Treatment of APE

[NYMedic828]

I seem to get ALOT of APE patients in my area considering I work the morning shift.

I had a few questions in how everyone treats their patients as far as medications go.

Today I had two legitimate APE patients, one with a history of COPD, both had audible wheezing and basilar rales.

Both had HTN. Normal 3/12 EKGs.

For both all we did was q5 nitro with a doubled up initial dose. Both had improvement but still had signs/symptoms of APE.

So heres where my questions come in, in NYC our protocol permits for standing order Nitro and CPAP if equipped, which we are not. Med control options of low dose benzos, morphine or lasix.

Our first patient felt a lot better after 2 hits of nitro so we started a lock and left it at that.

The second, was extremely dehydrated based on her skin condition so we didn't consider lasix a valid option. Should we have called for morphine? My partner said no due to her sat being 100%

My understanding is morphine is used to cause a further more long standing vasodilation on top of the nitro?

The benzos my understanding is for when the patient is so bad they are agitated with a feeling of drowning and it is used for anxiolytic purposes.

Also, my partners both told me if you have obvious APE, it is more than likely the underlying cause of the patients wheeze and giving combivent could potentially cause a flash flooding of the lungs, but when we took the last pt to the ER, they put her on a combivent treatment while waiting for a CPAP machine?

 

[triemal04]

First patient: Continue with the ntg as needed. If they are volume overloaded then give lasix, if not then don't.

Second patient: same, but be careful about their BP.

Morphine in CHF is kind of tricky. It can decrease preload which is the goal, it can help as an anxiolytic which can be good, but it also can cause resperatory depression, which isn't good. Though low doses generally don't. The studies that showed an increased mortality with MS had some problems, and at least 1 admitted it; does MS really increase mortality, or is it that the patient's who are allready much, much sicker the ones getting MS in the first place?

I've only really used MS when I haven't had CPAP available and have had to assist someone with a BVM; it's not the best option, and when done incorrectly can be worse, and even when done right can be very uncomfortable and anxiety provoking for patients. A small dose of MS has helped as a bridge until the other treatements took effect.

Generally I'd say don't use it as it isn't needed; ntg and CPAP are better.

As for giving albuterol...cardiac asthma is a real thing. If that is the cause of the wheezes then ntg and treatement for pulmonary edema should be your first treatement. But, if you still have bronchoconstriction that isn't resolving, then yes, some albuterol could help. I wouldn't load the patient up with it, but one dose would be appropriate. And in the patient's you mentioned, it could have been constriction from their normal COPD.

 

[46Young]

First patient: Continue with the ntg as needed. If they are volume overloaded then give lasix, if not then don't.

Second patient: same, but be careful about their BP.

Morphine in CHF is kind of tricky. It can decrease preload which is the goal, it can help as an anxiolytic which can be good, but it also can cause resperatory depression, which isn't good. Though low doses generally don't. The studies that showed an increased mortality with MS had some problems, and at least 1 admitted it; does MS really increase mortality, or is it that the patient's who are allready much, much sicker the ones getting MS in the first place?

I've only really used MS when I haven't had CPAP available and have had to assist someone with a BVM; it's not the best option, and when done incorrectly can be worse, and even when done right can be very uncomfortable and anxiety provoking for patients. A small dose of MS has helped as a bridge until the other treatements took effect.

Generally I'd say don't use it as it isn't needed; ntg and CPAP are better.

As for giving albuterol...cardiac asthma is a real thing. If that is the cause of the wheezes then ntg and treatement for pulmonary edema should be your first treatement. But, if you still have bronchoconstriction that isn't resolving, then yes, some albuterol could help. I wouldn't load the patient up with it, but one dose would be appropriate. And in the patient's you mentioned, it could have been constriction from their normal COPD.

+1 on the above.

I'd like to add, that if you have quantitative capnography (the sidestream nasal cannula ETCO2), you can use that to help guide your decision whether to give bronchodilators or not. CO2 diffuses through fluid at about the same speed as it does through air. So, the capnometry (the number) and capnometry (with the waveform) will be the same regardless of how much pulmonary edema the pt has. So, you can use capnography to help you decide if the the pt is experiencing concominant bronchoconstriction with their APE, or if the fluid id causing the sound of wheezing. In addition, if you understand ETCO2 capnography, it works in real time, and you can see changes there a minute or two before other S/Sx develop. This would be helpful in knowing when to start bagging and maybe drop a tube, among other things.

I remember you saying that FDNY won't purchase CPAP due to cost. It really is the standard of care. At NS-LIJ, we did the CPAP trials on 46Y, 53Y and 54Y. I've seen it work wonders when we couldn't do anything else of ther than nitro. I've done more than a few EJ's on a conscious CHF'er, but that's not always possible, and we didn't have the EZ-IO drill back then.

We found that if we started CPAP in the house, we would blow through all three of our bottles before we even got out to the bus, and we weren't doing more than two or three floor walkups if not using an elevator. We changed our protocol to only initiate CPAP in the bus. Here in VA, we carry two larger cylinders. We can get about 15 mins give or take out of each cylinder typically.

Also, in Fairfax City, my neighboring department, for a severe APE, they can initiate a ntg drip with CPAP, and give ntg via IVP from 10mcg/min to 20 (IIRC). Breaking the mask seal to give SL ntg in these patients compromises the treatments. Something to think about.

 

[the_negro_puppy]

We don't have many options for APE patients, We can give SL nitro, have no CPAP, no lasix and can use BVM for assisted vents

 

[cruiseforever]

I take it APE = Acute Pulmonary Edema. I wish people would spell out in the begining what they are talking about. The same thing goes for using codes. What might be common in your area is not for the rest of the EMS world.

 

[STXmedic]

We treat our Acute Pulmonary Edema/Congestive Heart Failure exacerbation patients with continuous positive air pressure, high dose sub-lingual nitroglycerin, morphine sulfate, and still have the consideration for furosemide intravenously. We just added the option for intravenous nitroglycerine as well. Hopefully we will be getting it in soon Rapid sequence intubation should be arriving shortly as well. It will come in handy for those severe congestive heart failure patients that require endotracheal intubation.

 

[ShotMedic]

Defintely would like the ability to give NTG through an IV drip when having a patient on CPAP, I've been sitting in the back of the rig many a time popping that cpap mask off to give a follow up sprays and then thinking to my self there has to be an easier way. Glad to see there are systems that adapt to the times.

Had a very similiar situation to the OP of this thread last shift, Where we had a 73yo Male with respiratory distress, who is a frequent flyer for different issues, but mainly respiratory. Patient on arrival was tripoding, lots of accessory muscle use, speaking 1-2word sentences RA sat 88%. at this point i never saw the patient this acute. on auscultation of the lungs patient had rales bi-lateral. At this time i was confused due to the patients HX of COPD. I did a second check to make sure it wasnt more of a Rhonchi sound and had my partner check as well. I asked the wife if he had any pneumonia HX recently and she states not for 2 months. Patient had clear sputem no tinges or "gunk" what so ever. Temp was normal. bp-180/100. So I treated this patient as a pulmonary edema 0.8mg SL CPAP, During transport Patients sats climbed to around 95% and the rales cleared up. At this point his lungs were still very dimineshed but i couldn't hear any wheezing. The ER treated him as a COPD patient. I took some heat from the Radio nurse as to why I treated the patient as a CHF/Pulmonaryedmawith out any definte HX. Then i explained that due to the HX of prior MCI, CAD, and HTN i figured it to be new onset. i was a little thrown of by no pedal edema signs. Any thoughts??

 

[46Young]

Defintely would like the ability to give NTG through an IV drip when having a patient on CPAP, I've been sitting in the back of the rig many a time popping that cpap mask off to give a follow up sprays and then thinking to my self there has to be an easier way. Glad to see there are systems that adapt to the times.

Had a very similiar situation to the OP of this thread last shift, Where we had a 73yo Male with respiratory distress, who is a frequent flyer for different issues, but mainly respiratory. Patient on arrival was tripoding, lots of accessory muscle use, speaking 1-2word sentences RA sat 88%. at this point i never saw the patient this acute. on auscultation of the lungs patient had rales bi-lateral. At this time i was confused due to the patients HX of COPD. I did a second check to make sure it wasnt more of a Rhonchi sound and had my partner check as well. I asked the wife if he had any pneumonia HX recently and she states not for 2 months. Patient had clear sputem no tinges or "gunk" what so ever. Temp was normal. bp-180/100. So I treated this patient as a pulmonary edema 0.8mg SL CPAP, During transport Patients sats climbed to around 95% and the rales cleared up. At this point his lungs were still very dimineshed but i couldn't hear any wheezing. The ER treated him as a COPD patient. I took some heat from the Radio nurse as to why I treated the patient as a CHF/Pulmonaryedmawith out any definte HX. Then i explained that due to the HX of prior MCI, CAD, and HTN i figured it to be new onset. i was a little thrown of by no pedal edema signs. Any thoughts??

Many patients have both COPD and CHF. My thought is that the pt can start out with COPD, develop pulmonary HTN, which eventually causes CHF.

 

[the_negro_puppy]

Defintely would like the ability to give NTG through an IV drip when having a patient on CPAP, I've been sitting in the back of the rig many a time popping that cpap mask off to give a follow up sprays and then thinking to my self there has to be an easier way. Glad to see there are systems that adapt to the times.

Had a very similiar situation to the OP of this thread last shift, Where we had a 73yo Male with respiratory distress, who is a frequent flyer for different issues, but mainly respiratory. Patient on arrival was tripoding, lots of accessory muscle use, speaking 1-2word sentences RA sat 88%. at this point i never saw the patient this acute. on auscultation of the lungs patient had rales bi-lateral. At this time i was confused due to the patients HX of COPD. I did a second check to make sure it wasnt more of a Rhonchi sound and had my partner check as well. I asked the wife if he had any pneumonia HX recently and she states not for 2 months. Patient had clear sputem no tinges or "gunk" what so ever. Temp was normal. bp-180/100. So I treated this patient as a pulmonary edema 0.8mg SL CPAP, During transport Patients sats climbed to around 95% and the rales cleared up. At this point his lungs were still very dimineshed but i couldn't hear any wheezing. The ER treated him as a COPD patient. I took some heat from the Radio nurse as to why I treated the patient as a CHF/Pulmonaryedmawith out any definte HX. Then i explained that due to the HX of prior MCI, CAD, and HTN i figured it to be new onset. i was a little thrown of by no pedal edema signs. Any thoughts??

Its a matter of covering all your bases. Its difficult for us sometimes to distinguish between conditions in the pre-hospital environment. CPAP would have helped regardless and with a bp of 180/100 SL Nitro would have helped significantly if it was cardiogenic APE, and done no harm if it was COPD exacerbation.

 

[NYMedic828]

Defintely would like the ability to give NTG through an IV drip when having a patient on CPAP, I've been sitting in the back of the rig many a time popping that cpap mask off to give a follow up sprays and then thinking to my self there has to be an easier way. Glad to see there are systems that adapt to the times.

Had a very similiar situation to the OP of this thread last shift, Where we had a 73yo Male with respiratory distress, who is a frequent flyer for different issues, but mainly respiratory. Patient on arrival was tripoding, lots of accessory muscle use, speaking 1-2word sentences RA sat 88%. at this point i never saw the patient this acute. on auscultation of the lungs patient had rales bi-lateral. At this time i was confused due to the patients HX of COPD. I did a second check to make sure it wasnt more of a Rhonchi sound and had my partner check as well. I asked the wife if he had any pneumonia HX recently and she states not for 2 months. Patient had clear sputem no tinges or "gunk" what so ever. Temp was normal. bp-180/100. So I treated this patient as a pulmonary edema 0.8mg SL CPAP, During transport Patients sats climbed to around 95% and the rales cleared up. At this point his lungs were still very dimineshed but i couldn't hear any wheezing. The ER treated him as a COPD patient. I took some heat from the Radio nurse as to why I treated the patient as a CHF/Pulmonaryedmawith out any definte HX. Then i explained that due to the HX of prior MCI, CAD, and HTN i figured it to be new onset. i was a little thrown of by no pedal edema signs. Any thoughts??

Im no expert but that nurse must be retarded...

Who is to say the patient isn't experiencing it for the first time in your presence? There has to be an initial occurrence at some point to be diagnosed with CHF...

 

[Traumjunk]

We use the NTG, Lasix, and CPAP. If too critical, then straight to RSI

 

[medicsb]

+1 on the above.

I'd like to add, that if you have quantitative capnography (the sidestream nasal cannula ETCO2), you can use that to help guide your decision whether to give bronchodilators or not. CO2 diffuses through fluid at about the same speed as it does through air. So, the capnometry (the number) and capnometry (with the waveform) will be the same regardless of how much pulmonary edema the pt has.

You might want to check your sources. CO2 diffuses through air ~10,000 times faster than through water.

Capnography is a great tool, but I don't know of any evidence that shows that it has any diagnostic significance for CHF or COPD other than CO2 tends to be higher in COPD patients. The shark-fin appearance is probably pretty specific, but I doubt it is very sensitive (I don't know of any objective measurement of the "shark fin" waveform angles and/or any calculation of sensitivity and specificity of the "shark fin" wave form).

Obviously, you will need to correlate what is seen on the capnograph with what you see with the patient. A CHF patient could have a high EtCO2 if they have begun to go into respiratory failure. Some asthma/COPD patients may be compensating enough that they're blowing off enough CO2 to achieve "normal" values.

 

[usalsfyre]

I took some heat from the Radio nurse....

This is why I don't see myself being a paramedic outside of Texas. I can't play nice with people who want to give me grief who aren't in my direct chain of command and don't know what they are speaking of.

 

[usalsfyre]

CPAP and high-dose NTG here. These patients probably can't get enough NTG. Lasix is there is overt evidence of volume overload, which is rare.

Albuterol is probably not as horrible as its made out to be, especially in your patient with multiple respiratory comorbidities.

 

[IrightI]

We use the NTG, Lasix, and CPAP. If too critical, then straight to RSI

Same for our service. We are on the more aggressive side of things since we are a more rural service with an average ETA of 30mins to our ER.

Our protocols for APE, CPAP, NTG drip, lasix, morphine, and if neccessary or if I dont like how they are maintaining their airway then its RSI for the ride in. if im showing bronchoconstriction on the cap, then we can run a treatment through our CPAP. It seems that a NTG drip, vs intermittent sprays, seems to fair a lot better for pt outcomes when we arrive at the ER. Having CPAP on our rigs has saved alot of tubes thats for sure.

 

[Petey0397]

We actually stopped carrying Lasix about a year and a half ago after doing some research on our usage.

Not to beat a dead horse, but CPAP really is becoming/has become the go to for these patients. It does a better job of treating the underlying issue, which isn't necessarily fluid overload so much as it is fluid in the wrong places.

Without CPAP, I suppose you're relient upon NTG and will probably have to jump to RSI if the patient continues to show signs of deterioration.

The only times I've really used breathing treatments in CHF patients is when I failed to recognize initially that the patient's breathing problems were cardiac in nature and not due to their asthma. Subsequently, I had to deal with the elevated heart rate that comes as a side effect, and put un-due stressed on an already stressed heart.

All that to say, without getting CPAP, I'm not sure what else there is to be done.

 

[sir.shocksalot]

It seems that a NTG drip, vs intermittent sprays, seems to fair a lot better for pt outcomes when we arrive at the ER.

I wonder if there are any studies regarding this. We have those cheap crappy NTG tabs, so to continue NTG treatment we have to discontinue CPAP. I wonder if you lose some of the effectiveness by taking CPAP off? Kinda like CPR where you stop the pressure and you're back to square one. While it would greatly amuse me to drop the tabs in the oxygen tubing and have it blown in their mouth that way I think we would be better off with a NTG drip, or at least the paste.

 

[usalsfyre]

I wonder if there are any studies regarding this. We have those cheap crappy NTG tabs, so to continue NTG treatment we have to discontinue CPAP. I wonder if you lose some of the effectiveness by taking CPAP off? Kinda like CPR where you stop the pressure and you're back to square one. While it would greatly amuse me to drop the tabs in the oxygen tubing and have it blown in their mouth that way I think we would be better off with a NTG drip, or at least the paste.

In theory everytime you break the seal of the mask you derecruit alveoli. Unknown how much of a difference this makes.

I know for kids on things like HFOV they clamp the tube when the circuit is disconnected so as not to lose pressure, so I assume the effect can be significant.