Neurogenic pulmonary edema

[harold1981]

Patient is a 87yo in a nursing home with an acute onset of dyspnea. Upon arrival patient presents a GCS of 1-1-1, severe tachypnea, sweating, audible rales (confirmed by auscultation on four lung areas), fluid in the throat, sternal and intracostal retractions and surprisingly an initial oxygen sats of 93%. BP 160/100. No edema on the legs/ankles. No history of CHF, no complaints of chest pain, no signs of aspiration. EKG shows an AFib with a frequency around 100bpm with no signs of ischemia. We start oxygen therapy per nonrebreathing mask, which brings the sats up to 99%, with no improvement in work of breathing. We start 0.4mg of sublingual nitroglycerin and 80mg of furosemide and proceed to transport him, code 3, to a level 1 facility.
Upon arrival in the ED the condition of the patient remains unchanged. He is quickly moved into a CAT-scan and diagnosed with neurogenic pulmonary edema, secondary to a brainstem bleed. Prognosis is infaust.

I have two questions:
1. was treatment with furosemide justified in this case?
2. was RSI indicated based on the clinical presentation, despite the sats of 99%?

 

[STXmedic]

Your patient with a GCS of 3 wasn't complaining of chest pain, huh?... Lol

I doubt I would have considered lasix (even if we still carried it). With it being acute onset, I wouldn't expect the patient to be overloaded with fluid. I'd likely have followed down the NTG path a bit more to hopefully pull a bit more fluid back into the vasculature.

I think RSI would have been reasonable/defendable, especially if it was a decent transport.

 

[harold1981]

Thanks STXmedic. I asked the nurses if he had complained about chest pain during the night, before he stopped responding.

 

[SpecialK]

I wouldn't give him frusemide or GTN. In a patient with a GCS of 3, airway management takes priority over giving him GTN and one spray of GTN is unlikely to be clinically significant.

Yes, I would perform RSI on him.

 

[Gurby]

I didn't know neurogenic pulmonary edema was a thing that happened. Thanks for sharing. I will keep it in the back of my mind going forward!

 

[Doczilla]

So, he's altered, so CPAP is off the table.

Nitro isnt a bad idea, if you think the wet lungs is contributing to/the underlying problem. Of course in restrospect, you don't wanna mess with the pressure in a bleed, but no one could have saw that coming.

As far as RSI, with a GCS of 3, are you looking to create the optimal intubating conditions with the paralytic (Trismus etc)?

Most places don't give Lasix before they're maxed on nitro, but that might still be a thing in your area.

 

[TXmed]

yes i would RSI for the basis of airway control. i would also hold off of the NTG on any patient with a low gcs for fear of a stroke (neurogenic mycardial stun). head bleeds have a way of exacerbating A-fib into RVR and can sometimes very rarely present with global ST elevation.

so there BP good? there BGL good? o2 sats good ? why are they altered then ?

 

[SpecialK]

yes i would RSI for the basis of airway control. i would also hold off of the NTG on any patient with a low gcs for fear of a stroke (neurogenic mycardial stun). head bleeds have a way of exacerbating A-fib into RVR and can sometimes very rarely present with global ST elevation.

so there BP good? there BGL good? o2 sats good ? why are they altered then ?

I would say he has a poor level of consciousness because his haemorrhagic stroke has been from one of the vertebrobasilar arteries which supply the brain stem, but that is just a hunch.

As for RSI, yes, I would anaesthetise and paralyse him (suxamethonium). Why? Because it creates ideal intubating conditions and also assures us he has no memory of events. Even if somebody is completely seemingly unconscious I would rather give them a general anaesthetic prior to intubating than not. The local flavour is ketamine, or midazolam if ketamine is contraindicated.

 

[harold1981]

So, he's altered, so CPAP is off the table.

Nitro isnt a bad idea, if you think the wet lungs is contributing to/the underlying problem. Of course in restrospect, you don't wanna mess with the pressure in a bleed, but no one could have saw that coming.

As far as RSI, with a GCS of 3, are you looking to create the optimal intubating conditions with the paralytic (Trismus etc)?

Most places don't give Lasix before they're maxed on nitro, but that might still be a thing in your area.

Is altered consciousness a contraindication for CPAP-use? If yes, why? Taking into account that CPAP is also used to treat sleep apnea in patients who can't manage their airway in their deepest sleep.
I considered RSI because of the extreme work of breathing that the patient needed to keep his sats up and the risk of apnea due to exhaustion. In my region we have to call in HEMS for an RSI. And we normally load severe cases of CHF with NTG, morphine, and 80mg of lasix, which will be continued on the ED with a continuous lasix-injector. They'd get either a NRB or CPAP from us as well.

 

[harold1981]

yes i would RSI for the basis of airway control. i would also hold off of the NTG on any patient with a low gcs for fear of a stroke (neurogenic mycardial stun). head bleeds have a way of exacerbating A-fib into RVR and can sometimes very rarely present with global ST elevation.

so there BP good? there BGL good? o2 sats good ? why are they altered then ?

Good point. In this case we decided to get moving (level 1 facility at 10 min), instead of waiting for HEMS (20+ min), but if the times were different, we would probably have opted for the RSI. Although when we arrived at the ED the emergency physician did not want to intubate, before having seen the CAT-scan.

 

[Gurby]

I'm on a non-RSI service as well. Don't forget to consider assisting ventilations with a BVM in a situation like this (tired patient, labored breathing, decreased level of consciousness to the point that you're worried about CPAP). I've done it a few times and it gets their O2 sat up, but they always get tubed on arrival anyways.

 

[harold1981]

I'm on a non-RSI service as well. Don't forget to consider assisting ventilations with a BVM in a situation like this (tired patient, labored breathing, decreased level of consciousness to the point that you're worried about CPAP). I've done it a few times and it gets their O2 sat up, but they always get tubed on arrival anyways.

Indeed. We had the BVM ready, but felt that we wouldn't help him much by assisting ventilations (as in decreassing his work of breathing) and what he needed was paralizing his respiratory muscles and taking over the ventilations. If his sats dropped, I would have bagged him anyway. Please correct me if I am wrong in my reasoning.

 

[NomadicMedic]

Harold, you're not in the US, correct?

Everyone does things a little differently. The lasix has fallen out of favor here, replaced by NTG and, if not contraindicated, CPAP.

I don't think than an RSI is way off the mark here, but, like you, my service is not RSI certified.

 

[Carlos Danger]

Indeed. We had the BVM ready, but felt that we wouldn't help him much by assisting ventilations (as in decreassing his work of breathing) and what he needed was paralizing his respiratory muscles and taking over the ventilations. If his sats dropped, I would have bagged him anyway. Please correct me if I am wrong in my reasoning.

Assisting the ventilations of a conscious, anxious patient can be tricky. But if he really was a GCS 3 and breathing effectively, simply adding some pressure support and CPAP with a BVM might not be that hard to do. RSI is something to consider for sure, but anytime non-invasive support works, it is preferable to intubation.

 

[harold1981]

Harold, you're not in the US, correct?

Everyone does things a little differently. The lasix has fallen out of favor here, replaced by NTG and, if not contraindicated, CPAP.

I don't think than an RSI is way off the mark here, but, like you, my service is not RSI certified.

That's correct. I work in the Netherlands.

 

[Nova1300]

Oh man, an 87 year old with a brainstem hemorrhage is bad news. The prognosis is abysmal, especially if the patient has an emv of 3 at ictus.

But, neither nitroglycerin, nor Lasix would have dramatically changed anything in this patient. Although the goal would be to lower the blood pressure slightly, usually to around 140 systolic, this is much easier to achieve with a titratable drip, and generally a calcium channel blocker such as nicardipine would be chosen instead of nitroglycerine.

There are a few points from this case to take away:
Generally, unless you are treating cardiac failure-related pulmonary edema or life threatening hyperkalemia, Lasix won't do much for you. We don't fully understand the mechanism behind neurogenic pulmonary edema, but the treatment is medical stabilization and positive pressure ventilation, not diuretics.

The most important point from this case is that the patient needs an endotrachral tube. Head bleeds, especially those in the posterior fossa of the skull where the respiratory center lives, do not protect their airways and love to vomit. Even though that patient was sitting in front of you breathing, there were likely secretions being aspirated into the airway throughout transport.

I would NEVER place this patient on CPAP. Never.

I would utilize RSI and secure the airway.

If I didn't have RSI I would slap on a non-rebreather, sit the patient bolt-upright on the bed and stand there with a suction catheter at the ready as we ran to the hospital. Plus or minus a nasal trumpet if they obstruct. And drive. Fast.

By the time you guys get these patients to the ER, the ER mucks around getting an airway, and they make it up to the ICU they almost always have foreign matter in their lungs when we bronch them.

 

[harold1981]

Thank you very much for your input, Nova1300 !
You're saying that the CPAP would increase his ICP? Or is there another reason?
One more thing...would sedation with midazolam, eventually with assisted ventilation have been a bad option?

 

[Nova1300]

Assisting the ventilations of a conscious, anxious patient can be tricky. But if he really was a GCS 3 and breathing effectively, simply adding some pressure support and CPAP with a BVM might not be that hard to do. RSI is something to consider for sure, but anytime non-invasive support works, it is preferable to intubation.

I think it's important to address this. Remi is correct- mechanically these patients are usually just obstructing. Especially as our population get fat. So in theory, a little positive pressure is all they would need.

BUT... these brain injured patients like to vomit. There is something very emetogenic about free blood in the brain parenchyma or subarachnoid space. They vomit, without warning, and it tends to be copious and I'm actually gagging a little thinking about it so I'm going to stop.

But, that is why I would never use non-invasive ventilation in this group. They need an endotrachral tube, a well-inflated cuff, and an OG on suction.

 

[Nova1300]

Thank you very much for your input, Nova1300 !
You're saying that the CPAP would increase his ICP? Or is there another reason?
One more thing...would sedation with midazolam, eventually with assisted ventilation have been a bad option?

No. Sedation isn't indicated here. The patient has a GCS of 3. Sedated.

i would avoid doing any airway manipulation in this patient unless it was intubation. If I couldn't RSI I would position the patient appropriately, keep a suction cath handy, and maintain. Only touch the ambubag if the patient deteriorated.

 

[harold1981]

I meant sedation for the purpose of getting muscle relaxation and ease down the heavy work of breathing, while taking over ventilations. But I guess that would be tricky under these circumstances.