position dependent. However, I did not see any febrile or even temp changes, even subtemp is not unusual in sepsis. 

One diagnosis that I have not seen discussed, and truthfully believe should be considered is a pulmonary embolus ( Hx. of URI, confinement). This could be the presentations tachypnea, ischemia changes, clear lungs, and diaphoresis as well. PE's are misdiagnosed in about 80% of the cases. 

You are also correct in describing to assist the patient ventilation's. The difficulty in this case is determining if the ventilatory status is sufficient in allowing the patient for Vq and perfusion level. Does one control the breathing, increase the oxygen level, control the airway or attempt to do all at one time?

These are difficult questions, & obviously hard to determine without a better clinical presentation as well, even then multiple disciplinary interventions can be thought of, none being wrong or the most correct. I don't think CPAP is most appropriate treatment in this patient, at this time from the clinical picture. In fact if it is a P.E., could be potentially detrimental. 

Many are correct one can assist the ventilatory system and be correct, as well as consider "knocking down" the respiratory drive and controlling it by RSI and intubation. The goal of course is not "securing" the airway as much as controlling the gas exchange. Again, one needs to understand the full impact, when doing so. Like other treatments, it does have some major side effects (good and bad)  patients when placed on a vent to control the respiratory pattern. My point in previous posts is to be sure to fully understand the risks. It might help the immediate problem only to cause more 
detrimental effects in the end. 


Many still do not understand CPAP. Many still believe that it still "blows fluid" back into the alveoli (in some ways it does) but actually CPAP reduces stroke volume, and some, but not all, some studies have shown a fall in cardiac output. This response may be the result of reduced venous return and thus stroke volume, it has also been proposed that the CPAP-mediated reduction in the work or breathing may also offer an explanation for the associated fall in cardiac output. It has also been shown that CPAP improves left ventricular afterload by reducing transmural (wall) left ventricular pressure. In conjunction with these studies, another study demonstrated a significant reduction in those of near end point of death and the need for transplantation in CHF patients. So CPAP is very beneficial with frank pulmonary edema, CHF. 

R/r 911


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## Pablo the Pirate (Aug 11, 2007)

well heres my 2 cents for what its worth, and regards to that is one of the crappiest 12 leads i've seen.(no offense) I don't know what i'd settle on calling it other than a wide tachycardia with on demand pacing.  I see some p waves although they do not all look unifocal.  also the qt seems quite wide, and no i didn't count to see if it was.  please correct me if i'm wrong. I have a question as to rather or not someone actually physically checked his pulse.  were all those beats perfusing?  what did it feel like?  checkin a pulse can give you alot of info without even hooking up the moniter.  I also agree with r/r on the toss out the pulse ox at this point... regardless of what it reads the man can't breathe.  plus with a recent lung infection how much of his lungs is he actually using?  I believe i would try the CPAP also before I hauled off and RSI'd this guy.  I know that alot of recent literature is questioning the use of nebs on CHF, but what are his current meds?  is there a history of asthma or copd?  and do his lungs "sound clear"  because he's so tight and not moving good air.  obviously with a rate of 40 something its hard to tell.  My main priority in any case would be get his breathing under control, not waste time on scene, and "drive fast and take chances"


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## DwayneW (Aug 11, 2007)

Hey Pablo,

I'm just not seeing physiologically how CPAP is going to help him much, or at all...what am I missing here?

Dwayne


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## Pablo the Pirate (Aug 11, 2007)

ummm...nothing im just willing to try it before knockin him down.  I'm really curious to know if it helped.  plus i've seen CPAP work on someone that i thought for sure would end up tubed but it was an asthmatic.


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## Pablo the Pirate (Aug 11, 2007)

one more thing...if this guy started feeling short of breath and then worked himself into a real tissy (which is possible but not probable givin other signs and symtoms) it would help


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## Arkymedic (Aug 14, 2007)

*Oh how I wish...*

I wish we had CPAP protocol and recognition by the state of Ark. I also wish we were able to RSI pts but that would be inappropriate in this case in my opinion. Since I don't have either option I would do assessment, v/s, and airway mgmt and the only things I really could do would be universal CHF algorithm of:
Lasix
Morphine
Nitro
Oxygen
Position 

and transport. 

I also am worried about the post about unstable VT but I also asked some stupid questions when I was a student and learned a lot by asking those ?s...


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## coolidge (Aug 14, 2007)

*adverse drug reaction(s)*

Author originally stated, "however states he has just recently been put on Lasix for his "lung infection."

Can you clarify the patient's medications? Was there a possible adverse drug reaction in the making, ie is there a temporal relationship between the drug the patient just started for his lung infection?  Was there excessuve use of his inhalers?

Pharmacist Bob


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