CHF with low BP

RICollegeEMT said:
My thoughts were CHF underlying (RN did mention Lasix being given "occasionally") which when they NEBed the person caused flash edema. Because undoubtedly I don't think the person could've survived the condition they were in for the length of time the RN indicated.
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Albuterol causing flash pulmonary edema is not really a proven thing.
 
Tigger said:
Albuterol causing flash pulmonary edema is not really a proven thing.
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This is a good point. Before our protocols were re-written, I liberally gave patients with "wet" (or even absent due to all of the fluid build up) breath sounds in-line nebs even in the face if CHF hx.

Now mind you, if they're were already tachycardiac, and/ or in an AF with RVR, not so much, but all in all I don't recall flash edema being a factor. Granted they were already on CPAP, but my PEEP valve was not eve maxed out. 9 out of 10 times these patients improved, which was reflected by the ventilatory status amongst other things.

So I agree, I don't know how big of a threat flash edema truly is with strong clinical feelers, and the advent of CPAP/ BiPap in the prehospital realm.
 
VentMonkey said:
This is a good point. Before our protocols were re-written, I liberally gave patients with "wet" (or even absent due to all of the fluid build up) breath sounds in-line nebs even in the face if CHF hx.

Now mind you, if they're were already tachycardiac, and/ or in an AF with RVR, not so much, but all in all I don't recall flash edema being a factor. Granted they were already on CPAP, but my PEEP valve was not eve maxed out. 9 out of 10 times these patients improved, which was reflected by the ventilatory status amongst other things.

So I agree, I don't know how big of a threat flash edema truly is with strong clinical feelers, and the advent of CPAP/ BiPap in the prehospital realm.
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Obviously your treatment needs to be directed at fixing the issue and obviously a beta2 agonist is not going to likely fix a CHF exacerbation and may worsen it with the increase in MVO2 demand. But I can't really find anything about flash pulmonary edema.

The patient needs something to improve cardiac output.
 
Tigger said:
The patient needs something to improve cardiac output.
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Typically the Beta-2 would open said patient up enough so that the PPV initiated with the CPAP pushed at least enough through to improve some V/Q mismatch, even if only temporarily.

And again, I concur with the above statement. More often than not if these cardiogenic patients are refractory to therapies provided in the field, and/ or ED, I would think inotropes would be appropriate.
 
Vent: The two goals are to compare my rationale and understanding with those who have more experience to ensure my train of thought is going down the right path. The INR was mentioned because someone mentioned labs-- that was the only lab available. And the 4 Sh*ts is because someone else mentioned assessment and I was mentioning how little is usually available. RNs in this state unfortunately consider us "that taxi with a bed" as opposed to medical professionals so we've gotta fight tooth and nail for any kind of report that's mildly accurate. Hell can't tell you how many times I get asked "do you guys carry oxygen?".

And I'm glad you guys chimed in on the albuterol thing-- clearly we were taught entirely wrong, and were always told "albuterol with chf = flash edema". Same with the fluids for CHF pts-- we were always taught that was a big no-no.

Unfortunately if you ever notice my responses seem very "Mcguyver" its not because I enjoy working in the stone age its because how backasswards this state is. For example we don't have CPAP (its "optional"), pressors, analgesics, hell a working SpO2 probe all fall into that category. Mind you its all stuff we're licensed to do!
 
RICollegeEMT said:
Vent: The two goals are to compare my rationale and understanding with those who have more experience to ensure my train of thought is going down the right path. The INR was mentioned because someone mentioned labs-- that was the only lab available. And the 4 Sh*ts is because someone else mentioned assessment and I was mentioning how little is usually available. RNs in this state unfortunately consider us "that taxi with a bed" as opposed to medical professionals so we've gotta fight tooth and nail for any kind of report that's mildly accurate. Hell can't tell you how many times I get asked "do you guys carry oxygen?".

And I'm glad you guys chimed in on the albuterol thing-- clearly we were taught entirely wrong, and were always told "albuterol with chf = flash edema". Same with the fluids for CHF pts-- we were always taught that was a big no-no.

Unfortunately if you ever notice my responses seem very "Mcguyver" its not because I enjoy working in the stone age its because how backasswards this state is. For example we don't have CPAP (its "optional"), pressors, analgesics, hell a working SpO2 probe all fall into that category. Mind you its all stuff we're licensed to do!
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Perhaps get your paramedic, and/ or move, good luck.
 
medichopeful said:
Can we get a POC lactate on this patient? Sepsis is a possibility.
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Bear in mind that lactate is not a test for sepsis, and in this clearly shocked patient it's probably a safe bet their lactate will be elevated regardless of the cause.
 
Brandon O said:
Bear in mind that lactate is not a test for sepsis, and in this clearly shocked patient it's probably a safe bet their lactate will be elevated regardless of the cause.
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Very true, but if we start giving fluids it's nice to have a baseline for the hospital for trending. It's not a rule in/out for sepsis, but a trending tool and just another piece of info to try to figure out what's going on.
 
medichopeful said:
Very true, but if we start giving fluids it's nice to have a baseline for the hospital for trending. It's not a rule in/out for sepsis, but a trending tool and just another piece of info to try to figure out what's going on.
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Of course. But that's a means of following the resuscitation, not so much an aid to diagnosis. (Although in a somewhat meta-medical sense, it's true that lactate has become part of the reimbursable sepsis quality measures in many hospitals.)
 
Brandon O said:
Of course. But that's a means of following the resuscitation, not so much an aid to diagnosis. (Although in a somewhat meta-medical sense, it's true that lactate has become part of the reimbursable sepsis quality measures in many hospitals.)
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Very good point!
 
I assume you are on an ALS truck? How do you not have a pressor, do you not carry epi at all?
 
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my protocols call for dopamine drip, standing order. can call the doc for epi drip.

If anybody is still watching this thread, what's your take on that.
 
Talk about wading in to the tall weeds in 2 pages...wow...I'll add to the stew with my $ 0.02....

1. If a patient like this has a radial pulse, I don't care what BP it corresponds to. It means there's blood getting to peripheral tissues and that tells me I've got a little time and makes me feel good.

2. In trying to tease out the role of giving volume as treatment, I may try a passive leg raise and see what happens to the BP.

3. Dopamine is what we call a "dirty drug" because you don't really know what you'll get until you get it going in terms of improved BP/cardiac output with or without a bump in the HR. It has fallen way out of favor in CC circles in favor of epinephrine/NE. IF a pressor was called for here, it would begin with epinephrine, if I were in charge.
 
Alan L Serve said:
Why in the world in the PT's INR 5.9? Who the heck overdosed them on their Warfarin. For that matter WHY are they on an anticoagulant? Give VitK to reverse that and do it right away.
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Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.
 
E tank said:
In trying to tease out the role of giving volume as treatment, I may try a passive leg raise and see what happens to the BP.
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This is interesting - I wish I had heard of this earlier! I know there isn't much predictive value from orthostatics, but a quick review found some good evidence (I cite a review here) for this!
 
Chase said:
Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.
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What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?
 
Alan L Serve said:
What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?
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He isn't talking about the margin of error in testing the INR, but in dosing the warfarin.

A high INR doesn't necessarily mean that someone "overdosed" the patient on warfarin. INR's fluctuate based on lots of factors, which is why they are checked so frequently when someone is on warfarin. When patients get sick, sometimes the INR changes quickly.

Also, warfarin isn't the only cause of an elevated INR. And vitamin K won't work on most of the other causes.
 
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