Treat My Patient

MedicPrincess

MedicPrincess

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82 y/o M, called 911 for respiratory difficutly. ALS FD on scene for approximatley 2 minutes before we arrive. They have managed to put him on O2 NRB 15LPM and where standing there watching him breath.

Patient is extremely pale, dripping wet all over, using all his accessory muscles to breath even on the O2.

RR = 42, Pulse (from pulse ox) = 166

Patient was released from a local hospital x9 days ago with "a lung infection." He also has a pacemaker/defibrilator. Pitting edema to feet at a +3 present. Patients caregiver denies CHF, however states he has just recently been put on Lasix for his "lung infection."

BBS- clear, equal, all fields.

Patient loaded onto stretcher and taken to ambulance. Monitor is applied in the ambulance with BP obtained.

BP= 136/54
RR= 48
O2 sat = 96% on 15LPM NRB - CPAP put in place my medic on truck.
IV - 22g R forearm (20 in L AC blew, really crap for peripheal veins_

Monitor show this....

ECG6second.jpg




12- lead obtained-

12lead.jpg




Patient is still very pale, even more diaphoretic now. However his is still conscious and can answer yes and no questions.

Where would you have gone from here?
 
First place the pulse ox away.. it is incorrect and does not matter anyway. Chances this patients maybe septic .. with acceberated CHF and possible AMI on top.

Now, I do question why the why the CPAP if the lung sounds were clear ? Indication of CPAP is for pulmonary edema.. I question the lung sounds, since the recent HX of lasix and pitting edema.

I would need more information.. skin color, temp, JVD,etc...

R/r 911
 
I agree with Rid.........

"Who" listened to the lungs?

It does look lik elevation in II,III and F. There is depression in I and L as well.
(I wonder which QRS the machine is reading for V1 to be a RBBB, it could have a LBBB too)
If the LBBB is present everything else is pretty much out the window..........

But that is just one piece of the puzzle.

Remember...... sometimes when people are "air hungry" it can be from more than just one source. If there is a VQ mismatch or a bleed, people can be in respiratory distress while the lungs are clear.
 
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Patient was very pale, cool, diaphoretic. I didn't notice any JVD.

BBS were reported by FD to be clear. My medic checked them and said they sound clear to her.

CPAP was put in place d/t RR and it not improving with just O2. He had began to have the resp difficutly 2 hrs prior to calling, and seemed to be getting tired. CPAP in an effort to get it under control, before taking him down to intubate.

The only pitting edema was in his feet. It didn't extend into his legs or anywhere else, like I have seen with others.

I am thinking his respiratory difficulty was directly related to his cardiac status.....
 
so we have a diff breather w/bad vitals ?

O2, line, load and report to med con, and ask what thier drug of choice may be

S~
 
Just a question, but does anyone believe he is taking adequate breaths to assess his lung sounds at 42/min? It sounds as if this poor guy is panting. Need a better exam, no offense intended. Sounds like this guy was sent home with pneumonia and his "caregiver" hasn't followed the doctor's instructions well leading to his getting worse. CPAP is not a bad choice, lasix might be beneficial, consider MONA (okay O is already there) for the possible AMI developing. All things considered his vitals are pretty good except his resp rate, which I think the CPAP might help. Write this date down... because I agree with Stevo, turn it over to the doctors. They paid that much to become doctors, let them show what they know.
 
Write this date down... because I agree with Stevo
Click to expand...

gawd, feels like we should buy lotta tickets there OldSchool :)

don't get me wrong,i think it's great practice to try and put the pieces of the puzzle together

but sometimes simple works too...

i end a lot of my patches asking what else i can relay, or what else can be done btw. i get my best feedback (and ultimately best patient care) asking

~S~
 
Always involve someone with deeper pockets!!! :)
 
Speaking of MONA, you're going to start seeing protocols change in the near future. Morphine is going by the wayside, especially in CHF patients. Evidenced based research is showing it's doing more damage then good.
 
CPAP is not indicated with clear lung sounds. Lasix should not be given to pneumonia PT's due to the fact that it will dry the mucus secretions in the lungs into concrete and created a bigger problem. Lasix isn't going to clear them up.

The RR needs to be managed, whether it's by assisted ventilations or whatnot. Good tidal volume, and slowing the rate down is key.

As far as the AMI issue....I'd probably shoot another 12 lead and look for changes. You didn't mention any chest pain complaints from the patient. Med control is probably the ideal answer once the respiratory status is controlled.



On a side note, to the above post, they just released a big study in my area showing how MSO4 is beneficial in an ACS case... It's funny to hear you say that.
 
Read this month's edition of JEMS. The same author was at the National EMS Expo in Baltimore and presented on the exact same thing and it is evidenced based. Morphine increased the mortality of the patient by 13%.

They want Bipap and Cpap used prehospital (which some medical directors do not in the midwest) and instead of Morphine they are requesting we start looking at benzodiazepines for the patient to relax them. Lasix may also go to the wayside for prehospital according to literature I have been reading.
 
Strike3, could you share that study that you're talking about because we have a rather large controversy here regarding this.
 
Tachypnea with clear lung sounds....
Sounds like pulmonary embolism...
Sedation,intubation,heparin IV and VERY fast to hospital...
Someone that breath 40 b/min will not hold for long...
 
you've got time for coffee at Timmies. It's when they drop down to 6 RR/min with profound bradycardia that you better G-L-H to the big H. :D
 
Sophie said:
Read this month's edition of JEMS. The same author was at the National EMS Expo in Baltimore and presented on the exact same thing and it is evidenced based. Morphine increased the mortality of the patient by 13%.

They want Bipap and Cpap used prehospital (which some medical directors do not in the midwest) and instead of Morphine they are requesting we start looking at benzodiazepines for the patient to relax them. Lasix may also go to the wayside for prehospital according to literature I have been reading.
Click to expand...

On CHF with associated Frank Pulmonary edema, research is demonstrating that CPAP is one of the few treatments that is actually reducing admissions, admissions to ICU, etc. The contradiction to Morphine is debated, but studies have demonstrated that there is a possibility of increasing infarct size on right or inferior wall AMI with Morphine administration.

The second recommended medication in Frank CHF is the use of nitrates. Then followed bu diuretics, with caution. The reason diuretics is heavily debated is due to poor assessment and history taking making a false diagnosis. Nitrates is now being more and more administered in proper dosage as per IV route in the field setting.

We are developing protocol the use of NTG IV in the field. Fortunately we already have infusion pumps. Most services do not explore the possibilities due to one has to have IV infusion pumps for administration of NTG. Of course with this one can start using other medications such as Levophed, Sodium Nitroprusside, etc. which we are exploring as well.

With CHF being one of the largest percentage medical disorder of our elderly we will see more and more advance treatment.

R/r 911
 
I like all the comments but, did anyone think that this pt is in unstable v-tach? in witch case instead of treating with mona, or treating for ami, consider 5 of valume and cardiovert starting at 100 joules...
 
dtermnd said:
I like all the comments but, did anyone think that this pt is in unstable v-tach? in witch case instead of treating with mona, or treating for ami, consider 5 of valume and cardiovert starting at 100 joules...
Click to expand...



A couple of things... First welcome to the site!

Now, please don't tell me that you actually thought that was V-tach, when it is a paced rhythm! You can't see the pacer spikes? ... Now you tell me you are going to shock them ?.. WOW!!! See ya in court!

What does it matter she is a witch or any faith for that matters ? ;) I don't know what Valume is... I do know what Valium is and personally rather not give it because of the duration and time of onset, but much rather give Versed instead, since it is faster acting and has amnesic effects as well.

R/r 911
 
Hello to all.
Like a few others here I would like a little more information about this case as well as a better 12 lead to suggest a different treatment. One question I have is did the C-PAP work? Understanding that IV access was poor and only a 22 gauge was placed I would hesitate to begin Ntg. until I was more sure of what I was dealing with, an extremely high BP might warrant it but not this one. I have to agree with some that suggest that breath sound evaluation might not have been accurate due to RR as well as the seriousness of the patient condition and the rush to "do something" If there was no indication of bronchospasm or other air retention issue I can't think of any harm of the CPAP if no improvement or worsening noted remove it. I agree that we need to assist in some way before the patient crashes and CPAP is non-invasive and can be changed quickly if needed. This is a difficult call to handle, when in doubt call med control.
Ridryder911 I am a little disappointed at the sarcasm you demonstrated. This was a good opportunity for you to educate the less informed about the finer points of reading 12 leads as well as encourage the new folks to continue posting without fear of ridicule. I believe we can all help each other and continue to improve the professional standing of EMS as a credible healthcare profession. Mike
 
Sorry your offended, rather you should be quite offended that a "quote" medical trained person is actually out there that could actually kill someone, by cardioverting a paced rhythm! Sorry, this is not a "feel good" profession and in fact that is part of the problem, we have coddled so many and allowed such to continue... Either get with the education or get out before you kill someone... yes, it can and does happen!

Do you not realize, what discountability this disproves to our so called profession, especially when one cannot interpret such a simple rhythm with obvious pacer spikes? Then not to even know how to spell common words and knowledge of the differential spelling as which and witch, and Valium? Sorry, I just spent a week as an expert witness in court and I can attest, the attorneys would have a field day ! Yes, you are based upon your education level both professional and in general knowledge.

We continue to discredit our profession as long as we "sugar coat" and continue to be politically correct, thus allowing anyone into and allow continuation representing our profession. Yes, forums can be a learning tool and yes, even awaken one to take action in simple things such as to start studying the basics of English, spelling, and understanding of cardiac care, which not only individuals are judged upon, but our whole profession is as well.

R/r 911
 
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I'm sorry that I wasn't clear with my last post. I agree with you completely that we must not coddle folks and that they can and do kill people with their lack of knowledge or critical thinking skills. I am suggesting that if we look to the root of the problem we may find that we are very destructive to ourselves as a profession when we don't take "teaching moments" and use them to help the patients that they will treat. I have been in EMS since the early 80s when the classes were tough and failure rates were high. The first ACLS class I took only had RN's and MD'S teaching it and mega-code was a bear. Now with the "kinder gentler" AHA everybody should pass. I currently run an EMS training program at a local community college full time and work in the street on average of 48 hrs/wk. So I have an insight into some of the problems we have. First let’s think of the "training" that many folks get. The average student will complete an EMS program that includes a little "ride time" at the ALS level a little more. After that they will sit for a local or national exam and receive a credential. Many systems will place that newly credentialed medic on a truck to begin treating patients often times with bls partner. Other students will test and receive their credential and then be precepted for a period of time. Problem is who are the preceptors? Often times they don't want newbie’s, are burned out, have little more experience than the new person, or have no idea of how to teach. Students and new medics that ride with these folks often times do just that, ride! Evaluations consist of the simplest route with the least resistance "average" Management is often aware but they need a "patch and a pulse" to fill a spot in the least amount of time and least amount of money. When a mistake is made by this untrained individual his career is finished and he is dumped. Is this a fair thing to do to our young? Now, how does that fit in here? When we have the opportunity to educate those of us that can must do that. If we help those that are "misguided" then we help their patients. I certainly don't want to come off as a bleeding heart that believes everybody should succeed but we must try to help those that want to succeed. If education doesn't work it is time for a career change. As far as the spelling issue remember that most of these folks are the product of government schools that are only interested in teaching the lowest common denominator to pass the standardized tests. Many, if not most of these 12th grade graduates can't place out of 10th grade English in college testing. Now that’s quality education!! (remember: no idiot oops child left behind) I hope that I cleared up my statement and that we can use this forum to help not intimidate. If we intimidate then we lose the opportunity to teach. BTW I failed my first mega code in "84" when I forgot to turn back the Isuprell after the HR increased. Mike
 
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