Basic Life Support - Question of the Day - Medic 27

[Medic27]

Scenario:

Medic 27 respond to 2122 N. Lakeview Ave, respond to chest pain and possibly disoriented male.

Pulse: 128 bpm
Respirations: 30 per minute
O2 Sat: 95%
Blood pressure: 188/102 mmHg
Eyes: PERL @ 3 mm
LOC: Alert
Lung sounds: Crackles/Rales bilaterally
Skin: Pale, cool and clammy

You have no other information BLS (EMT-Basics) on the forum is first on scene (ALS EMT-A's/EMT-P's) are enroute at this time. Both please feel free to contribute to the scenario. How do you treat this patient and what are you treating them for?

@wtferick @bakertaylor28 @Gurby

 

[Old Tracker]

I'd be considering CHF which is leading to pulmonary edema. BVM time, or at least an NC @ 6 lpm to see if that would bring the RH down. Pt would also get a 12 lead to see what the heart is doing.

 

[EpiEMS]

BVM time, or at least an NC @ 6 lpm to see if that would bring the RH down.

Do you have BLS CPAP? That would have been my go-to, personally.

 

[Old Tracker]

No we don't have it, and I meant RR, not RH.

 

[EpiEMS]

No we don't have it, and I meant RR, not RH.

Gotcha. (Yeah, I figured that was what you meant )

@Medic27

I'd start with positioning (high Fowler's) & a NRB at 15lpm, then transition to CPAP. I'd consider administering nitro and albuterol if they have them. Obviously, I'd like ALS, but I would consider getting off scene quickly, given the complaint & tachypnea.

Any recent travel? Any recent surgery?

As far as differentials:

1) CHF (likely left sided or both sides)
2) Pulmonary embolism
3) ACS
4) COPD exacerbation (doesn't seem likely)
5) Pneumonia
6) Pericardial tamponade

Like @OldTracker said, I'm thinking that this is CHF leading to pulmonary edema.

 

[Medic27]

Do you have BLS CPAP? That would have been my go-to, personally.

Personally I would have did non rebreather 100% 02, depending on whether it went up then apt to have ALS do a CPAP...

 

[Medic27]

Gotcha. (Yeah, I figured that was what you meant )

@Medic27

I'd start with positioning (high Fowler's) & a NRB at 15lpm, then transition to CPAP. I'd consider administering nitro and albuterol if they have them. Obviously, I'd like ALS, but I would consider getting off scene quickly, given the complaint & tachypnea.

Any recent travel? Any recent surgery?

As far as differentials:

1) CHF (likely left sided or both sides)
2) Pulmonary embolism
3) ACS
4) COPD exacerbation (doesn't seem likely)
5) Pneumonia
6) Pericardial tamponade

Like @OldTracker said, I'm thinking that this is CHF leading to pulmonary edema.

CHF was the answer has probability of leading to pulmonary edema

 

[Medic27]

Gotcha. (Yeah, I figured that was what you meant )

@Medic27

I'd start with positioning (high Fowler's) & a NRB at 15lpm, then transition to CPAP. I'd consider administering nitro and albuterol if they have them. Obviously, I'd like ALS, but I would consider getting off scene quickly, given the complaint & tachypnea.

Any recent travel? Any recent surgery?

As far as differentials:

1) CHF (likely left sided or both sides)
2) Pulmonary embolism
3) ACS
4) COPD exacerbation (doesn't seem likely)
5) Pneumonia
6) Pericardial tamponade

Like @OldTracker said, I'm thinking that this is CHF leading to pulmonary edema.

Would you consider aspirin, why or why not?

 

[EpiEMS]

Would you consider aspirin, why or why not?

The symptoms suggest that acute coronary syndrome is possible, and CHF could be the result of an infarct OR the infarct could exacerbate the underlying CHF, so perhaps ASA would be indicated. That said, I'd do a nice detailed history & physical first.

@VentMonkey, @Gurby, @Chase, @Akulahawk, anybody have an opinion? Should ASA be administered here?

 

[hometownmedic5]

Folks, you had pulmonary edema from the opening post(rales on auscultation). CHF doesn't lead to pulmonary edema. Edema is a finding of CHF(and many other diagnoses, but I wont derail the discussion).

ASA would have been fine here(chest pain) from a literal application of the protocols; keeping in mind that the pain the patient is feeling is much more likely be caused by acute failure than by an MI.

ASA, NTG (theirs or yours), O2 all good choices. What this patient needs immediatley is CPAP with some judicious vasodilation and a ride to the hospital.

 

[Medic27]

Sorry if my scenario wasn't great guys haha, I did my best. Feel free to send me some suggestions you would like to see.

 

[VFlutter]

The symptoms suggest that acute coronary syndrome is possible, and CHF could be the result of an infarct OR the infarct could exacerbate the underlying CHF, so perhaps ASA would be indicated. That said, I'd do a nice detailed history & physical first.

@VentMonkey, @Gurby, @Chase, @Akulahawk, anybody have an opinion? Should ASA be administered here?

It's hard to rule out ACS in these patients so although ASA probably isn't needed it won't hurt. Pulmonary edema usually occurs in two situations, Cardiogenic shock or Diastolic Dysfunction. This guy is later with hypertension and pulmonary edema. Nitro, nitro, and more nitro. Reducing afterload is key. CPAP if needed until you get the blood pressure down.

 

[Medic27]

It's hard to rule out ACS in these patients so although ASA probably isn't needed it won't. Pulmonary edema usually occurs in two situations, Cardiogenic shock or Diastolic Dysfunction. This guy is later with hypertension and pulmonary edema. Nitro, nitro, and more nitro. Reducing afterload is key. CPAP if needed until you get the blood pressure down.

Sorry I didn't get a full sentence but I think you meant ASA wouldn't have hurt them regardless as precaution?

 

[hometownmedic5]

ASA is appropriate in this case because as a basic, you can't rule out ACS(I as a medic can't rule it out 100% either). So you have chest pain, give asprin unless otherwise contra indicated.

Since this patients issue most likely isn't an MI, The asprin isn't going to help(by reducing platelet aggregation). It won't hurt, but it won't help either.

 

[Medic27]

ASA is appropriate in this case because as a basic, you can't rule out ACS(I as a medic can't rule it out 100% either). So you have chest pain, give asprin unless otherwise contra indicated.

Since this patients issue most likely isn't an MI, The asprin isn't going to help(by reducing platelet aggregation). It won't hurt, but it won't help either.

Typically per local protocol for us as chest pain if we as basics don't have ALS administer ASA. However, we always have ALS.