Renal Failure/CHF/Pulmonary Edema/Cardiogenic shock

[fma08]

I'd like to hear some thoughts on treatments for a pt. who has renal failure, CHF, and "fluid overloaded" to the point of pulmonary edema exhibiting signs of cardiogenic shock from the CHF. The scenario would be a pt. transfer, about an hour long to the receiving facility.

This came up from a transfer I did with a renal failure/ CHF pt. who did have some SOB and lowered SpO2. The nurse said on the phone when we were on our way over that the pt. had "fluid overload" and sounded like the pt. was nearing her time, however the pt. managed more than fine on a nasal cannula at 4L/min. The rest of the trip was pretty much a "keep an eye" on her sort of thing. But, on the way over my partner and I got to talking about some what if scenarios that could arise from this pt.

Sorry for the long spiel, have at it! ^_^

 

[MSDeltaFlt]

Speaking from a ground medic's point of view. My ALS service does not have CPAP or even bi-level ventilation for that matter. Wish we did, but we don't. So I'm speaking from a very limited ALS service.

The vast majority of RF'ers with CHF, Pulm. Ed., and Cardiogenic Shock in my area are our hemodialysis pts who do not urinate at all and are about to crap out on us.

When they are in cardiogenic shock, their BP's either dropping or just about gone. Your pt is also getting into Respiratory Failure as well, not just Respiratory Distress. Their SpO2's are dropping as is their GCS. By a "dropping GCS" I mean 8 or less.

This is where you need to be very aggressive. What do you do? If they're making any kind of audible words, they still have an airway. So you're stuck on Breathing, or "B". Though they may have an airway, you'll still need to secure one so you can better assist their breathing as best as you can. It may mean ETI with RSI, BNTI, Combitube/King LT (if that's all you got), or even assisting their respirations with BVM. If you can't then you can't. You do what you gotta do following your protocols. If your pt falls outside of your protocols, then call OMC.

For renal failure pts Lasix is pretty much a no-go, if it worked at all it'd be slow, so all you got is NTG. If their lungs are full and their BP's low, you can't just give them Lasix or NTG. Iatragenic medicine is bad joojoo. You'll need to get a dopamine drip if they're hypotensive. For the Pulm. Ed. refer to the above paragragh.

If this is not what you were wondering, then scratch this post.

 

[fma08]

Just as kind of a relate side topic, does anyone's protocols allow the use of morphine along with lasix?

 

[Shishkabob]

Yes.

Nitro and Lasix. Once nitro is maxed out, you can give morphine.

 

[Akulahawk]

Sacramento protocol has Albuterol (if wheezing), NTG, CPAP (if available), Morphine/Lasix. Goes like this:

• Mild: Albuterol (if wheezing), NTG (SBP >90)
• Moderate: Albuterol (if wheezing), NTG (SBP >90), consider CPAP @ 7.5 cm H2O
• Severe: Albuterol (if wheezing), NTG (SBP >90), CPAP @ 7.5 cm H2O, Morphine, Lasix (if the patient already takes it).... BHO: Dopamine if SBP consistently <90.

Lasix is only given if the patient already takes it... and it's 80mg. Other systems I've been in state: 40 mg, or match the patient's dose, if above 40 mg.

 

[medicdan]

I'd like to hear some thoughts on treatments for a pt. who has renal failure, CHF, and "fluid overloaded" to the point of pulmonary edema exhibiting signs of cardiogenic shock from the CHF. The scenario would be a pt. transfer, about an hour long to the receiving facility.

This came up from a transfer I did with a renal failure/ CHF pt. who did have some SOB and lowered SpO2. The nurse said on the phone when we were on our way over that the pt. had "fluid overload" and sounded like the pt. was nearing her time, however the pt. managed more than fine on a nasal cannula at 4L/min. The rest of the trip was pretty much a "keep an eye" on her sort of thing. But, on the way over my partner and I got to talking about some what if scenarios that could arise from this pt.

Sorry for the long spiel, have at it! ^_^

I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.

 

[TransportJockey]

Yes.

Nitro and Lasix. Once nitro is maxed out, you can give morphine.

Same protocol here. We also have CPAP in some areas as well (my county area being one of them). Wound up running that as my first call last internship cycle. Got through the Lasix (40mg), NTG (1.2mg), and had 2mg of MS on board before we got to the hospital.


Our state guidelines for Lasix are usually double what the pt takes PO, but here in county we are maxed out at 40mg regardless or what the pt takes.

 

[MrBrown]

GTN and lasix

 

[TransportJockey]

GTN and lasix

GTN=NTG? Just wondering...

 

[Shishkabob]

Glycerin the nitro?

^_^




I've noticed all our people from down under say GTN.

 

[VentMedic]

I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.

Why? Is this the only service available?

GTN - Glyceryl trinitrate

 

[Smash]

CPAP, nitrates (SL) with no upper limit, plus transdermal nitrate patch. This is interim measure until we get the systems and logistics sorted for IV nitrates.

Lasix, match daily dose to max of 80mg, otherwise 40 (or less at discretion of medic).

Morphine only if patient agitated and not tolerating CPAP or if they have pain.

Sedation and intubation if necessary.

Albuterol ONLY if patient has a history of reactive airways disease/COPD as increasing myocardial workload is the last thing we want.

Lasix is not really flavour of the month anymore, although I suspect it still has a place in some settings, particularly where CPAP is used, however more research is needed in the prehospital field.

 

[fma08]

I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.

I would want them on the monitor... The renal failure part alone gives potential for cardiac problems.

 

[medicdan]

Why? Is this the only service available?

We certainly do have ALS available, but the distinction is based on "skills" not necesssarily the condition of the patient. I may, and probably have taken a patient very similar to this to dialysis from an SNF. None of the outpatient dialysis clinics in our region have monitors, so if a patient in this condition needs dialysis, they need it in an acute setting (hospital).

I know I just contradicted myself, but what I am trying to say is that, fairly often, when encountered wth a patient like this, the SNF doesnt know what else to do other then send them for dialysis.

When the above situation is met with a brand new EMT in the back of the truck, possibly an EMT who has no real understanding of dialysis, and has been told, "Oh, you dont need a blood pressure on these patients, we see them all the time!", we often have a problem.

[/soapbox, hijack]

 

[Smash]

Sorry, forgot the inotrope. Epi infusion if shocked.

 

[medic417]

I know this is an ALS forum, so I will attempt not to interfere, but unless the patient needs to be on a monitor, in my area, this is a BLS patient.

Read the scenario!!!!!!!!!! THIS PATIENT NEEDS THE MONITOR. If you BLS a patient as described you need to lose your certification and if your service allows it they need out of business.

 

[emtjack02]

Wow, Epi gtt. That seems like going straight to the "big guns".

 

[Shishkabob]

Lasix .5-1mg/kg

0.5 mg for people not on it.

1 mg for people on it already.

 

[medic417]

So everyone is talking about Lasix are you intending to give it to the OP's patient? If so explain your reasoning.

 

[ResTech]

Smash... why the Epi infusion over Dopamine or Dobutamine for cardiogenic shock?