# 77 y/o female respiratory distress



## rhan101277 (May 26, 2014)

You are called for a patient with sob.  You arrive to find the fire department on scene with the patient on a NRB at 15L/m.  Pt is sitting in a chair and leaning forward in obvious distress.  She denies any pain, RR is 46 labored and shallow.  Pt blood pressure is 220/120, HR is 98 NSR on the monitor, 99% of 15L NRB, 12 lead shows no stemi.  Pt denies n/v/d, pt skin is w/p/d.  Pt has diffuse rales in her right lung field and basilar rales on the right.  She does not have any pedal edema or hx of chf, she does have jvd.  Pt has no obvious signs of stroke.  How do you proceed?

PmHx:
COPD
Dialysis
HTN
CVA


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## Anjel (May 26, 2014)

12 lead shows no stemi. Ok is it a completely normal 12 lead? 
Anything that would suggest any electrolyte imbalances, hypertrophy. 

I'd get a line and go with the pulmonary edema/CHF treatment modality. Nitro and Cpap if she will tolerate and call for orders for lasix.

When was her last dialysis treatment. Has she missed a couple days? Anything that would suggest why she is all of a sudden filling up with fluid. 

Is she compliant with her medications?


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## Angel (May 27, 2014)

Anjel pretty much covered the bases

CPAP right away

id do the same tx except lasix since we dont carry it here

sputum production? missed dialysis, med compliance, recent illness ect ect

what was her room spo2? is she on oxygen normally? mentation normal?


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## rhan101277 (May 27, 2014)

no cough, she is compliant with medications and has not missed any dialysis appointments.  Did not get a room air sat.  Good mentation.  12 lead does shows LVH.


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## Anjel (May 27, 2014)

I've had a patient who ended up with flash pulmonary edema who did not have a cough. When breathing at 40+ a minute I wouldn't expect too much coughing. 

Did she get CPAP? Nitro? Any improvement from any treatments?


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## rhan101277 (May 27, 2014)

I administered CPAP, ASA, NTG and her RR was lower by the time we reached the ER but she was still in distress.  Her chest xray showed fluid as well.  Spoke with the doctor and he said new onset CHF or fluid overload and that my treatment was correct.  This was not a classic CHF.  Where the patient has a hx of CHF, pedal edema is taking lasix, spironolactone etc.

I think her blood pressure was so high it was causing acute pulmonary edema.  LVH forms over time but that could help contribute to it especially in severe HTN situations such as this.

I try to follow up on serious calls, that way if I did something wrong I can re-evaluate and figure out where I made the mistake.

ER placed patient on Bi-PAP and in line breathing tx, which they seem to do for CHF many times nowadays.  Though in the field you aren't supposed to do it.  I will follow up further and see if she got admitted and such.  The patients' relative said thank you several times, I don't hear that often and it makes me feel good.


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## Anjel (May 27, 2014)

Sounds like you did a good job. Covered all your bases. 

Only thing different I would of done is no ASA. Not that it would hurt, just not part of my CHF treatment plan. 

This patient has a lot of different comorbidities and any combo of them can cause bad juju on the heart.


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## Angel (May 27, 2014)

ha, i also had this call and screwed it up

just like yours; no hx of chf, new onset, xray showed fluids, audible LS without a steth and i just wasnt aggressive enough. i wasnt convinced it was CHF (exacerbation) because everyone else ive had, had a hx of it.

the thing with her was she had lung CA and was getting chemo (?) and thats what contributed to the the pul. edema

really good learning lesson and this just reaffirmed it. if it looks like a duck, quacks like a duck....

thanks for the reminder ^_^


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## rhan101277 (May 27, 2014)

ASA is in our protocols for CHF.  The thinking is that people with CHF have ventricular dysfunction and blood will pool, administering ASA reduces the risk of further clots developing.


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## Anjel (May 27, 2014)

rhan101277 said:


> ASA is in our protocols for CHF.  The thinking is that people with CHF have ventricular dysfunction and blood will pool, administering ASA reduces the risk of further clots developing.




Ah gotcha. Makes sense. It is not in my protocol. Something to consider though.


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## VFlutter (May 27, 2014)

rhan101277 said:


> ASA is in our protocols for CHF.  The thinking is that people with CHF have ventricular dysfunction and blood will pool, administering ASA reduces the risk of further clots developing.



Eh ASA is minimally beneficial in the treatment or prevention of Apical Thrombi. They need true anticoagulantion therapy, not anti-platelet. Not that it hurts the situation.


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## Handsome Robb (May 27, 2014)

Definitely an acute left sided failure. 

Fluids, NTG, C/BiPAP, RSI/NTI PRN, upright positioning and on to the ER. Lasix's efficacy has been questioned in the acute care setting. I think without obvious signs of fluid overload I'd be hesitant to give it, especially with renal failure in the history and the fact that they're compliant with their treatment from the sounds of it.  This doesn't sound like a volume problem it's a pump problem. Fluid bolus could help due to lovely Mr. Frank Starling.

I need to not drink beer and post.


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## FLdoc2011 (May 28, 2014)

Fluid bolus?  Explain


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## FLdoc2011 (May 28, 2014)

I think you did fine with this,  she's obviously in resp distress and you recognized probably pulm edema/CHF and treated so and got her safely to the hospital.  

Are you able to see what was done after admission?   See if they did an ECHO,  willing to bet she likely has a relatively normal EF but bad diastolic dysfunction.  

And someone already mentioned, but with dialysis patients always good to ask when they get it (M/W/F vs T/Th/Sat) and if they've missed any sessions as well as do they still make any urine.


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## Anjel (May 28, 2014)

Robb said:


> Definitely an acute left sided failure.
> 
> Fluids, NTG, C/BiPAP, RSI/NTI PRN, upright positioning and on to the ER. Lasix's efficacy has been questioned in the acute care setting. I think without obvious signs of fluid overload I'd be hesitant to give it, especially with renal failure in the history and the fact that they're compliant with their treatment from the sounds of it.  This doesn't sound like a volume problem it's a pump problem. Fluid bolus could help due to lovely Mr. Frank Starling.
> 
> I need to not drink beer and post.




Robby dear.... 

Why would you give a fluid bolus to someone with a BP in the 200s and lungs filling up with fluid. So much so that it's backing up and causing JVD?

I understand what you mean with the starling effect, but I think there are better ways to go about it than to give a hypertensive renal failure patient a ton of fluid.


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## Handsome Robb (May 28, 2014)

I'm not saying a ton of fluid, I'm talking about a little 250mL bolus to see if we can't boost his force of contraction and cardiac output. 

Without knowing when her last dialysis was it's a little more difficult to decide if this is due to a fluid overload or something else. If we're after the weekend ok I agree fluids are a bad choice but if we just had our third sesh of the week yesterday I'm going to bet that she's not full of fluids. That's my thought process on it, maybe I'm totally off base.

ACE-Inhibitors might be appropriate if you carry them as well.


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## Anjel (May 28, 2014)

Robb said:


> I'm not saying a ton of fluid, I'm talking about a little 250mL bolus to see if we can't boost his force of contraction and cardiac output.




You didn't specify and I assumed a lot. Sorry love.


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## Rialaigh (May 28, 2014)

Robb said:


> I'm not saying a ton of fluid, I'm talking about a little 250mL bolus to see if we can't boost his force of contraction and cardiac output.
> 
> Without knowing when her last dialysis was it's a little more difficult to decide if this is due to a fluid overload or something else. If we're after the weekend ok I agree fluids are a bad choice but if we just had our third sesh of the week yesterday I'm going to bet that she's not full of fluids. That's my thought process on it, maybe I'm totally off base.
> 
> ACE-Inhibitors might be appropriate if you carry them as well.




Doc ordered me to give Labetalol to the last patient I had with a pre flash pulmonary edema presentation, BP was 240's/130's when I started medicating and I dropped it down to about 150/90 with improved lung sounds without having to CPAP the patient or use any oxygen...


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## Handsome Robb (May 28, 2014)

FLdoc2011 said:


> Fluid bolus?  Explain




Sorry should've been more specific as to the volume I was talking.


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## Handsome Robb (May 28, 2014)

Rialaigh said:


> Doc ordered me to give Labetalol to the last patient I had with a pre flash pulmonary edema presentation, BP was 240's/130's when I started medicating and I dropped it down to about 150/90 with improved lung sounds without having to CPAP the patient or use any oxygen...




That's one I haven't heard of...I know ACE-I is indicated due to the activation of the renin-angiotensin-aldosterone system secondary to hypervolemia so in this particular patient probably not a good option now that I thought that over a bit more.


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## FLdoc2011 (May 28, 2014)

Actually it should be pretty easy in this patient to get an idea of her volume status.....  She's got JVD, rales/crackles, known renal failure and hypertensive.  

I could see you thinking fluids since that's something we do/consider in setting of RV failure and PE but this presentation doesn't fit those scenarios.


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## Handsome Robb (May 28, 2014)

I guess I'm stuck on the lack of peripheral edema. Wow...this actually kinda scares me that I'd get that single track minded like that and I've still got 4 more months before I can go back to the field...


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## FLdoc2011 (May 28, 2014)

Yea I've definitely seen that quite a bit from others getting caught up on something like peripheral edema or lack thereof.   

If more of acute left sided failure then may not have significant edema.   

In this case I think just more of acute pulmonary edema (from whatever caused it) and not necessarily chronic left & right heart failure where you'd expect more peripheral edema.


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## VFlutter (May 28, 2014)

Robb said:


> That's one I haven't heard of...I know ACE-I is indicated due to the activation of the renin-angiotensin-aldosterone system secondary to hypervolemia so in this particular patient probably not a good option now that I thought that over a bit more.



If hypertension is causing the pulmonary edema then treat the pressure. Labetalol is a great option.


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## Handsome Robb (May 28, 2014)

Chase said:


> If hypertension is causing the pulmonary edema then treat the pressure. Labetalol is a great option.




It makes sense.


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## Rialaigh (May 28, 2014)

Chase said:


> If hypertension is causing the pulmonary edema then treat the pressure. Labetalol is a great option.



Much better than slapping on an inch of nitro in the name of chest pain...at least IMO. Nice that you see the effects immediately and it doesn't continue to tank pressures, easy to give repeat doses to hit target pressures.


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## TheLocalMedic (May 29, 2014)

Robb said:


> I'm not saying a ton of fluid, I'm talking about a little 250mL bolus to see if we can't boost his force of contraction and cardiac output.



There's a hospital near my area that does some interesting stuff by treating CHF with fluids, but if I recall they don't jus bolus, they SLAM 250 mls at a time in order to get the desired Starling effect.  I know that there's "theory" behind giving fluids for CHF, but I wouldn't want to be attempting it pre-hospital.


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## FLdoc2011 (May 30, 2014)

Rialaigh said:


> Much better than slapping on an inch of nitro in the name of chest pain...at least IMO. Nice that you see the effects immediately and it doesn't continue to tank pressures, easy to give repeat doses to hit target pressures.




Actually some nitro would probably help here,  give a quick spray or something.

In the hospital if I have someone in distress with acute pulmonary edema I can usually get them over the acute hump by throwing in bipap, hanging nitro gtt at fairly high doses to start, giving some diuretic and controlling their BP.


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## Rialaigh (May 30, 2014)

FLdoc2011 said:


> Actually some nitro would probably help here,  give a quick spray or something.
> 
> In the hospital if I have someone in distress with acute pulmonary edema I can usually get them over the acute hump by throwing in bipap, hanging nitro gtt at fairly high doses to start, giving some diuretic and controlling their BP.



Sorry I was referring to the patient I had and not his scenario, My patient did not require CPAP and was pre flash pulmonary edema enough that just BP control without opening the lungs fixed everything. In his patient with this scenario I completely agree that nitro would probably help, but I hate when people use nitro in the name of just blood pressure control.


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