Big Heart

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MrBrown

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You're send down to the local doc in a box (urgent care) for a shortness of breath.

O/A 86 yom with chest discomfort for 5 days had sob for 6-8 hours, is pale and anxious, increased wob incl acc muscle use but no cyanosis pt states has felt fluey and unwell for about a week, no pmhx, nka

O/E GCS 14 (4/5/5) BP 98/68 RR 16 laboured HR 65 SPO2 90% on 3lpm NC temp 38.5° BS mid and basalar crackles, 12 lead ECG negative for MI but does show new onset 1° AVB and multifocal PVCs

Chest x-ray shows enlarged right heart

What are you going to do ..... and more importantly what are you not going to do, and why?
 
High flow O2, blankets, rapid transport... maybe use bolus fluids (NS most likely) just to be safe.


I'd avoid any nitro because the BP is so low.
 
I can't edit it but let me put in another question:

- If the BP was say, 140/100 how would that change your treatment modality?
 
MrBrown said:
I can't edit it but let me put in another question:

- If the BP was say, 140/100 how would that change your treatment modality?
Click to expand...

I'd still be gun shy bout giving nitro... since there is no signs of an MI/STEMI, i'd be more likely to give a low dose aspirin as opposed to the nitro. do you have a pt list of meds as well? that might help for any ALS personnel (not so much for us BLS folk)?
 
Sounds like CHF.

Any pedal edema, ascites, JVD? Productive cough? Skin turgor?

No meds - possible new onset.
Right-sided EKG?
Usual diet?
General appearance?

No Pmhx - When did he last see his doctor? How often does he see his doctor? What for? Family medical history? Surgical history? Daily Routine? Smoker? Drinker? Any change in sleeping habits?

Do you have CPAP over there?
 
DV_EMT said:
High flow O2, blankets, rapid transport... maybe use bolus fluids (NS most likely) just to be safe.
Click to expand...

In someone who has fluid halfway up their lungs?
 
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CPAP and access. No fluid, but a saline lock.

Depending on the length of transport, I'd consider some SL nitro.
 
Scott33 said:
Sounds like CHF.

Any pedal edema, ascites, JVD? Productive cough? Skin turgor?

Yes, No, Some, No, some turgor

No meds - possible new onset. Would say so
Right-sided EKG? Not something we can do
Usual diet? Unremarkable
General appearance? Looks "sick", pale and anxious, increases wob

No Pmhx - When did he last see his doctor? 1951
What for? Patient at a MASH unit in Korea for ex-lap
Family medical history? Unremarkable
Surgical history? Ex lap in '51
Daily Routine? Watches Matlock and walks the dog
Smoker? Drinker? No/No
Any change in sleeping habits? No

Do you have CPAP over there? No
Click to expand...

n7lxi said:
Depending on the length of transport, I'd consider some SL nitro. !
Click to expand...

Why do you want to give this patient GTN?
 
MrBrown said:
You're send down to the local doc in a box (urgent care) for a shortness of breath.

O/A 86 yom with chest discomfort for 5 days had sob for 6-8 hours, is pale and anxious, increased wob incl acc muscle use but no cyanosis pt states has felt fluey and unwell for about a week, no pmhx, nka

O/E GCS 14 (4/5/5) BP 98/68 RR 16 laboured HR 65 SPO2 90% on 3lpm NC temp 38.5° BS mid and basalar crackles, 12 lead ECG negative for MI but does show new onset 1° AVB and multifocal PVCs

Chest x-ray shows enlarged right heart

What are you going to do ..... and more importantly what are you not going to do, and why?
Click to expand...

I'm worried about pulmonary perfusion as well as him not getting enough gas exchange due to fluid. I am going to stick him on NRB @ 15L, 40mg furosemide pushed SLOWLY. If he has to potty, he has to potty. This fluid needs gone and this problem needs to be fixed to see if perhaps once it clears up his vitals clear up. An SPO2 of 90% is roughly equivalent to 60% PaO2 which isn't good.

Now he will need monitored very closely, I would be concerned about his blood pressure dropping as the effects of furosemide kick in, but I think he would be at hospital before any worries. I would consider nitro if he continued to deteriorate but it wouldn't be my first thought. Mid-clavicular and basalar crackles must be fixed. It doesn't matter how much blood his heart is getting, if he isn't getting enough gas exchange.

I will also stick him on waveform capnography to see if treatment is working.

P.S. this a good scenario
 
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With a bp in the 90/60's, the problem isn't excess fluid, so giving him Lasix will only compound the bad juju of a lowering blood pressure.


It depends on your specific protocols, but many places won't allow you to push Nitro, Lasix OR morphine if Bp is below 100 (or 90, depending).





I'd skip the nitro, lasix and morphine all together, if we're making 100mmHg the cutoff, and go CPAP while preparing to intubate / RSI, depending on how the CPAP improves him or not.
 
rhan101277 said:
I'm worried about pulmonary perfusion as well as him not getting enough gas exchange due to fluid. I am going to stick him on NRB @ 15L, 40mg furosemide pushed SLOWLY ... I would be concerned about his blood pressure dropping as the effects of furosemide kick in, but I think he would be at hospital before any worries.
Click to expand...

I would shy away from fruseomide personally, if you bum his pressure out we can't pump it back up and we run the risk of depleting his K or Na and causing more stress on his buggered conduction system.

Now I need a cardiac arrest, but i'm not into making them!

You may not have meant it this way but the "we will be at ED before any problems" could sound like "it wont be my problem anymore", I'm not into handing ED a patient I made worse!



rhan101277 said:
I would consider nitro if he continued to deteriorate but it wouldn't be my first thought. Mid-clavicular and basalar crackles must be fixed. It doesn't matter how much blood his heart is getting, if he isn't getting enough gas exchange.

I will also stick him on waveform capnography to see if treatment is working.
Click to expand...

I would be very judicious with GTN, if we lower his pressure much and decrease preload it's going to worsen his edema and .... the only thing we could do to pump him back up would be fluid but he is already overloaded so I'm leaning away from any nitrates
 
Linuss said:
I'd skip the nitro, lasix and morphine all together, if we're making 100mmHg the cutoff, and go CPAP while preparing to intubate / RSI, depending on how the CPAP improves him or not.
Click to expand...

CPAP is good stuff
 
MrBrown said:
I can't edit it but let me put in another question:

- If the BP was say, 140/100 how would that change your treatment modality?
Click to expand...

So what BP are we going with, I thought it was 140/100?
 
Linuss said:
With a bp in the 90/60's, the problem isn't excess fluid, so giving him Lasix will only compound the bad juju of a lowering blood pressure.


It depends on your specific protocols, but many places won't allow you to push Nitro, Lasix OR morphine if Bp is below 100 (or 90, depending).





I'd skip the nitro, lasix and morphine all together, if we're making 100mmHg the cutoff, and go CPAP while preparing to intubate / RSI, depending on how the CPAP improves him or not.
Click to expand...

You can still have excess fluid with low pressure. You have the osmotic pressure not being high enough to move the fluid where it needs to go.
 
The actual BP was 96/68

However, theoretically, if the BP was 140/100, would that change your treatment?

Two part question
 
MrBrown said:
The actual BP was 96/68

However, theoretically, if the BP was 140/100, would that change your treatment?

Two part question
Click to expand...

with low BP like that... i'd still go the bolus NS route... did we determine pedal edema?
 
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