71yoM c/o difficulty breathing

[OCCPR]

Resp difficulty

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

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

occpr

 

[MrBrown]

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

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

 

[Rykielz]

1) He is using accessory muscles to breath, and is speaking in aprox 4 word phrases.

2) He also has a very weak, but productive, cough. He is coughing up thick mucus that is almost orange in color.

3) Rx: simvistatin, lisinopril, actos, ASA
Hx: hypertension, high cholesterol, NIDDM. He was also shot 4 times in the abdomen & leg in 1995.


4) BBS=extremely diminished in all lobes, to the point I can't hear any air movement. SpO2 is 80% on room air.


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

6) I notice he appears to have a small amount of swelling in his ankles, but he insists that is something he "always" has and that it is not new. He denies ever having any sort of cardiac or respiratory problems in the past & states he is "healthy as a horse."

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

 

[Veneficus]

I would like to again point out.

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

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

That should not be confused with pink or red sputum.

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

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

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

 

[Rykielz]

I would like to again point out.

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

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

That should not be confused with pink or red sputum.

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

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

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

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

 

[Veneficus]

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

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

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

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

 

[Rykielz]

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

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

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

I'll agree with you on that