What sign did I miss? 65 y o female seated in chair (not tripod), pos sob. (l) lung severe rale sound. (r) lung less severe rales. Lower ext edemic. Bp dont quite remember, but somewhat elevated. Son poor historian, so pmh not full. Gave pt nrb 15 lpm. Took min to write down meds for er. If i didnt see improvement w sob on nrb (which son blamed anxiety, altho i blamed on pos fluid in lungs) was planning on bvm. On way to bus, pt rips off nrb. As i bend dow to explain it nrb may feel like its suffocating her, but it's helping, my partner spotted an imminent code sign that i missed and immediately called for als. Her RR rate had slowed some on NRB. Until that moment she pulled it off and immed coded, I was anticipating only assisted vents. Is there some "universal" sign that a chf pt, although seemingly improving w nrb, is about to code? I've had other pts, with all dif diagnoses remove nrb and have had no problem in coaxing it back on, and have never before seen that moment be their last breath. What indicates a chf pt, seemingly improving on nrb, is getting ready to code? Like i said, other pts have removed nrb and been coaxed back into it. Any suggestions?
suspected CHF sudden code
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akflightmedic
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Why did you wait for an "imminent code sign" to call for ALS?
That is what you missed...this call was ALS from the moment you walked in the door.
That is what you missed...this call was ALS from the moment you walked in the door.
The son may have been a poor historian but your written communication skills aint much better mate. Speak in proper words.
Are you talking about respiratory failure or cardiac arrest?:
Myocardial ischaemia is the #1 cause of acute pulmonary edema and what is the #1 cause of cardiac arrest? That's right, acute myocardial ischaemia!
Sounds like this bloke needed an RSI qualified Intensive Care Paramedic with much of the expeditiousness.
Are you talking about respiratory failure or cardiac arrest?:
Myocardial ischaemia is the #1 cause of acute pulmonary edema and what is the #1 cause of cardiac arrest? That's right, acute myocardial ischaemia!
Sounds like this bloke needed an RSI qualified Intensive Care Paramedic with much of the expeditiousness.
This. What made you think this was a call that didn't need medics?
I know it's probably not what you want to hear, but I've got to add that dyspnea in a patient of this age, with rales and presumably new/worsened peripheral edema, sounds pretty ALS. Perhaps your system doesn't have a lot of ALS resources?
There's a lot of information missing from what you've provided that would be necessary to establish a decent working diagnosis and differentials. This could definitely be an exacerbation of pre-existing CHF. Evidence to support this theory would come from prior hx, medication record, hx of recent changes in diuretic therapy, noncompliance with meds. Ideally you'd want to know about renal function in this patient. This could also be acute CHF caused by an acute MI. A 12-lead would be useful here, as in any patient with dyspnea. There's other possibilities, of course, this could be exacerbated COPD / asthma in a patient with poor cardiac function, or a pneumonia, sepsis, or a PE. Failure could result from an arrhythmia, like a perfusing VT. There could be many other issues going on.
The assumption here is that her worsening dyspnea, anxiety, noncompliance with the NRB all point to respiratory, and a hypoxic arrest. Given the patient was conscious and trying to remove their NRB, it also seems possible that they either air-trapped really badly or had an arrhythmic arrest. The feeling of suffocation while on high flow O2 may be a sign that they're decompensating.
You ask:
Firstly:
- It's not certain that this was a CHF patient, or that the primary problem was CHF, although it's certainly possible.
- Were they "seemingly improving" with the NRB? It's hard to get a feeling with this without being there, but you say the respiratory rate slowed after application --- was this accompanied by signs of improved oxygenation? Because if the patient is becoming obtunded and increasingly hypoxic, their respiratory rate will also slow right before they check out.
That being said, signs of impending code are not really specific to CHF. As with any other patient you're looking at signs of decompensation.
- altered mental status (the simplest indicator of end-organ perfusion)
- cyanosis
- hypotension
- bradycardia / arrhythmia
- bradypnea / hypopnea / apnea
- hypoxic seizures
There's a lot of information missing from what you've provided that would be necessary to establish a decent working diagnosis and differentials. This could definitely be an exacerbation of pre-existing CHF. Evidence to support this theory would come from prior hx, medication record, hx of recent changes in diuretic therapy, noncompliance with meds. Ideally you'd want to know about renal function in this patient. This could also be acute CHF caused by an acute MI. A 12-lead would be useful here, as in any patient with dyspnea. There's other possibilities, of course, this could be exacerbated COPD / asthma in a patient with poor cardiac function, or a pneumonia, sepsis, or a PE. Failure could result from an arrhythmia, like a perfusing VT. There could be many other issues going on.
The assumption here is that her worsening dyspnea, anxiety, noncompliance with the NRB all point to respiratory, and a hypoxic arrest. Given the patient was conscious and trying to remove their NRB, it also seems possible that they either air-trapped really badly or had an arrhythmic arrest. The feeling of suffocation while on high flow O2 may be a sign that they're decompensating.
You ask:
Firstly:
- It's not certain that this was a CHF patient, or that the primary problem was CHF, although it's certainly possible.
- Were they "seemingly improving" with the NRB? It's hard to get a feeling with this without being there, but you say the respiratory rate slowed after application --- was this accompanied by signs of improved oxygenation? Because if the patient is becoming obtunded and increasingly hypoxic, their respiratory rate will also slow right before they check out.
That being said, signs of impending code are not really specific to CHF. As with any other patient you're looking at signs of decompensation.
- altered mental status (the simplest indicator of end-organ perfusion)
- cyanosis
- hypotension
- bradycardia / arrhythmia
- bradypnea / hypopnea / apnea
- hypoxic seizures
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Anjel
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Not to...
:deadhorse:
But you should of called ALS immediately. Or at least arranged an intercept. If you are considering bagging a person, because they aren't breathing well enough. A basic doesn't need to be handling that on their own.
Can you handle it? Sure. Just make sure you are up to date on your CPR.
:deadhorse:
But you should of called ALS immediately. Or at least arranged an intercept. If you are considering bagging a person, because they aren't breathing well enough. A basic doesn't need to be handling that on their own.
Can you handle it? Sure. Just make sure you are up to date on your CPR.
Good hx finding is what meds is the patient taking? Even if the patient or family can't tell you what the history is, the meds will tell you what history they have.
If they are taking Diabetic meds, they have a Diabetic history, even if they say they don't.
If they are taking Diabetic meds, they have a Diabetic history, even if they say they don't.
abckidsmom
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Not necessarily. Meds give you a great clue, but there are quite a few reasons a person would be on diabetic meds without having an official diabetes history.
fast65
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Like everyone else has said, why didn't you request ALS sooner? This was definitely a call that needed them; also, taking the time to write out the scenario in proper English would be immensely helpful for everyone.
In what position were you transporting the patient?
In what position were you transporting the patient?
medicstudent101
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*Immensely is the word of the day.
DrParasite
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difficulty breathing should be an automatic ALS dispatch, before you even walk in the door.
diff breathing, bilateral rales? needs ALS.
person feels like she is suffocating? needs CPAP, she probably has her lungs full of fluid, making her feel like she was suffocating. sit her up all the way, need ALS, try bagging to assist with respirations. If that fails, need ALS, possible intubation
biggest sign of the imminent code when dealing with a resp patient? when she stops breathing, her pulse stopping isn't far behind.
diff breathing, bilateral rales? needs ALS.
person feels like she is suffocating? needs CPAP, she probably has her lungs full of fluid, making her feel like she was suffocating. sit her up all the way, need ALS, try bagging to assist with respirations. If that fails, need ALS, possible intubation
biggest sign of the imminent code when dealing with a resp patient? when she stops breathing, her pulse stopping isn't far behind.
fast65
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I've been waiting to read the OP's answers to our questions, and I'm a little disappointed that they haven't responded yet.
medicstudent101
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I can't say I blame the OP for not responding. I agree with everyone that his grammer could improve, but there's been a lot of bashing between everybody. Rather discouraging if I was the OP.
fast65
Doogie Howser FP-C
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Mine was more of a suggestion. However, I would have at least answered the questions if I were him. It would be immensely helpful
medicstudent101
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Mine was more of a suggestion. However, I would have at least answered the questions if I were him. It would be immensely helpful
Agreed. B)