77 y/o female respiratory distress

[FLdoc2011]

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.

 

[Handsome Robb]

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...

 

[FLdoc2011]

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.

 

[VFlutter]

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.

 

[Handsome Robb]

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

It makes sense.

 

[Rialaigh]

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.

 

[TheLocalMedic]

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.

 

[FLdoc2011]

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.

 

[Rialaigh]

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.