I was right, I failed that skill station for lack of treatment. :[ Oh well, next time I get CHF exacerbation, I'll remember to appropriately treat it.
Patients with acute congestive cardiac failure are often very, very sick and the mortality rate is quite high so yes, you need to be very aggressive with treating this group of patients, probably the closest example to compare the level of "ambo-ing" these people need is those with life threatening asthma.
Get them onto the bed and put their legs over the side, slap on a non rebreathing mask with a very high flow rate, like these patients will be profoundly hypoxic and need a much higher rate of oxygen delivery than what is normally used (we use 15 LPM) and ensure a good seal as two easy, simple first actions.
Acquire an ECG quickly and look for treatable causes of ventricular insufficiency; the most common reasons are infarction and tachydysrhythmia, particularly VT. Nothing wrong with cardioverting somebody who is in VT with cardiogenic pulmonary edema, if they have cardiogenic shock as a result of their lowered ventricular output then you're in a bit of a sticky situation; cardioverting them is going to hurt with much of the paining but it may very well save their life; I suppose if you have it you might try some fentanyl or more preferably some ketamine given the haemostatic properties.
GTN is really the only proven thing that works well for somebody who is in cardiogenic pulmonary edema, use 0.8 mg unless they have blood pressure a bit more towards the lower side of whatever limit you have (ours is 100) then it might be a good idea to use 0.4 mg.
CPAP is a good idea I reckon, I asked the Clinical Standards Unit why we don't have it, their answer was that it has not clearly demonstrated a lower mortality rate and that it will empty an oxygen tank very fast and our ambulances only carry one and refilling them can get very expensive so for now we have PEEP.
I wouldn't bother calling for an Intensive Care Paramedic with RSI because these patients have a time critical problem who need to the transported to hospital without delay and it's going to take less time to take them to hospital than it is to get RSI backup.
Get these patients into the ambulance once you've got them on the bed, given them a couple minutes of very high flow oxygen and a dose of GTN (if their blood pressure will allow) and get moving.
I'd recommend placing an early RT call to the hospital before you leave the scene or as you are doing so.
So um yeah, CHF patients are going to be crook and treat them as such!