Hypotensive CHF patient

ChrisEMTA

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So had a patient say in there 60s with CHF. She complained of weakness and her husband mentioned in just a few weeks her legs got so much more swollen. So first we checked the ABCs she was protecting her airway, her breathing was very congested had coughing and heard some crackling, circulation showed normal color and A&O x4. Vitals revealed a HR in 120s and a BP around 90/40, 02 was around 88% which was not normal for her she explained. Her RR was in the 20s temp was 99.1f and BGL was 110. We then did a ECG which was read as sinus tachycardia otherwise WNL. So what we did on this case is I established a line and DIDN'T give fluids just got a line for the ED. I originally started 6lpm NRB which the medic changed to CPAP. No I didn't get a intercept this time because I was already working with a medic this shift. After we spent about 10min on scene we were ready to go and I stayed in the back and just comforted her by letting her talk and just listen. She had a sad story but I got to see her O2 come up and she said this resolved her sob which we weren't informed about on presentation just something mentioned as we were arriving. Anything you would have done differently?
 

johnrsemt

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What was her normal BP? People get so stressed out about BP being low, without ever asking what the patients normal BP is.
If this patient was my dad, yes that is a low BP (he is normally 150/90).
If this is me, this is a little high (normal 80/40).
 
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ChrisEMTA

ChrisEMTA

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What was her normal BP? People get so stressed out about BP being low, without ever asking what the patients normal BP is.
If this patient was my dad, yes that is a low BP (he is normally 150/90).
If this is me, this is a little high (normal 80/40).
Around 90/40 but she informed me about a history of high blood pressure
 

Aprz

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6 LPM for a non rebreather mask? I'm used to either 10-15 or 12-15.
 
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ChrisEMTA

ChrisEMTA

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6 LPM for a non rebreather mask? I'm used to either 10-15 or 12-15.
I usually do but when they were breathing fast an I just get a anxious vibe around them I tend to use a NRB it just calms some people down.
 

Aprz

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Man, I don't know dude. If my patient is anxious, I just verbally reassure them without giving them oxygen they don't need. It wouldn't cross my mind to intentionally incorrectly use the non breather mask by setting it to 6 LPM. It's 10-15 LPM or 12-15 LPM everywhere I've worked.
 
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ChrisEMTA

ChrisEMTA

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Man, I don't know dude. If my patient is anxious, I just verbally reassure them without giving them oxygen they don't need. It wouldn't cross my mind to intentionally incorrectly use the non breather mask by setting it to 6 LPM. It's 10-15 LPM or 12-15 LPM everywhere I've worked.
It's not giving unnecessary oxygen it's just something around there face that covers more they needed 6lpm I could give it thru NC but it's harder for her to keep her mask on and she is a germ-phobe and covering her mouth reassured her.
 

mgr22

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It's not giving unnecessary oxygen it's just something around there face that covers more they needed 6lpm I could give it thru NC but it's harder for her to keep her mask on and she is a germ-phobe and covering her mouth reassured her.

Chris, start by reading the above article. I'm also wondering why you'd use a NRB at 6LPM if "it's harder to keep her mask on." I'm not convinced that "reassured her."
 

E tank

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I think the point of the article link was to demonstrate that a NRM depends on higher O2 flows to avoid re-breathing CO2. Elevated CO2 is not just an issue for COPD patients as it can adversely affect any patient's acid/base status and mental status.

I guess it doesn't matter in this case because your partner put the patient on a CPAP mask who then shared a sad story...still trying to figure out how that works....
 

mgr22

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I will keep that in mind for future cases. But the article refers to COPS patients which already well known that have C02 retention
I wasn't suggesting the article is a blueprint for treating your CHFer. I do think it addresses NRBs vs. nasal cannulas in a way that's relative to some of the comments and might be helpful to you.
 
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ChrisEMTA

ChrisEMTA

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I wasn't suggesting the article is a blueprint for treating your CHFer. I do think it addresses NRBs vs. nasal cannulas in a way that's relative to some of the comments and might be helpful to you.
Ok thank you. :)
 

Tigger

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I’d probably try O2 by cannula first and see if her sats improved. There is no reason to incorrectly underflow a non rebreather, I think you should probably never do that again. If the patient’s work of breathing looked concerning to me I’d use CPAP too, even if the SpO2 is “ok.”

Be very careful about using “tricks” to treat patients. Use equipment as designed to treat the correct conditions. Treating hypoxia may fix anxiety, giving oxygen just fix anxiety is not a real treatment.
 
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ChrisEMTA

ChrisEMTA

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I’d probably try O2 by cannula first and see if her sats improved. There is no reason to incorrectly underflow a non rebreather, I think you should probably never do that again. If the patient’s work of breathing looked concerning to me I’d use CPAP too, even if the SpO2 is “ok.”

Be very careful about using “tricks” to treat patients. Use equipment as designed to treat the correct conditions. Treating hypoxia may fix anxiety, giving oxygen just fix anxiety is not a real treatment.
I won't do it again. Thank you for the tips that I can learn from. :)
 

spimx

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You might need to work a differential diagnosis of pneumonia with this patient. Regardless, sounds like you did a good job. NRB at 10 is fine
 

Akulahawk

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To the OP:

Overall, I would say that the basic process of this call went fine. There's some fine-tuning that should be done for both you and the medic partner, but on the whole, not bad.

What you BOTH appear to have missed is that the patient has a low-ish BP and is tachycardic, especially in the setting of someone that's normally hypertensive. Yes, this patient has CHF, is probably having an exacerbation of this, but she's also showing signs of sepsis. The low SpO2 should have been corrected, and it looks like you took steps to correct it but you attempted to "compensate" for the COPD by lowering the O2 flow rate through the NRB. While the action itself wasn't ideal, I think I know where you were coming from, and I think you were trying to prevent shutting down oxygen-related respiratory drive. This tells me that you're trying to think through problems your patient is presenting with. I suspect your Medic noticed something wasn't working or saw that the patient could probably benefit from CPAP and started that therapy instead. What would I have done in that instance? I'd look at her work of breathing. If she's working really hard and not doing well despite her effort, I might go straight to CPAP. In the short-term, I'm not too concerned about shutting down her respiratory drive with too much oxygen. If her breathing stops, the BVM will do just fine. She certainly tolerated the CPAP just fine and sounds like she was improving because of it.

Getting a line (even if it's a saline lock) was probably a GREAT thing for the ED because you have vascular access and they're likely going to start giving her a decent amount of fluids because of her soft BP and high-ish heart rate and they can do it a bit more quickly because you did get that line placed.

While I think the medic should have attended this patient, you were also in a position to potentially be able to address anything that might have been needed. If the patient became more hypotensive, you could have possibly initiated a fluid bolus. You (and the medic) would have needed to be watchful for this and ready to react if needed. So, mostly this was a wash, but leaning toward medic attending, good learning call for both.

Whatever you do, don't beat yourself up over this call or think we're trying to beat you up either. Pretty much all of us have been doing this stuff for years and we all remember what we were like when we were newer to the field. There's a LOT to learn! This patient has a few problems all running concurrently and sometimes it's just not that easy to sort them all out.

My guess as to what happened? CHF probably was getting slowly worse, her lungs probably started getting more wet than usual, eventually becoming a GREAT place for infection to start, and as that got going, it probably exacerbated the COPD, which probably was what caused her (or her husband) to call. I think she probably called sooner than most of the patients like this that I've seen.

I think as long as you approach this from "what could I have done better" and learn from calls like this, you'll only get better and better at doing the work you do.
 
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ChrisEMTA

ChrisEMTA

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To the OP:

Overall, I would say that the basic process of this call went fine. There's some fine-tuning that should be done for both you and the medic partner, but on the whole, not bad.

What you BOTH appear to have missed is that the patient has a low-ish BP and is tachycardic, especially in the setting of someone that's normally hypertensive. Yes, this patient has CHF, is probably having an exacerbation of this, but she's also showing signs of sepsis. The low SpO2 should have been corrected, and it looks like you took steps to correct it but you attempted to "compensate" for the COPD by lowering the O2 flow rate through the NRB. While the action itself wasn't ideal, I think I know where you were coming from, and I think you were trying to prevent shutting down oxygen-related respiratory drive. This tells me that you're trying to think through problems your patient is presenting with. I suspect your Medic noticed something wasn't working or saw that the patient could probably benefit from CPAP and started that therapy instead. What would I have done in that instance? I'd look at her work of breathing. If she's working really hard and not doing well despite her effort, I might go straight to CPAP. In the short-term, I'm not too concerned about shutting down her respiratory drive with too much oxygen. If her breathing stops, the BVM will do just fine. She certainly tolerated the CPAP just fine and sounds like she was improving because of it.

Getting a line (even if it's a saline lock) was probably a GREAT thing for the ED because you have vascular access and they're likely going to start giving her a decent amount of fluids because of her soft BP and high-ish heart rate and they can do it a bit more quickly because you did get that line placed.

While I think the medic should have attended this patient, you were also in a position to potentially be able to address anything that might have been needed. If the patient became more hypotensive, you could have possibly initiated a fluid bolus. You (and the medic) would have needed to be watchful for this and ready to react if needed. So, mostly this was a wash, but leaning toward medic attending, good learning call for both.

Whatever you do, don't beat yourself up over this call or think we're trying to beat you up either. Pretty much all of us have been doing this stuff for years and we all remember what we were like when we were newer to the field. There's a LOT to learn! This patient has a few problems all running concurrently and sometimes it's just not that easy to sort them all out.

My guess as to what happened? CHF probably was getting slowly worse, her lungs probably started getting more wet than usual, eventually becoming a GREAT place for infection to start, and as that got going, it probably exacerbated the COPD, which probably was what caused her (or her husband) to call. I think she probably called sooner than most of the patients like this that I've seen.

I think as long as you approach this from "what could I have done better" and learn from calls like this, you'll only get better and better at doing the work you do.
Thanks for the feedback:)
 
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