Interesting Case, Need some input

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Dorsky01

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Hello All,
I am a relatively new medic operating full time as a firefighter paramedic. I am the primary medic on my shift. Today i ran on a 86 yo F. PT complaining of diff breathing. Pt with significant CHF history. Initial room air pulse ox was 87%. Pt was not moving a lot of air. She had bilateral wheezes (not consistent with her CHF) normal 12 lead, showed sinus tach at 104. Pt with bp of 240/120.

Because she had no indication of fluid i decided to say no to the lasix and nitro. I gave her albuterol and atrovent and she puked. not sure whether i should have treated her as a chf,er or a copd'er because of the wheezin. let me know
 
What were her breath sounds like in the upper lobes? Wheezing in all fields?

Any peripheral edema? Was she c/o chest pain or just the SOB?

If you didn't hear any ronchi, then i agree it didn't sound like any pulmonary edema.

Atrovent causes nausea

albuterol causes nausea and vomiting.

was her breathing / breath sounds / and pulse ox improved with this treatment?

was she on any heart medications? did she take her heart medications today?

Did she have any history of COPD or Asthma?

little more info please :)
 
You are supposed to treat what you see, hear, and feel so don't beat yourself up about going down the nebs route in this instance. Just watch your vitals before giving meds which you know will place further stress on the heart.

When you get a minute, read up on "cardiac asthma" / "cardiac wheezes" and see if anything you find rings a bell. Remember that more often than not, more than one medical condition can preexist in our patients, and this is often the problem with trying to make protocols fit the patients.

I agree more Hx needed here though. Do you have a scan of the EKG? If not, what do you mean by normal? any large QRS complexes in the V-leads? any axis deviation? Capnograph would be nice too ;)

Home meds? Time of onset? Any physical activity prior? Time of day? last meal? Did the patient state or indicate that this was similar to prior episodes? Skin condition? JVD? Cyanosis?

What was the outcome?
 
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Scott's guess is the same as mine. Seems to be "classic" paroxysmal nocturnal dyspnea.
 
Not only that, I would look up differential of CHF and asthma. With a pressure that high, significant history of CHF and poor oxygenation and cardiac wheezes, she is in pulmonary edema. She needed the NTG and CPAP!

Do beat yourself up! You missed it and should had never thought of nebulizers! What was your tx 02 and transport? .....

Now, that you have seen it don't do it again. Take it as a learning experience and quit thinking inside the box.

R/r 911
 
Just a quick note.

Rales are not always present in failure, especially in chronic cases or cases where gradual onset is present.
 
Sorry I thought you stated rales.
 
Did she have a hx of COPD/asthma? If not, it seems unlikely she would have developed it suddenly at 86 years of age. She's extremely hypertensive, sob, with a hx of CHF. I would put my money on history repeating itself.
 
Thanks for all of the responses. I appreciate all of the help.
 
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