rhan101277
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Oh I see, yeah no lasix with systolic BP under 100mmHg
Big Heart
- Thread starter MrBrown
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Oh I see, yeah no lasix with systolic BP under 100mmHg
What about GTN?
Would you give fluid with mid & baslar crackles?
Is this patient hypovolemic or third spaced?
LondonMedic
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You'll drown him before you pull his BP up to 'normal'. The cause of low BP in this case is unlikely to be low volume (although of course CCF punters can bleed or get dehydrated just like any other) and although you could force the BP up with colloid you'll ultimately be making the cardiogenic problem worse.
LondonMedic
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Sometimes. But more judiciously.
18G
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With a description of being "fluey", has the patient had any cough, chills or generalized weakness? What is the quality of the chest discomfort? How frequent are the PVCs?
Given the chest discomfort for 5 days, dyspnea, crackles, and presence of fever (101.5F), poor skin turgor, decreased SpO2, and productive cough, all combined with this patients age... I'm thinking pneumonia.
Now with the slight JVD and pedal edema along with the EKG changes we also have obviously some cardiac involvement. Usually, CHF patients do not present with a fever. Could there be a myocarditis? Pericarditis usually presents with ST elevation in all the leads which none was reported.
With the presence of fever, Im looking for an infectious process as the culprit to the patients problem. Although, perhaps the pt. has more than one problem going on as well. I've had a patient with severe bilateral pneumonia who was filled with fluid who presented similar to this patient.
What is the doctor thinking at the clinic? His input would be helpful in developing a treatment plan. This patient could very well be dehydrated as well.
As far as treatment...
Given this patient is having obvious issues with gas exchange with the crackles, I would place the pt. on CPAP to improve ventilation and recruit atelectatic areas of the lung (alveoli that collapsed due to being filled with fluid) to participate in gas exchange. With the low B/P, there is a small risk of further reducing it so a watchful eye on the B/P will also be had. Although at a PEEP of less than 10cm/H2O, this should not be a problem.
If pt. does not respond or tolerate CPAP, pt. will need to be nasally intubated.
IV at KVO... if pressure drops I would give a 250mL bolus (perfectly okay for CHF) and see what that does. If pressure continues to drop, than dopamine.
As long as the pressure maintains less than a 100, NTG and captopril are both out.
I think as long as we can improve this patients ventilation and oxygenation and reduce the workload of the heart with CPAP, we can stabilize and improve patients conditions until arrival at the hospital.
Quite possibly, this patient may need antibiotics to treat the underlying cause.
Given the chest discomfort for 5 days, dyspnea, crackles, and presence of fever (101.5F), poor skin turgor, decreased SpO2, and productive cough, all combined with this patients age... I'm thinking pneumonia.
Now with the slight JVD and pedal edema along with the EKG changes we also have obviously some cardiac involvement. Usually, CHF patients do not present with a fever. Could there be a myocarditis? Pericarditis usually presents with ST elevation in all the leads which none was reported.
With the presence of fever, Im looking for an infectious process as the culprit to the patients problem. Although, perhaps the pt. has more than one problem going on as well. I've had a patient with severe bilateral pneumonia who was filled with fluid who presented similar to this patient.
What is the doctor thinking at the clinic? His input would be helpful in developing a treatment plan. This patient could very well be dehydrated as well.
As far as treatment...
Given this patient is having obvious issues with gas exchange with the crackles, I would place the pt. on CPAP to improve ventilation and recruit atelectatic areas of the lung (alveoli that collapsed due to being filled with fluid) to participate in gas exchange. With the low B/P, there is a small risk of further reducing it so a watchful eye on the B/P will also be had. Although at a PEEP of less than 10cm/H2O, this should not be a problem.
If pt. does not respond or tolerate CPAP, pt. will need to be nasally intubated.
IV at KVO... if pressure drops I would give a 250mL bolus (perfectly okay for CHF) and see what that does. If pressure continues to drop, than dopamine.
As long as the pressure maintains less than a 100, NTG and captopril are both out.
I think as long as we can improve this patients ventilation and oxygenation and reduce the workload of the heart with CPAP, we can stabilize and improve patients conditions until arrival at the hospital.
Quite possibly, this patient may need antibiotics to treat the underlying cause.
LondonMedic
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Would you prone him?
18G
Paramedic
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Prone? As in lay the patient face down?
So with the lungs sounding the way they do, you want to lay him face down flat so any blood or fluid building in in the lungs can move all over the rest of the alveoli! Awesome... He's staying fowlers.
LondonMedic
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Blood? What do you think is going on with this chap?
(And the lungs will already be doing a good job of moving the fluid up and down)
18G
Paramedic
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Anymore info on this scenerio? I'm interested in knowing the diagnosis.
It was myocarditis.
The big issues here was differentiating between left and right ventricular failure as there are obvious contraindications to GTN, fluid and possibly frusemide in the setting of RVF.
I posed this scenario with two possible BPs as the actual BP (98/68) contraindicates GTN whereas say, 150/110 does not while if we look at what is happening I wouldn't be the first to use it. The lower BP may in the minds of some providers indicate fluid however if we take the large clinical picture of pump insufficency causing the pedal edema, JVD and crackles fluid would be contraindicated.
Some also have problems differentiating between hypovolemic (low volume) and third spacing (such as in cardiogenic edema, the volume is not "low" but rather in the wrong place and if we pump him full of fluids its not ging to help).
The big issues here was differentiating between left and right ventricular failure as there are obvious contraindications to GTN, fluid and possibly frusemide in the setting of RVF.
I posed this scenario with two possible BPs as the actual BP (98/68) contraindicates GTN whereas say, 150/110 does not while if we look at what is happening I wouldn't be the first to use it. The lower BP may in the minds of some providers indicate fluid however if we take the large clinical picture of pump insufficency causing the pedal edema, JVD and crackles fluid would be contraindicated.
Some also have problems differentiating between hypovolemic (low volume) and third spacing (such as in cardiogenic edema, the volume is not "low" but rather in the wrong place and if we pump him full of fluids its not ging to help).
18G
Paramedic
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Thanks for posting the diagnosis. Good scenario.
Was this a real patient? If so, how did the providers manage them in the field?
Was this a real patient? If so, how did the providers manage them in the field?
Jeffrey_169
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For the patient I would not be giving IV fluids. It seems fairly obvious to me he is experiencing Right Sided Heart Failure, and although I would state and IV it would be a hep lock/ Saline lock. I wold position the patient in POC (probably Fowler's position) and off the hospital we would go Lots of O's for this patient as well. While in route I would certainly consider the administration of an diuretic to get some fluid off his lungs.