# CHF with low BP



## RICollegeEMT (Nov 16, 2016)

I'm throwing another scenario out here:

You respond for an Altered MS-- on arrival RN states that patient has been lethargic and O2 Sats were low around 80 so they placed them on the customary 2L NC with 500 feet of tubing and gave them a Neb Treatment (straight albuterol).  Denies having checked a BgL "they're not a diabetic" or administering any recent Narcotics. They also stated that the patient has been lethargic since this morning (its around dinner time now).

Patient is lying semi-fowlers in bed, with a very audiable "wet" sound when they exhale with labored respirations.  Lower extremities show pitting edema.  And they are responsive to verbal.  Questioning is futile due to patient being advanced dementia.

Get them into the truck, place them on a NRB at 15L which improves Sat to 95%.  12-lead shows no elevation or block.  HR is around 100bpm.   Blood Pressure is 65/42.  Lung assessed as crackles in all fields. BgL 290.  Closest facility is 20 minutes out.  And no pressors on board the truck although it is otherwise fully stocked.

What would be your coarse of action?

**Edited to fix grammar**


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## VentMonkey (Nov 16, 2016)

RICollegeEMT said:


> I'm throwing another scenario out here:
> 
> You respond for an Altered MS-- on arrival RN states that patient has been lethargic and O2 Sats were low around 80 so they placed them on the customary 2L NC with 500 feet of tubing and gave them a Neb Treatment (straight albuterol).  Denies having checked a BgL "they're not a diabetic" or administering any recent Narcotics. They also stated that the patient has been lethargic since this morning (its around dinner time now).
> 
> ...


Nothing more than what you have already provided, an IV (2 if they're that critical) with _judicious fluid boluses_ until we have a SBP (>) 90 mmHg, and/ or a MAP (>/=) 60-65 mmHg. Is the patient febriled, are they _more altered than usual_? How do we know for sure that this is a CHF exacerbation vs. pneumonia brought about by another underlying condition, and/ or they aren't septic? These are two different disease processes with two completely different courses of treatment.

What's the patient's history aside from dementia? Is there cardiac hx (previous MI's, CHF, HTN), pulmonary (COPD/ emphysema), kidney disease, all of the above? what does their medication list tell me? Are they on any diuretics, or medications indicating a cardiac, and/ or pulmonary history? Are they/ were they on recent antibiotics for an unknown or undisclosed infection, and if so, did they complete said antibiotics with a persistent fever in spite of them being completed (i.e., did they fail the antibiotic)? Knowing their allergies is always nice, too.

With a 20 minute ETA a BP q 5 minutes, and if I luck out, and I am able to trend the BP upwards past 90 mmHg systolic, with enough time left en route, I can try CPAP. Keep in mind at this point the BP needs to be monitored very closely. If there's no improvement about what the baseline BP is say after 500 ml's of crystalloids then I would keep them on the 15 lpm NRB and continue to reassess for further signs of fluid overload (JVD sitting upright, worsening crackles/ dependent edema).

Ultimately, op, sometimes less is better. This patient probably fits that category where aside from reassessment, and the above mentioned treatments, there isn't a whole lot in the field we can do; they need definitive treatments. Our job is to help figure out what is it that is actually causing the chief complaint/ respiratory distress---with a good initial assessment---so that the EM physician can get a jump on which treatments will need to be initiated on arrival, etc. If no improvement to their blood pressure (not trending upward) after 2-3 cycles (not a bad idea to confirm via auscultation/ palpation, BTW), then I would bump up my transport to L/S. I would also bump up my transport priority if they had any deterioration...obviously. If they get worse, or code, they get worse, and/ or code. It happens, people get really sick, _then_ you enter that treatment tree (respiratory, and/ or cardiac arrest treatment).


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## medichopeful (Nov 16, 2016)

Can we get a POC lactate on this patient?  Sepsis is a possibility.  How about a temp too?  Skin condition?  I know the EKG doesn't show any elevation or block, but what does it show?  NSR to sinus tach?  Any signs of right ventricular strain?  LVH?

Any recent episodes of cough, fever, UTI, aspiration, or anything else?  Edema normal for patient?  What meds is the patient on, and what's their history, age, and code status?

Why no pressors on board?


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## RICollegeEMT (Nov 16, 2016)

no pressors because they're "optional" per oems ; if it's optional You don't have it. Lol. 

No temp although a few wounds. 

EKG sinus t-waves peaked but has a hx of hyperkalemia. A med list 10 pages long.  Age around 90.  DNR/dni. And INR elevated 5.9 or so-- only lab value available.


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## RICollegeEMT (Nov 16, 2016)

And BP was confirmed by palp. No radial but present (weak) carotid pulse.  So that ballparks it around 60-70.


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## VentMonkey (Nov 16, 2016)

medichopeful said:


> code status?


This goes without saying to most experienced providers, but an excellent question nonetheless. And to the op, this is the first question out of my mouth more often than not in these scenarios. 

It is at a SNF/ assisted living? That's the impression I got. Also something you might want to keep in mind for your scenarios, again, most experienced providers are going to ask a ton of questions especially pertaining to the patient's H/A/M. This is what paints the picture for their course of treatment. Again, this goes back to a *good primary assessment*. The reason I highlight this is to emphasize the fact that regardless of provider level, if you get all the pertinent info, your treatment will soon follow.


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## VentMonkey (Nov 16, 2016)

RICollegeEMT said:


> no pressors because they're "optional" per oems ; if it's optional You don't have it. Lol.
> 
> No temp although a few wounds.
> 
> EKG sinus t-waves peaked but has a hx of hyperkalemia. A med list 10 pages long.  Age around 90.  DNR/dni. And INR elevated 5.9 or so-- only lab value available.


Proceed with transport. Do you have a question somewhere? There isn't much to be done with this patient other than bring the DNR in. Also, what did, sorry, "does" this hypothetical patient's DNR say? How specific are the wishes? The patient is 90, I am going to guess their INR being elevated is for any number of reasons, again, none of which will change my treatment course.


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## medichopeful (Nov 16, 2016)

RICollegeEMT said:


> And BP was confirmed by palp. No radial but present (weak) carotid pulse.  So that ballparks it around 60-70.



There actually isn't any reliable correlation between presence of pulses and SBP (besides saying that if they have a pulse, they have a BP )
http://rebelem.com/atls-wrong-palpable-blood-pressure-estimates/

On a related note, this patient's BP is dangerously low however you measure it!



RICollegeEMT said:


> no pressors because they're "optional" per oems ; if it's optional You don't have it. Lol.
> 
> No temp although a few wounds.
> 
> EKG sinus t-waves peaked but has a hx of hyperkalemia. A med list 10 pages long.  Age around 90.  DNR/dni. And INR elevated 5.9 or so-- only lab value available.



How many of those medications are cardiac related?  This includes diuretics as well.  Does the patient have any history of CHF?

A-febrile is good, but doesn't rule in/out sepsis.  I'm guessing no POC lactate machine is available either lol.  Do the wounds look infected?

All of that being said, I'm with VentMonkey on this one.  Fluid boluses with caution, and if we get the BP up enough (which I doubt we'll be able to do), CPAP.  However, the DNR/DNI might change the treatment options that we have.  Transport, continue O2 (but D/C the neb if it's not already finished).  Tough to tell from just reading about the situation, but PPV might be needed (but again, depends on DNR/DNI directions).


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## medichopeful (Nov 16, 2016)

VentMonkey said:


> This goes without saying to most experienced providers, but an excellent question nonetheless. And to the op, this is the first question out of my mouth more often than not in these scenarios.



That's the only kind of question that I ask! 



VentMonkey said:


> It is at a SNF/ assisted living? That's the impression I got. Also something you might want to keep in mind for your scenarios, again, most experienced providers are going to ask a ton of questions especially pertaining to the patient's H/A/M. This is what paints the picture for their course of treatment. Again, this goes back to a *good primary assessment*. The reason I highlight this is to emphasize the fact that regardless of provider level, if you get all the pertinent info, your treatment will soon follow.



That's the impression I had as well (facility patient).


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## Handsome Robb (Nov 16, 2016)

RICollegeEMT said:


> And BP was confirmed by palp. No radial but present (weak) carotid pulse.  So that ballparks it around 60-70.



How did you palate a blood pressure if there was no radial pulse present? 




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## VentMonkey (Nov 16, 2016)

Handsome Robb said:


> How did you palate a blood pressure if there was no radial pulse present?


He didn't, it's "theoretical" remember?


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## DesertMedic66 (Nov 16, 2016)

RICollegeEMT said:


> And BP was confirmed by palp. No radial but present (weak) carotid pulse.  So that ballparks it around 60-70.


The whole radial= SBP of at least 80 is not accurate in the slightest


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## DesertMedic66 (Nov 16, 2016)

Handsome Robb said:


> How did you palate a blood pressure if there was no radial pulse present?
> 
> 
> 
> ...


I'm assuming he went "no radial pulse means it's under 80 but the patient has a carotid pulse which means it has to be above 60"


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## VentMonkey (Nov 16, 2016)

DesertMedic66 said:


> I'm assuming he went "no radial pulse means it's under 80 but the patient has a carotid pulse which means it has to be above 60"


I will _never _forget an LACoFD FF trying to "teach" me how to guesstimate an estimated SBP this way when I went to grab the cuff.

It was this "method" I later learned he was trying to show me, he taught me alright...that I would never take a blood pressure that way myself.


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## Alan L Serve (Nov 16, 2016)

Sounds like decompensated HF. They are wet and white. They need inotropic support (Digitalis), _very careful_ loop diuresis, and pressors like epi. By very careful I mean slowly and with heavy monitoring so that you don't further tank their BP. What is their LVEF%?

Why in the world in the PT's INR 5.9? Who the heck overdosed them on their Warfarin. For that matter WHY are they on an anticoagulant? Give VitK to reverse that and do it right away.

The cause of the PT's right sided heart failure is from their left sided heart failure. This patient is unlike to survive and if they have a DNR/DNI you need to have a serious chat with them or the family about just how aggressive they want you to be.


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## SpecialK (Nov 16, 2016)

It sounds like we are picking this person up from a rest home?.  

So my first question is what does this patient want done or what advance directive or such does he have?

What does his chart say about medical history?

Sounds like he has got bilateral heart failure and at the moment he's got acute cardiogenic pulmonary oedema.

Do a good 12 lead ECG and exclude VT or other tachyarrythmia or STEMI.  Oxygen.  No GTN.

Under normal circumstances I would firmly recommend transport to ED via ambulance but we need to know what wishes he has or has expressed in the past.  If nothing else, hey, could just ask if he wants to go to the hospital!


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## EpiEMS (Nov 17, 2016)

RICollegeEMT said:


> And BP was confirmed by palp. No radial but present (weak) carotid pulse.  So that ballparks it around 60-70.



Nope...for example, see this study: Those ballpark estimates actually "are inaccurate and generally overestimate the patient’s systolic blood pressure and therefore underestimate the degree of hypovolaemia." For more summary, check this out.


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## RICollegeEMT (Nov 17, 2016)

Ok sorry again it took a bit to reply. 

Patient is an SNF special-- nurse is doing the "I just got here, the last nurse gave report, I never work this floor (in a one floor facility!)" 

DesertMedic is correct, I did the "no radial means below 90/80, carotid means its above 60, so split the difference and say 70 is not outlandish".  Mind you this is backing up an NiBP  (no manual because it wasn't audiable).  I'm not disputing whether its "100% correct" or not, I use it only as a secondary/tertiary measure however I will definitely read up on it. 

The INR was due to Coumadin which they were withholding until it normalized.

The code status DNR.

Unfortunately in the "granny grabbing" side of EMS the impressions are limited.  More often than not I note the four sh*ts: Looks like sh*t, sounds like sh*t, nurse doesn't know sh*t, and the patient just tried to eat their sh*t.  Horay dementia! 

My thoughts were CHF underlying (RN did mention Lasix being given "occasionally") which when they NEBed the person caused flash edema.  Because undoubtedly I don't think the person could've survived the condition they were in for the length of time the RN indicated.


Now mind you this is all *hypothetical* and bears no resemblance to any persons living or diseased-- deceased either!-- events, or what have you.   Keeps the ambulance chasers at bay lol!


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## SpecialK (Nov 17, 2016)

Right, I want to locate and read his DNR/advance directive.  

If I ask him if he wants to go to the hospital what does he say?

FYI the "X pulse mens BP above Y" thing is an old wives tale from years ago thats bollocks.


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## VentMonkey (Nov 17, 2016)

RICollegeEMT said:


> Unfortunately in the "granny grabbing" side of EMS the impressions are limited.  More often than not I note the four sh*ts: Looks like sh*t, sounds like sh*t, nurse doesn't know sh*t, and the patient just tried to eat their sh*t.  Horay dementia!


I'm not quite sure I understand the relevance of this paragraph here.

Also op, if memory serves correct you have thrown some pretty randomly vague scenarios out, and on to this forum in the past before. Is there something for us, and/ or you to take away from them?

I'm not knocking you, or inciting anything, I am simply asking. Them (SNF) withholding the Warfarin until the INR normalizes for example, what's the point? Without a full set of clotting factors (pt, ptt, and an INR) and perhaps in a slightly younger patient I would like a full chem panel, but with this patient I am still not too concerned. Perhaps this was something to distract us?

There's not a whole lot of critical thinking involved with a 90 year DNR in severe distress. Paperwork, contact numbers (I try and make sure I have the POA/ NOK's phone number on the face sheet with these types of patients), excellent charting, and med comm are my go to's here.

I'm just trying to understand your scenarios a bit better is all, cheers.


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## Tigger (Nov 17, 2016)

RICollegeEMT said:


> My thoughts were CHF underlying (RN did mention Lasix being given "occasionally") which when they NEBed the person caused flash edema.  Because undoubtedly I don't think the person could've survived the condition they were in for the length of time the RN indicated.


Albuterol causing flash pulmonary edema is not really a proven thing.


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## VentMonkey (Nov 17, 2016)

Tigger said:


> Albuterol causing flash pulmonary edema is not really a proven thing.


This is a good point. Before our protocols were re-written, I liberally gave patients with "wet"  (or even absent due to all of the fluid build up) breath sounds in-line nebs even in the face if CHF hx. 

Now mind you, if they're were already tachycardiac, and/ or in an AF with RVR, not so much, but all in all I don't recall flash edema being a factor. Granted they were already on CPAP, but my PEEP valve was not eve maxed out. 9 out of 10 times these patients improved, which was reflected by the ventilatory status amongst other things. 

So I agree, I don't know how big of a threat flash edema truly is with strong clinical feelers, and the advent of CPAP/ BiPap in the prehospital realm.


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## Tigger (Nov 17, 2016)

VentMonkey said:


> This is a good point. Before our protocols were re-written, I liberally gave patients with "wet"  (or even absent due to all of the fluid build up) breath sounds in-line nebs even in the face if CHF hx.
> 
> Now mind you, if they're were already tachycardiac, and/ or in an AF with RVR, not so much, but all in all I don't recall flash edema being a factor. Granted they were already on CPAP, but my PEEP valve was not eve maxed out. 9 out of 10 times these patients improved, which was reflected by the ventilatory status amongst other things.
> 
> So I agree, I don't know how big of a threat flash edema truly is with strong clinical feelers, and the advent of CPAP/ BiPap in the prehospital realm.


Obviously your treatment needs to be directed at fixing the issue and obviously a beta2 agonist is not going to likely fix a CHF exacerbation and may worsen it with the increase in MVO2 demand. But I can't really find anything about flash pulmonary edema. 

The patient needs something to improve cardiac output.


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## VentMonkey (Nov 17, 2016)

Tigger said:


> The patient needs something to improve cardiac output.


Typically the Beta-2 would open said patient up enough so that the PPV initiated with the CPAP pushed at least enough through to improve some V/Q mismatch, even if only temporarily.

And again, I concur with the above statement. More often than not if these cardiogenic patients are refractory to therapies provided in the field, and/ or ED, I would think inotropes would be appropriate.


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## RICollegeEMT (Nov 17, 2016)

Vent:  The two goals are to compare my rationale and understanding with those who have more experience to ensure my train of thought is going down the right path.  The INR was mentioned because someone mentioned labs-- that was the only lab available.  And the 4 Sh*ts is because someone else mentioned assessment and I was mentioning how little is usually available.   RNs in this state unfortunately consider us "that taxi with a bed" as opposed to medical professionals so we've gotta fight tooth and nail for any kind of report that's mildly accurate.  Hell can't tell you how many times I get asked "do you guys carry oxygen?". 

And I'm glad you guys chimed in on the albuterol thing-- clearly we were taught entirely wrong, and were always told "albuterol with chf = flash edema".  Same with the fluids for CHF pts-- we were always taught that was a big no-no.

Unfortunately if you ever notice my responses seem very "Mcguyver" its not because I enjoy working in the stone age its because how backasswards this state is.  For example we don't have CPAP (its "optional"), pressors, analgesics, hell a working SpO2 probe all fall into that category. Mind you its all stuff we're licensed to do!


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## VentMonkey (Nov 17, 2016)

RICollegeEMT said:


> Vent:  The two goals are to compare my rationale and understanding with those who have more experience to ensure my train of thought is going down the right path.  The INR was mentioned because someone mentioned labs-- that was the only lab available.  And the 4 Sh*ts is because someone else mentioned assessment and I was mentioning how little is usually available.   RNs in this state unfortunately consider us "that taxi with a bed" as opposed to medical professionals so we've gotta fight tooth and nail for any kind of report that's mildly accurate.  Hell can't tell you how many times I get asked "do you guys carry oxygen?".
> 
> And I'm glad you guys chimed in on the albuterol thing-- clearly we were taught entirely wrong, and were always told "albuterol with chf = flash edema".  Same with the fluids for CHF pts-- we were always taught that was a big no-no.
> 
> Unfortunately if you ever notice my responses seem very "Mcguyver" its not because I enjoy working in the stone age its because how backasswards this state is.  For example we don't have CPAP (its "optional"), pressors, analgesics, hell a working SpO2 probe all fall into that category. Mind you its all stuff we're licensed to do!


Perhaps get your paramedic, and/ or move, good luck.


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## Brandon O (Nov 18, 2016)

medichopeful said:


> Can we get a POC lactate on this patient?  Sepsis is a possibility.



Bear in mind that lactate is not a test for sepsis, and in this clearly shocked patient it's probably a safe bet their lactate will be elevated regardless of the cause.


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## medichopeful (Nov 18, 2016)

Brandon O said:


> Bear in mind that lactate is not a test for sepsis, and in this clearly shocked patient it's probably a safe bet their lactate will be elevated regardless of the cause.



Very true, but if we start giving fluids it's nice to have a baseline for the hospital for trending. It's not a rule in/out for sepsis, but a trending tool and just another piece of info to try to figure out what's going on.


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## Brandon O (Nov 18, 2016)

medichopeful said:


> Very true, but if we start giving fluids it's nice to have a baseline for the hospital for trending. It's not a rule in/out for sepsis, but a trending tool and just another piece of info to try to figure out what's going on.



Of course. But that's a means of following the resuscitation, not so much an aid to diagnosis. (Although in a somewhat meta-medical sense, it's true that lactate has become part of the reimbursable sepsis quality measures in many hospitals.)


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## medichopeful (Nov 18, 2016)

Brandon O said:


> Of course. But that's a means of following the resuscitation, not so much an aid to diagnosis. (Although in a somewhat meta-medical sense, it's true that lactate has become part of the reimbursable sepsis quality measures in many hospitals.)



Very good point!


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## StCEMT (Nov 18, 2016)

I assume you are on an ALS truck? How do you not have a pressor, do you not carry epi at all?


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## EpiEMS (Nov 18, 2016)

[Delete]


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## VentMonkey (Nov 18, 2016)

By no means am I suggesting delineating from protocols, but...
http://www.emdocs.net/push-dose-pressors/


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## StCEMT (Nov 18, 2016)

VentMonkey said:


> By no means am I suggesting delineating from protocols, but...
> http://www.emdocs.net/push-dose-pressors/


I was thinkin something similar. 1mg of epi in 500ml or 1L and set a drip.


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## BassoonEMT (Feb 22, 2017)

my protocols call for dopamine drip, standing order. can call the doc for epi drip.

If anybody is still watching this thread, what's your take on that.


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## E tank (Feb 22, 2017)

Talk about wading in to the tall weeds in 2 pages...wow...I'll add to the stew with my $ 0.02....

1. If a patient like this has a radial pulse, I don't care what BP it corresponds to. It means there's blood getting to peripheral tissues and that tells me I've got a little time and makes me feel good. 

2. In trying to tease out the role of giving volume as treatment, I may try a passive leg raise and see what happens to the BP.

3. Dopamine is what we call a "dirty drug" because you don't really know what you'll get until you get it going in terms of improved BP/cardiac output with or without a bump in the HR. It has fallen way out of favor in CC circles in favor of epinephrine/NE. IF a pressor was called for here, it would begin with epinephrine, if I were in charge.


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## VFlutter (Feb 22, 2017)

Alan L Serve said:


> Why in the world in the PT's INR 5.9? Who the heck overdosed them on their Warfarin. For that matter WHY are they on an anticoagulant? Give VitK to reverse that and do it right away.



Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.


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## EpiEMS (Feb 23, 2017)

E tank said:


> In trying to tease out the role of giving volume as treatment, I may try a passive leg raise and see what happens to the BP.



This is interesting - I wish I had heard of this earlier! I know there isn't much predictive value from orthostatics, but a quick review found some good evidence (I cite a review here) for this!


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## Alan L Serve (Feb 24, 2017)

Chase said:


> Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.


What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?


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## Carlos Danger (Feb 24, 2017)

Alan L Serve said:


> What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?



He isn't talking about the margin of error in testing the INR, but in dosing the warfarin. 

A high INR doesn't necessarily mean that someone "overdosed" the patient on warfarin. INR's fluctuate based on lots of factors, which is why they are checked so frequently when someone is on warfarin. When patients get sick, sometimes the INR changes quickly.

Also, warfarin isn't the only cause of an elevated INR. And vitamin K won't work on most of the other causes.


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## E tank (Feb 24, 2017)

Alan L Serve said:


> What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?



A Coumadin does is difficult to dial in because of variables that differ from patient to patient. Liver function and diet play a big role in getting the dose right. A patient can be on more than 2 times the dose of another for the same INR. That's why frequent INR's need to be checked, sometimes as frequently as every 2 weeks. It's also why Xa inhibitors and direct thrombin inhibitors (DTI's) are becoming so popular. They don't need any testing at all, but they're not approved for some things patients need blood thinners for, like mechanical heart valves.


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## FLdoc2011 (Feb 25, 2017)

Alan L Serve said:


> Sounds like decompensated HF. They are wet and white. They need inotropic support (Digitalis), _very careful_ loop diuresis, and pressors like epi. By very careful I mean slowly and with heavy monitoring so that you don't further tank their BP. What is their LVEF%?
> 
> Why in the world in the PT's INR 5.9? Who the heck overdosed them on their Warfarin. For that matter WHY are they on an anticoagulant? Give VitK to reverse that and do it right away.



An elevated INR doesn't mean someone "overdosed" them on warfarin.   There are some many drug and diet interactions that it's one of the tougher drugs to manage.  And in the absence of acute bleeding I'm not at all excited about an INR of 5.9 and would just let it trend down.  Certainly if the guy has a mechanical heart valve the last thing you want to do is give him a dose of Vit K if you can avoid it.   Treat the patient, not a number.


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## FLdoc2011 (Feb 25, 2017)

Not much to add here, other than honestly the most important that can be done is clarifying his code status and bringing in the DNR paperwork.  I routinely see these patients in the ED after they show up, there's no family or paperwork and they get intubated.   

Otherwise not much to do beyond supportive care, give O2, can use some sort of CPAP or BiPAP if needed depending on his mental status and go from there.  If they want to be aggressive in medical treatment and he's truly in a low cardiac outpt state would put him on an inotrope, possibly dobutamine.


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## Alan L Serve (Feb 26, 2017)

FLdoc2011 said:


> An elevated INR doesn't mean someone "overdosed" them on warfarin.   There are some many drug and diet interactions that it's one of the tougher drugs to manage.  And in the absence of acute bleeding I'm not at all excited about an INR of 5.9 and would just let it trend down.  Certainly if the guy has a mechanical heart valve the last thing you want to do is give him a dose of Vit K if you can avoid it.   Treat the patient, not a number.


So true! But that doesn't answer my original question of the expected margin of error of INR and Warfarin.


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## jcroteau (Mar 5, 2017)

This is exactly why I love this forum! New information all the time. Now I know I can throw that "well they have a palpable pulse at this location, so their BP must be this" thought process out the window. 


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## GMCmedic (Mar 6, 2017)

Sadly, and this isnt a stab at anyone here, we have PI's teaching that whole systolic by palpation estimate stuff to Medic students to this day. 

Theyre also still warning that albuterol will cause flash edema and Ipratropium is a no no for patients with peanut allergies.

And I wonder why new medics in our area cant asses their way out of an open paper bag.

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## Handsome Robb (Mar 6, 2017)

GMCmedic said:


> Ipratropium is a no no for patients with peanut allergies.



I had a nurse at a pediatric hospital come unglued at me for giving an asthmatic 10 year old duonebs. 

"He has an allergy to peanuts, no wonder his wheezing didn't resolve!" 

"No...his wheezing didn't resolve because he's status asthmaticus and I probably should'be pulled the trigger on the epi but he had improved with duonebs, fluids, solumedrol and mag. "


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## E tank (Mar 6, 2017)

Alan L Serve said:


> So true! But that doesn't answer my original question of the expected margin of error of INR and Warfarin.



The sampling/instrument margin of error for INR? Not sure I'm following, but if that is the question, the answer is insignificant enough to not be any kind of consideration when sending these tests. Different brands of equipment will give different margins, but non of them will be large enough to affect a clinical decision.  Looking at results in the context of  what is going on with the patient, you can pretty much tell if it is instrument/sampling artifact or not. Further, an INR like this in a patient like this is not out of the ordinary and wouldn't be redrawn because it didn't make sense and might be an error.

A healthy 40 yo going for aortic valve replacement, yeah, you'd question it and resend. Margin of error of the lab equipment would have nothing to do with that decision.


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## Alan L Serve (Mar 6, 2017)

E tank said:


> The sampling/instrument margin of error for INR? Not sure I'm following, but if that is the question, the answer is insignificant enough to not be any kind of consideration when sending these tests. Different brands of equipment will give different margins, but non of them will be large enough to affect a clinical decision.  Looking at results in the context of  what is going on with the patient, you can pretty much tell if it is instrument/sampling artifact or not. Further, an INR like this in a patient like this is not out of the ordinary and wouldn't be redrawn because it didn't make sense and might be an error.
> 
> A healthy 40 yo going for aortic valve replacement, yeah, you'd question it and resend. Margin of error of the lab equipment would have nothing to do with that decision.


Right, but someone before indicated there is a wide margin of error with INR testing which was both confusing and incorrect.


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## Carlos Danger (Mar 7, 2017)

Alan L Serve said:


> Right, but someone before indicated there is a wide margin of error with INR testing which was both confusing and incorrect.


No, nobody said that.


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## Alan L Serve (Mar 7, 2017)

Remi said:


> No, nobody said that.


Yes, somebody said that.



			
				Chase said:
			
		

> Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.


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## Handsome Robb (Mar 7, 2017)

No they didn't.

Chase said: aside from the inherent margin of error with Warfarin *dosing* it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock. 

No one said there was a wide margin of error in INR *testing*, they said there's a wide margin of error in warfarin *dosing*.


Sent from my iPhone using Tapatalk


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## Carlos Danger (Mar 7, 2017)

Alan L Serve said:


> Yes, somebody said that.



Read Chase's comment again. He never mentions INR testing at all.


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## VFlutter (Mar 7, 2017)

I meant that there is a some inherent error in the dosing of Warfarin. It is not exact science but rather guess work usually trial and error. It is not uncommon to have supratheraptuic levels even with routine testing and consistent dosing. And as stated an INR of 5  isn't that impressive and usually the only treatment necessary is stopping dosing until levels drop, which will take longer in a shocky patient like this. But unless the patient is actively bleeding to death Vit K reversal can be more deleterious. Especially if they are on it for a valve/filter.


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## Alan L Serve (Mar 7, 2017)

Handsome Robb said:


> No they didn't.
> 
> Chase said: aside from the inherent margin of error with Warfarin *dosing* it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.
> 
> ...


Oh that's quite interesting. There is a reasonable chance you might be more right than otherwise.


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## MackTheKnife (Mar 20, 2017)

VentMonkey said:


> Proceed with transport. Do you have a question somewhere? There isn't much to be done with this patient other than bring the DNR in. Also, what did, sorry, "does" this hypothetical patient's DNR say? How specific are the wishes? The patient is 90, I am going to guess their INR being elevated is for any number of reasons, again, none of which will change my treatment course.


Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????


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## VFlutter (Mar 20, 2017)

MackTheKnife said:


> Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????



Bleeding could be on the differential however in this context cardiogenic shock sounds more likely. As stated most people with an INR of 5.9 do not have catastrophic spontaneous bleeds.


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## MackTheKnife (Mar 20, 2017)

Chase said:


> Bleeding could be on the differential however in this context cardiogenic shock sounds more likely. As stated most people with an INR of 5.9 do not have catastrophic spontaneous bleeds.


I'd like to know the BNP as well to help confirm it's truly CHF. As pressors aren't available, I'd transport and monitor BP. From the info, the MAP is approximately 50. Curious where the INR value came from.


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## VentMonkey (Mar 20, 2017)

MackTheKnife said:


> Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????


Lol, I'm too lazy to go back and re-read my other stuff. I do remember: 90, DNR, and hypotensive.

I guess i figured if I was this patient, what would _I_ want? 

For my DNR to be honored, i.e., transport, monitor accordingly, and enter whatever algorithm completely, and respectfully coincides with my wishes.


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## MikeC (Apr 27, 2017)

RICollegeEMT said:


> I'm throwing another scenario out here:
> 
> You respond for an Altered MS-- on arrival RN states that patient has been lethargic and O2 Sats were low around 80 so they placed them on the customary 2L NC with 500 feet of tubing and gave them a Neb Treatment (straight albuterol).  Denies having checked a BgL "they're not a diabetic" or administering any recent Narcotics. They also stated that the patient has been lethargic since this morning (its around dinner time now).
> 
> ...


Crackles/rales suggests pulmonary edema, which is often caused to left-sided CHF (which is unsure if she has this dx from what's posted here). The ekg could read normal with CHF.

With that low of a BP, I'd place in the semi-fowler position and elevate the legs using pillows/blankets. I'd try to get compression socks from the nurse prior to departure.

The bgl is 290 which is high. If the individual is "not diabetic" and at her age, it most likely is d/t insulin resistance and consuming food recently. The high blood sugar level will be treated with insulin at the hospital, and is not as high of a priority as her low blood pressure and respiratory distress.

I'd continue with the NRB at 15 lpm getting her to the closest facility asap. Positive pressure ventilations such as CPAP or BVM could potential help with the rales, but increasing the intrathoracic pressure with an already decreased blood pressure is contraindicated.


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## medichopeful (Apr 27, 2017)

Let's get the family and medcon (and/or the patient's healthcare provider) involved before we rush to transport this patient.  A 90 year old DNR/DNI in cardiogenic shock with a pressure of 65/42 isn't necessarily someone we want to be super aggressive with.  In all seriousness, letting the patient die in their own bed on comfort care might be the best course of action.


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