CHF with low BP

RICollegeEMT

Forum Crew Member
48
6
8
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**
 

VentMonkey

Family Guy
5,729
5,043
113
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**
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).
 

medichopeful

Flight RN/Paramedic
1,863
255
83
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?
 
OP
OP
R

RICollegeEMT

Forum Crew Member
48
6
8
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.
 
OP
OP
R

RICollegeEMT

Forum Crew Member
48
6
8
And BP was confirmed by palp. No radial but present (weak) carotid pulse. So that ballparks it around 60-70.
 

VentMonkey

Family Guy
5,729
5,043
113
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.
 

VentMonkey

Family Guy
5,729
5,043
113
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.
 

medichopeful

Flight RN/Paramedic
1,863
255
83
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 :p)
http://rebelem.com/atls-wrong-palpable-blood-pressure-estimates/

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

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).
 

medichopeful

Flight RN/Paramedic
1,863
255
83
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! :D

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).
 

Handsome Robb

Youngin'
Premium Member
9,736
1,173
113
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?

[emoji848]


Sent from my iPhone using Tapatalk
 

DesertMedic66

Forum Troll
11,268
3,450
113
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
 

DesertMedic66

Forum Troll
11,268
3,450
113
How did you palate a blood pressure if there was no radial pulse present?

[emoji848]


Sent from my iPhone using Tapatalk
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"
 

VentMonkey

Family Guy
5,729
5,043
113
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.
 

Alan L Serve

Forum Captain
258
51
28
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.
 

SpecialK

Forum Captain
457
155
43
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!
 

EpiEMS

Forum Deputy Chief
3,815
1,143
113
OP
OP
R

RICollegeEMT

Forum Crew Member
48
6
8
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!
 

SpecialK

Forum Captain
457
155
43
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.
 

VentMonkey

Family Guy
5,729
5,043
113
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.
 
Top