APE Call that I have questions about

[RedZone]

81 year old male at a SNF dispatched as respiratory distress / vent patient.

PMHx: HTN, A. Fib, CHF, Anemia, C. Diff (supposedly cleared, but still having watery stools), Resp Failure, questionable Renal Insufficiency, Vent Dependant (tracheostomy), currently being treated for pneumonia.

Rx: Cardizem, Acidophilus, Questran, Regular Insulin Coverage, Lasix, KCl,
Flagyl, Heparin, Percocet, Maxipene, Synthroid, Celexa, Prilosec, Metoprolol

Chief complaint was from the nurse (pt. unable to communicate): Respiratory distress. Patient was last hospitalized 2 weeks ago, and has been "like this" since being discharged. Today, they noticed rales which was the reason for EMS activation.

Patient presents as tachypneic (26 BPM on A.C. setting of 18 BPM), rales all the way to the calvicles, JVD, cool/pale/diaphoretic, edema to right arm (apparently normal), ascites, moderate edema to both legs (apparently normal) with pretty severe discoloration to both lower legs (apparently normal), pulse ox of 95%. Foley bag shows dark colored urine.

Initial v/s: 26 RR, 136 irregular HR, 110/60 BP. ECG: A. Fib between 130-140.

There were some secretions noted in the vent tubing, but tracheal suctioning did not remove any significantly excesssive secretions.

Nurse states this happened once in the past, and the MD ordered a fluid bolus which improved his status. ?????????

So, I'm concerned about the normotension and the pneumonia, but I decide to try a SL nitro and reassess (along with making sure the FiO2 was at 100%). I was sure I heard rales and not rhonchi, and the nurse denied any vomiting (plus he was trached). JVD was rather pronounced.

Give him 1st SL NTG, and his BP doesn't change. I go ahead and give 80 of Lasix IVP, and another SL. Still no change in BP and rales have not subsided at all. Give a third SL NTG and now his BP increases to 130/70 and his HR is 146.

Now we move him to our stretcher and get him to the bus. Since his BP hadn't dropped, I put on 1.5" NTP and I called med control for more NTG's. Had enough time to give 2 more en-route to hospital, and his BP on arrival was now 150/80 and a 148 HR (still A Fib).

No subsided rales, no change is general status, and urine output was increased (more watery/normal colored than the dark urine on arrival... ruling out Lasix toxicity).

While flipping through the SNF papers at the ED, I noticed he had a 12-lead 2 days prior which was computer interpreted as A.Fib (rate was about 90) and it was initialed (but no other notation of any practitioner interpretation. It was obvious A FLutter at about 3:1 or 4:1 conduction). I did notice the med sheet had many orders for Cardizem during this time, but the patient had never been sent to the hospital.

My main question here is... why did his BP go UP progressively with NTG treatment?? My med control physician couldn't give me an answer.

Thoughts?

 

[Ridryder911]

I am not sure why his pressure went up, unless it was more pulmonary congestion and was able to open the preload factor.

I do inquire the treatment of the CHF. I agree nitrates is the usual treatment, but it is ironic that the patient is normotensive. Since the patient has had history of this same scenario was dx. as dehydration, this is a teeter totter effect of dehydration with rales.

His urine being concentrated could indicate possible renal insufficiency or dehydration. Again, something to consider as well as changing the vent to PEEP mode @ >5cm/H20 and maintaining Fi02 @ 100%, if severe distress increase pressure more and use of nitrates. I agree use of Lasix is common, but I am recently more conservative in my use; especially those with potential renal problems. Sometimes, the Lasix will work other times... more trouble.

R/r 911

 

[Cowboy Medic]

Any word from the ED if this was just exacerbated pneumonia? (Noted that he was under current care for same at time of EMS activation... maybe would have substituted an inhaled beta-agonist like albuterol via mask for the Lasix.) If exacerbated pneumonia instead of APE (which requires HTN as a dx indicator) then the increased HR may be viewed as a compensatory mechanism for BP/pulmonary perfusion.

CM

 

[RedZone]

I am not sure why his pressure went up, unless it was more pulmonary congestion and was able to open the preload factor.

I do inquire the treatment of the CHF. I agree nitrates is the usual treatment, but it is ironic that the patient is normotensive. Since the patient has had history of this same scenario was dx. as dehydration, this is a teeter totter effect of dehydration with rales.

His urine being concentrated could indicate possible renal insufficiency or dehydration. Again, something to consider as well as changing the vent to PEEP mode @ >5cm/H20 and maintaining Fi02 @ 100%, if severe distress increase pressure more and use of nitrates. I agree use of Lasix is common, but I am recently more conservative in my use; especially those with potential renal problems. Sometimes, the Lasix will work other times... more trouble.

R/r 911

Dehydration with rales? I can't say I'm familiar with that. BTW, vent was at PEEP of 5, and afterwards I wondered if increasing the PEEP would have been helpful (thinking along the the lines that CPAP is now being promoted as a treatment for CHF), but I didn't during this particular call.

Also, to be more accurate, I pushed the Lasix in two doses (40 first... then the other 40 after the BP was 130/70). I should have mentioned this in my first post.

The renal problems weren't mentioned in the patient's chart. It was the nurse that said he had "some sort of renal issue" and that's why I said questionable renal insufficiency when stating his history.

The only other things I forgot to mention was that the family member present mentioned he had two prior episodes where his "foley was clogged" and the patient was able to complain about it (he can communicate on ocasion..... but unfortunately, today was one of the days he couldn't). I had the nurse flush the foley after no immediate sign of urine output, and she did stating that there was no resistance. By the time we got to the hospital, there was significant output (as mentioned in the first post).

Also, I know Lasix is going out of style (as well as Morphine)... which is why I usually max out my NTG standing orders before using it. The only time I won't use Lasix at all is if there is complete renal failure (presence of urine in the foley... well presence of a foley period ruled that one out). I do want to read up more on the Lasix/Morphine controversy though... but in journal articles.. I can't really justify altering my treatment based on an internet forum.

But back to my first sentence.... is dehydration with rales common? What's the pathophysiology behind that one?

 

[RedZone]

Any word from the ED if this was just exacerbated pneumonia? (Noted that he was under current care for same at time of EMS activation... maybe would have substituted an inhaled beta-agonist like albuterol via mask for the Lasix.) If exacerbated pneumonia instead of APE (which requires HTN as a dx indicator) then the increased HR may be viewed as a compensatory mechanism for BP/pulmonary perfusion.

CM

I haven't been able to follow up yet, but I might try to if I can... Sometimes it isn't that easy to do that here.

I could have rigged an albuterol tx thru the vent, but I'd have needed to call med control for that one during this particular case. I was still convinced of the cardiac cause as opposed to a pneumonia exacerbation.

And as far as exacerbated pneumonia... yes I was very concerned! It was a dilemma. But:

- Skin was cool, pale, diaphoretic... not warm and dry, and no cyanosis or low pulse ox (although 94% IS the low end of normal... still not enough for me to believe hypoxia due to exac. pneumonia).
- JVD... PRONOUNCED JVD... I mean, it looked like garden hoses sticking out of his neck!
- Hx of CHF, and peripheral edema (scrotal edema too... normal to patient) means Right Heart failure, not yet under control.
- And the A Flutter and lots of cardizem orders over 2 or 3 days really got to me. I was actually thinking mismanagement on the SNF side, completely missing the need for in-hospital ablation.
- The normotension and tachycardia could indicate pneumonia.... but it could also indicate this patient is progressing into cardiogenic shock which I would rather avoid than try to save him later.

A case of a challenging dilemma with those patients sufferring multiple chronic ilnesses.


I've had enough (probably a few hundred) cases of pneumonia vs. CHF and I've become good at differentiating the two. When I'm not too sure... I will use a single SL nitro as a diagnostic drug. Of course, there is an IV in place and I'm ready to give fluids. The pneumonia patients will have a SEVERE drop in BP.

 

[Flight-LP]

I agree on the CHF side of thought, but a key component has yet to be listed. What was the pts. temp???????

Max the NTG, absolutely, quick acting, and very effective. Personally, I would have withheld Lasix, but again with what was described, it probably wouldn't have been too risky. Fortunately, Morphine has fallen to the wayside in CHF pts, recent studies show an significantly higher mortality rate with its administration................

 

[Cowboy Medic]

Dehydration with rales... maybe his HF progressed to the L side as well.

 

[RedZone]

maybe his HF progressed to the L side as well.

That's what I was treating him for; Left HF with pulmonary edema.

but a key component has yet to be listed. What was the pts. temp???????

Sorry, don't have that information for you. I was already convinced of APE, so I didn't ask the nurse what his temp was (we don't take temps). Granted, a normal temp would have made me more confident, but a high temp wouldn't have made me less confident; I already KNEW he had pneumonia.

 

[Ridryder911]

It is not unusual to see elderly geriatric patients with multiple complications of CHF, Pneumonia, and sepsis with dehydration. Usually called "train wrecks" because of their complexity and a resident's nightmare.

I agree knowing the temperature can help differential, although not 100% diagnostic it does help. I also agree, they might have shifted from right side to left side. One usually sees a temporary improvement when work load reduction has occurred, until the left side fills up. As well the extreme engorgement of JVD is more pronounced in right sided failure.

I have much success with CPAP and nitrates, with morphine, Lasix. The typical ICU and vent cases has dramatically dropped about in half. Very rarely, I have to RSI or place the patient on a vent secodary to CHF anymore.

R/r 911

 

[Ridryder911]

It is not unusual to see elderly geriatric patients with multiple complications of CHF, Pneumonia, and sepsis with dehydration. Usually called "train wrecks" because of their complexity and a resident's nightmare.

I agree knowing the temperature can help differential, although not 100% diagnostic it does help. I also agree, they might have shifted from right side to left side. One usually sees a temporary improvement when work load reduction has occurred, until the left side fills up. As well the extreme engorgement of JVD is more pronounced in right sided failure.

I have much success with CPAP and nitrates, with morphine, Lasix. The typical ICU and vent cases has dramatically dropped about in half. Very rarely, I have to RSI or place the patient on a vent secondary to CHF anymore.

R/r 911

 

[Ridryder911]

It is not unusual to see elderly geriatric patients with multiple complications of CHF, Pneumonia, and sepsis with dehydration. Usually called "train wrecks" because of their complexity and a resident's nightmare.

I agree knowing the temperature can help differential, although not 100% diagnostic it does help. I also agree, they might have shifted from right side to left side. One usually sees a temporary improvement when work load reduction has occurred, until the left side fills up. As well the extreme engorgement of JVD is more pronounced in right sided failure.

I have much success with CPAP and nitrates, with morphine, Lasix. The typical ICU and vent cases has dramatically dropped about in half. Very rarely, I have to RSI or place the patient on a vent secondary to CHF anymore.

R/r 911