Fluids for CHF?

We do Nitro .4 and Lasix .5-1mg/kg, and then we do titrated Morphine after we max on the Nitro. CPAP and PEEP are also allowed.

Though there is a discussion some of us are having on a Texas EMS website where morphine induced respiratory depression with pulmonary edema is "bad".
 
Here is the Maryland high dose NTG protocol for CHF....

.4mg (preparing CPAP)
.8mg (Pt. education to CPAP)
.8mg (Pt. acclimatization to CPAP)

Total dose is 2mg... if B/P is greater than 110 then captropril follows it up.

CPAP Not Tolerated - Nitroglycerin Dose
(Dose at 3-5 minute intervals.)
(i) give 1 dose of 0.4 mg NTG
(ii) give 1 dose of 0.8 mg NTG
(iii) give 1 dose of 0.8 mg NTG
(iv) give 1 dose of 0.8 mg NTG
(v) give 1 dose of 0.8 mg NTG
(vi) give 1 dose of 0.8 mg NTG
(vii) complete dose= 4.4 mg
(viii) Then follow with captopril (SBP is equal to or greater
than 110); administer albuterol (medical consult if
there is cardiac history); and apply Nitroglycerin paste.

Lasix is no longer in the protocols for Maryland nor is morphine (CHF).
 
Linuss said:
should help push the fluid back in to the blood vessels.
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You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.
 
Melclin said:
You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.
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The sad part is that what Linuss said is what many instructors are teaching about CPAP. I've heard it in a few lectures and cringe when I think that there are providers out there who are going to take that information home.
 
Melclin said:
You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.
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I still don't see how my wording is wrong and yours is right considering it says basically the same thing... semantics on the word "push" I guess.
 
Linuss said:
I still don't see how my wording is wrong and yours is right considering it says basically the same thing... semantics on the word "push" I guess.
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Well in this case I think semantics is important. Bit like the difference between someone falling off a cliff and getting pushed off a cliff.

Besides fluid isn't pushed of moved back into the blood stream in any sense by the ventilation itself as far as I know.

It stops the problem from getting worse (the pre-load part) and provides better gas exchange by splinting the airway and making inspiration easier amongst other things. If the fluid dissipates it is because there is no longer too much fluid where it shouldn't be to overwhelm the drainage capacity of the lymphatic system.

As always happy to be proven wrong by some decent evidence.
 
Linuss said:
I still don't see how my wording is wrong and yours is right considering it says basically the same thing... semantics on the word "push" I guess.
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The word "push" is not correct terminology when discussing hemodynamics and cardiopulmonary pressures.

Redistribution of fluids, primarily preload, through changing intrathoracic pressure and splinting of the airways. The lymphatic system helps remove the fluid from the area.

CPAP has been around for at least 60 years. It has been used in home care for 30 years to reduce right heart failure.

Google Scholar or any good medical search engine will give you a wealth of information.


The sad part is that what Linuss said is what many instructors are teaching about CPAP. I've heard it in a few lectures and cringe when I think that there are providers out there who are going to take that information home.
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This goes with the lecture about Lidocaine numbing the heart.
 
This goes with the lecture about Lidocaine numbing the heart.
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Haha..oh....eh...oh dear. Never heard that little chestnut. That's quite disturbing.
 
We are not using morphine in our CHF/ Pulmonary edema treatment. We do have furosemide as well as nitro. We have no max dose on sublingual nitro as long as pulmonary edema is still noted and SBP is >100. We also have nitro paste that we can use.
 
When people say things like "push the fluid back" or "numbing the heart"; I'm sure they are just repeating things they've heard from preceptors, instructors, or other uneducated morons who "know it all".

We don't have CPAP on the ground units here. NTG, Albuterol, Morphine, and Lasix are all in the protocol for CHF exacerbation with sedation/intubation if needed.

Unfortunately, many medics rip through the protocol without waiting for relief just to intubate the patient.
 
Our protocols don't list giving fluids to a CHF patient. Instead, we initiate CPAP or PPV a our first line treatment for the hypotensive CHF'er. For the hypotensive patient, we also give Dopamine under medical direction.

A fluid bolus of 300ml can be administered with clear lung sounds(if you can get em) per out cardiac protocol, or a 500ml bolus per our shock protocol. But, I'd steer away form that one as I'll most likely end up drowning the patient in their own fluids.
 
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