91 y/o female shortness of breath

[rhan101277]

You arrive on scene at a nursing home to find a 91 y/o female lying semi-fowlers in her room @ facility. She is on 3L nasal cannula. Initial oxygen saturation is 88%, RR 28 and labored, she seems to have trouble getting more than 4 or 5 words out at a time.

Lung Sounds - Diffuse wheezing
EKG - Sinus Tachycardia with frequent PVC's and PAC's
B/P - 168/96
Pulse ox now 97% after you apply NRB at 15L
SOB started 30 minutes ago, denies asthma, COPD hx, never smoked, denies chest pain.
ETC02 waveform is normal, C02 value is 50mmHg. You don't understand why this is so since she has diffuse wheezing.
PMHx: CHF, hyperlipidemia, diabetes, stint placed in the 80's a whole page of diagnoses you have no time to read them all.

Upon loading pt. in ambulance she begins to complain of chest pain. Her sats are now good but her RR is still in high 20's, she says she feels like she can breath better. Chest pain is 6 out of 10, described as tightness.

You are across the street from the hospital. How do you proceed?

 

[46Young]

Since you're in the bus already, 12 lead, 162 of asa if not allergic, and txp across the street immediately. I'd hold off on the neb since she's moving good air despite the wheezing, the increase in SpO2, the perceived relief of dyspnea, frequent PVC's (multifocal?), and the possibility of developing APE. If STEMI and the closest hospital isn't a PCTA, then divert, get a line, start ntg (if no inferior changes or V4R) and CPAP. Give an in-line neb if significant bronchoconstriction. Do temp and BGL. No Q6H nebs or so on the pt's ppw?

 

[rhan101277]

No Q6 nebs, no asthma or copd hx. Your attempts at establishing a line fail. 12 lead EKG shows no ST-elevation. No pedal edema upon exam. RR is starting to increase to around 30-32, chest pain is decreased with one SL ntg spray (here you can give one spray without IV access). End tidal waveform continues to look normal, ETC02 continues increasing to 60mmHG. PVC's are multifocal and are occuring at around 12/min, rhythm is still Sinus Tach w/ Trigeminey PAC's, blood pressure is as above.

 

[MrBrown]

Could be a chest infection, what is her temperature?

 

[rhan101277]

98 with a forehead temperature strip, no fancy measurement tools on this ambulance.

 

[ffemt8978]

You are across the street from the hospital. How do you proceed?

Across the street to the ER entrance?!?

 

[46Young]

No Q6 nebs, no asthma or copd hx. Your attempts at establishing a line fail. 12 lead EKG shows no ST-elevation. No pedal edema upon exam. RR is starting to increase to around 30-32, chest pain is decreased with one SL ntg spray (here you can give one spray without IV access). End tidal waveform continues to look normal, ETC02 continues increasing to 60mmHG. PVC's are multifocal and are occuring at around 12/min, rhythm is still Sinus Tach w/ Trigeminey PAC's, blood pressure is as above.

A rising ETCO2 could suggest sepsis, malignant hyperthermia, increased metabolism, or perhaps decreased pulmonary compliance.

You could've at the ED bay before you even finished hooking up the 12, let alone started a line. Anyway, why was CPAP not started? She fits the criteria. If the multifocal PVC's cause R on T and she goes into V-fib, just drill her with the EZ-IO.

 

[46Young]

Almost forgot, tourniquet (sometimes called a VCB) release can also cause a transient increase in ETCO2. You said you just tried at drop a lock on the pt and failed.

 

[usalsfyre]

My guess based on the information present is APE/decompensated heart failure. I'd expect to see a decreased ETCO2 in most cases, but not always. High dose nitrates, CPAP and ACE inhibitors if you can get a line.

 

[46Young]

My guess based on the information present is APE/decompensated heart failure. I'd expect to see a decreased ETCO2 in most cases, but not always. High dose nitrates, CPAP and ACE inhibitors if you can get a line.

Yes, I forgot to ask for elaboration on the L/S. I mentioned that the pt was moving good air, and I wasn't corrected. I wouldn't give a duoneb unless the pt was constricted. There's no other indication to give one for the suspected cardiac APE otherwise. I'm curious as to what the capnogram was displaying. We were only given the capnometry values thus far. APE was my primary provisional Dx as well.

 

[Veneficus]

Across the street to the ER entrance?!?

exactly!

Very well said.

 

[rhan101277]

Across the street to the ER entrance?!?

Well done, I did not delay transport for a 12 lead. NTG spray and go, pt already had ASA and I was not sure of the cause of her respiratory distress.