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The Patient with Heart Failure CPAP as an Intervention

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1 The Patient with Heart Failure CPAP as an Intervention
April 2011 CE Condell Medical Center EMS System Site Code #107200E -1211 Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2 Objectives Define heart failure and congestive heart failure.
Upon successful completion of this module, the EMS provider will be able to: Define heart failure and congestive heart failure. Identify causes of heart failure. Identify symptoms of heart failure. Identify patterns of medical history related to the patient with heart failure. Identify current home medications typically taken by the patient with congestive heat failure.

3 Objectives cont’d Identify the difference between the patient with congestive heart failure and pneumonia. Identify the assessment of the patient with congestive heart failure. Identify the proper procedure for assessing breath sounds. Identify treatment goals and options for congestive heart failure following Region X SOP’s. Define CPAP as used by EMS for the patient with pulmonary edema.

4 Objectives cont’d Describe how CPAP will benefit the patient with pulmonary edema. State indications, contraindications and medications used with CPAP. Describe the process of setting up the CPAP device. Describe the process of adding in-line Albuterol with CPAP. Describe patient assessment while delivery CPAP. State components to document when using CPAP.

5 Objectives cont’d Demonstrate the set up of CPAP.
Demonstrate the set-up of regular and in-line Albuterol. Demonstrate adding in-line Albuterol with CPAP. Actively participate in case scenario discussion. Successfully complete the post quiz with a score of 80% or better.

6 What is Heart Failure? A clinical syndrome
Heart’s mechanical performance (ie: pumping action) is compromised Cardiac output unable to meet the demands of the body’s needs Generally divided into backward ventricular failure (right heart failure) and forward ventricular failure (left heart failure) Can be of a chronic or acute nature

7 Heart Failure Variety of causes Contributing factors to heart failure
Valve disease Heart disease Contributing factors to heart failure Diet - excess fluid or salt intake Hypertension Pulmonary embolism Excessive alcohol or drug usage Progression of an underlying disease

8 What is CHF? Congestive heart failure = CHF
Condition of excess build-up of fluid in the lungs and/or other body parts/organs Fluid build-up causes congestion in the organs seen as edema May be brought on by diseased heart valves, hypertension, or some form of obstructive pulmonary disease Often a complication of AMI AMI – acute myocardial infarction. For the patient in CHF, assume they are also having an AMI until proven otherwise.

9 Fluid build-up in CHF may be pulmonary, peripheral, sacral, or ascites

10 Understanding CHF A failure of the pumping action of the heart
Heart is a 2 sided pump Right side of heart is a low pressure system Left side of heart is a high pressure system

11 Heart as a Pump Left side of heart muscular
Needs to overcome pressure in the arteries to push/pump blood Pumps blood flow to the body Right side of heart less muscular Pumps blood to the lungs Does not need to be a very aggressive pump with a lot of force

12 Starling’s Law The more the myocardial muscle is stretched, the greater the force of contraction (the greater the recoil) Greater the preload (amount of blood returned to the right heart), the farther the myocardium is stretched and the more forceful a contraction that results leading to an increased cardiac output When Starling’s Law fails, the patient is no longer able to compensate The more and longer the myocardium is stretched, like a rubber band, the less effective the stretch is and the contraction becomes weaker and less effective.

13 Hypertension B/P is a measurement of force against the wall of the arteries When vessels stiffen due to calcium build-up (arteriosclerosis) and plaque develops (atherosclerosis), vessels are less compliant Higher pressures are needed to pump blood through stiffer vessels

14 Right Ventricular Failure
Failure of right ventricle as a forward pump Back pressure of blood into systemic venous circulation system Common causes Left ventricular failure (AMI) Systemic hypertension Pulmonary hypertension Cor pulmonale – heart disease due to pulmonary disease (ie; effects of COPD)

15 Progression of Right Heart Failure
Right ventricle cannot eject all of the blood out Fluid/pressure builds up In right atrium Backs up into the venous system Results in pedal/dependent edema  Visible as JVD

16 Right Sided Heart Failure - A Systemic Picture

17 Left Ventricular Failure
Failure of left ventricle to function as a forward pump Back pressure of blood into pulmonary circulation Often causes pulmonary edema Common causes Various types of heart disease Ischemia / acute MI Coronary artery disease (CAD)-arteriosclerosis/atherosclerosis Valve disease Chronic hypertension -  afterload Dysrhythmias

18 Progression of Left Ventricular Failure
Left ventricle cannot eject all the blood delivered from the right heart via the lungs Left atrial pressure rises and transmitted to pulmonary veins and capillaries These high pressures force blood plasma into alveoli (ie: pulmonary edema) Oxygen capacity of lungs reduced Hypoxia develops Acidosis develops MI is a common cause of left ventricular failure so assume all patients in pulmonary edema have had an MI.

19 Pulmonary Edema Severest form of congestive heart failure
Left ventricular forward failure Think left/lungs Patient develops respiratory distress due to fluid in the lungs Note: extremely rare to have unilateral pulmonary edema; then related to unusual pathology/med hx

20 Pathophysiological Changes in Pulmonary Edema
Left ventricle cannot empty effectively Fluid moves from capillary beds into surrounding interstitial tissue  alveoli Fluid in alveoli impedes oxygen exchange Surfactant lining alveoli washes out Alveoli stiffen Alveoli collapse after each breath and are harder to open Lungs develop  compliance, airflow obstruction, hyperinflation  to workload of breathing

21 Symptoms of CHF In the more chronic setting of right heart failure, symptoms usually related to excess fluids in organs and other body parts In the more acute left heart failure, symptoms usually related to excess fluid in the lungs and therefore respiratory distress

22 Signs and Symptoms Right Heart Failure
Dependent edema Peripheral edema Hepatomegaly Splenomegaly Jugular vein distension (JVD) Ascites Weight gain Dysrhythmias Nausea/vomiting Fatigue Dizziness Syncopal episodes Weakness Hepatomegaly – enlarged (engorged) liver Splenomegaly – enlarged spleen JVD – due to back up of blood from the right ventricle (can’t drain in, backs up) Ascites – excess fluid in the abdominal/peritoneal cavity

23 Signs and Symptoms Left Heart Failure
Shortness of breath Dyspnea Orthopnea Crackles Wheezing Hypoxia Respiratory acidosis Chest pain Sweating Productive cough Blood tinged sputum Cyanosis Palpitations Dysrhythmias Hypertension Anxiety/restlessness

24 Typical medical history pattern of patient with CHF
Hypertension Cardiovascular disease (CVD) Myocardial infarction (MI) Coronary artery disease (CAD) Arteriosclerosis Atherosclerosis Smoker Excessive alcohol or drug use Cocaine Methamphetamine Inhaled solvents PCP Dietary intake excess fluids, excess salt High cholesterol

25 Typical home medication history pattern of patient with CHF
Diuretic Digoxin  contractility force of the heart (inotropic) Home oxygen therapy Anti-hypertensive ACE inhibitors (end in “pril”) Beta blockers  heart rate & force of contractions  B/P Often end in “olol” Calcium channel inhibitors Slows movement of calcium into small muscles wrapped around blood vessels relaxing blood vessels  peripheral vascular resistance relaxing blood vessels Afterload – pressure heart has to pump against to push blood out of the left ventricle. Common beta blockers – atenolol (Tenormin), metoprolol (Lopressor, Toprol), nadolol (Corgard), propranolol (Inderal), and esmolol (Brevibloc). Common calcium channel inhibitors – amlopidine (Norvasc), diltiazem (Cardizem), isradipine (Dynacirc), nifedipine (Adalat, Procardia), and verapamil (Calan, Isoptin, Verelon). Common Ace inhibitors – benazepril (Lotensin), captopril (Capoten), enalapil (Vasotec), lisinopril (Prinivil, Zestril), quinapril (Accupril), and ramipril (Altace). ACE inhibitors – control blood pressure by relaxing smooth muscles wrapped around blood vessels and therefore decreasing blood pressure. Cardiac output is not affected. Example – Lisinopril, Enalapril, Captopril.

26 Herbal remedies that may be harmful when mixed with heart failure
St. John’s wort Ephedra Gingko biloba Kava Licorice Ginseng Aconite Alisma plantago Bearberry buchu Couch grass Dandelion Horsetail rush Juniper

27 Evaluation CHF/PE COPD History n/a Dyspnea Recent hx Cough Onset B/P
Pneumonia COPD History HTN, heart problems n/a Lung problems Dyspnea Orthopnea, PND Orthopnea possible Chronic; pursed lips Recent hx Acute weight gain, dependent edema Fever, malaise Gradual weight loss Cough Frothy sputum Productive thick green Chronic; productive Onset Rapid Gradual B/P High Normal Meds Dig, anti-HTN, diuretic Antibiotic, cold prep Bronchodilators, steroids Tx O2, NTG, lasix, MS O2, neb, fluids O2, neb HTN – hypertension PND – paroxysmal nocturnal dyspnea (becomes suddenly short of breath after lying flat for awhile during sleep) Orthopnea – dyspnea while lying flat

28 Separating Signs/Symptoms
CHF/PE Pneumonia COPD SOB Yes Cough Maybe Early a.m. Sputum Frothy pink Yellow/green Thick brown Fever No Skin Cold/clammy Hot/dry Normal or dusky Chest pain Possible Smoking hx Usually Wheezing Maybe; bilateral Maybe; same side as disease Usually, bilateral Crackles Yes; bilateral

29 A Note… “Old geezers don’t become new wheezers!”
COPD develops over a long period of time. If an elderly person does not have a history of COPD and they are suddenly wheezing, think a cardiac problem or pulmonary edema. Assume the worst, hope for the best

30 Patient Assessment - CHF
Acute findings Recent trouble sleeping  trips to the bathroom at night Orthopnea with  number of pillows Sleeping in the recliner New episodes of paroxysmal nocturnal dyspnea (PND)  use of nitroglycerin to stop chest pain  use of oxygen

31 Patient Assessment - CHF
General impression Labored respirations Audible noisy respirations Tripod positioning Frothy sputum production  work of breathing – retractions, tachypnea Wheezing/crackles bilaterally Diaphoretic Change in skin color from norm Severe anxiety/restlessness Severe hypertension may be present

32 Patient Assessment - CHF
Signs and symptoms pulmonary edema Tachypnea Orthopnea PND Noisy labored respirations Fine crackles/rales Wheezing – “cardiac asthma” Coarse crackles/rhonchi larger airways Coughing with frothy blood tinged sputum

33 Obtaining Breath Sounds
Use flat diaphragm surface of stethoscope Rub stethoscope head between hands to warm it up before placing on patient’s skin If audible sounds are heard, ask patient to cough gently to clear upper airway Auscultate side to side and top to bottom Anterior: Posterior:

34 Adventitious (Extra) Breath Sounds
Check for asymmetry Crackles: high pitched, continuous sounds like rubbing hair between fingers Wheezes: generally high pitched, of musical quality Stridor: Harsh inspiratory wheeze indicating upper airway obstruction Rhonchi: snoring or gurgling quality Any extra sound not a crackle or wheeze is usually rhonchi

35 Decision Making –What to Do?
Use critical thinking skills Decide if patient is sick or not Obtain current and past history Obtain vital signs Look Skin (wet/dry; color; temp) JVD present or not Peripheral / dependent edema present Subtle signs Listen Breath sounds

36 Making the Right Decision
Does the medical history include cardiovascular disease? Does the physical examination/patient assessment paint a picture of CHF? Use critical thinking skills Not treating pulmonary edema means the body becomes more hypoxic and acidotic Miss diagnosis (ie: pneumonia) could prove lethal This patient will arrest Once the patient in pulmonary edema arrests, the likelihood of a successful resuscitation is slim. The patient is hypoxic and acidotic and medications and treatments in this environment are not usually effective.

37 Treatment Goals for CHF
Decrease myocardial workload Decrease oxygen demand Decrease fluid retention Correct hypoxia Correct acidosis

38 Treating CHF/Pulmonary Edema
Decrease myocardial workload No physical activity (they don’t walk to the rig) Sitting the patient upright; dangle feet Administering oxygen – non-rebreather CPAP to increase oxygen absorption surface of lungs Medications to  preload and afterload Nitroglycerin Morphine Lasix – additionally works as diuretic Preload – amount of blood returning to the right side of the heart Afterload – pressure the left ventricle needs to pump against to pump/push blood out of the heart to the body

39 Treatment Goals for Pneumonia
Supply supplemental oxygen as needed Treat the bacterial infection Hydrate the patient Usually found in the elderly Often vague symptoms; use to feeling ill Immune system often already weakened so mortality rate is high with this diagnosis

40 Region X SOP- Acute Pulmonary Edema
Begin Routine Medical Care Take standard precautions Perform assessments Identify priority patient and make transport decisions Stay and play? Load N go? Perform routine tasks IV-O2-monitor Assessments include ABC’s; AVPU/GCS; VS/pain scale; determine patient weight; need for oxygen and if ventilatory assist is required; evaluation of cardiac monitor rhythm and obtaining 12 lead EKG (assume the patient in pulmonary edema is also experiencing an AMI); IV access for medications; blood glucose level if level of consciousness is altered; reassessment continually; early contact of Medical Control so they can prepare for the transport.

41 What About the IV and Nitroglycerin?
Region X Medical Directors discussion: Majority of patients in pulmonary edema will be hypertensive Nitroglycerin will help reduce preload which will lower blood pressure (beneficial) Do not delay NTG dose, if no contraindications, to start the IV If patient deteriorates before IV established, can always place an IO

42 Region X SOP- Acute Pulmonary Edema
Determine if the patient is stable or unstable Stability guided by status of perfusion B/P and level of consciousness If stable, the patient can receive more aggressive care including medications and procedures (ie: CPAP) If unstable, Medical Control needs to coordinate degree of care provided in the field (ie: meds and CPAP)

43 Region X SOP- Acute Pulmonary Edema - Stable
Nitroglycerin Nitrate vasodilator Decreases myocardial workload Dilates arterial and venous systems  preload  afterload Carefully monitor blood pressure Screen for concomitant use of sexual enhancement drug Viagra or Levitra in last 24 hours Cialis in past 48 hours

44 Stable Pulmonary Edema SOP
Lasix Loop diuretic Moves sodium (NA+) out of blood vessels Water follows sodium Potassium (K+) also pulled out Vasodilation effects within 5 minutes Decreases preload Diuresis within minutes Peaks within 30 minutes

45 Stable Pulmonary Edema SOP
Morphine sulfate Narcotic analgesic Reduces anxiety Dilates venous and arterial systems  preload  afterload  blood pressure Stimulates nausea center in the brain Slows respiratory rate in medulla

46 Region X SOP – Pulmonary Edema Medication Regimen
Stable patient Nitroglycerin 0.4 mg sl One every 3-5 minutes to max dose of 3 Begin CPAP Lasix 40 mg IVP (80 mg if taken at home) Morphine 2 mg IVP slow over 2 minutes May repeat 2 mg every 2 minutes to max of 10mg If wheezing, contact Medical Control for possible Albuterol neb treatment

47 CPAP Continuous positive airway pressure
Delivered throughout the respiratory cycle Noninvasive ventilatory support Most beneficial when initiated early Maintains airway in open position  intrathoracic pressure which  venous return to the heart Preload and afterload both decrease

48 Benefits of CPAP Increases amount of inspired oxygen
Decreases work load of breathing Reduces need for intubation Intubation requires ICCU stay Increased exposure to risks associated with complications due to intubation Increases overall hospital length of stay

49 Redistribution of extravascular lung water during use of CPAP
Without CPAP With CPAP


51 Indications for CPAP Patient in acute pulmonary edema with stable blood pressure Stable B/P = >100mmHg systolic FYI – with revised 2011 SOP’s, blood pressure levels will be shifting to systolic of 90 as a consistent guideline throughout the SOP’s

52 Contraindications for CPAP
Decreased or altered level of consciousness Inability of patient to protect their airway from aspiration Persistent nausea/vomiting Need for immediate intubation Hemodynamic instability (B/P<100) Note: B/P guideline will be changing to <90 with revised 2011 SOP Penetrating chest trauma

53 Medications Simultaneous With CPAP
Medications should be started NTG sl Then begin CPAP Then continue medication administration as indicated Lasix – 40mg or 80mg IVP Morphine – 2 mg IVP repeated every 2 min CPAP will buy time for the medications to work

54 CPAP works WITH medications in tandem
Did you know… It is not either / or (CPAP or meds) CPAP works WITH medications in tandem Lift the mask to continue administration of more NTG

55 CPAP Equipment Fixed whisper flow Connects to your oxygen source

56 O2 Tank Duration Approximate time at 30% FIO2 E tank 50 min.
D tank 30 min. E tank 50 min. M tank 253 min. H tank 508 min. *based on 50 psi output

57 CPAP Circuit Set-up Package includes: Mask Tubing Head strap
CPAP valve Air entrainment filter CPAP valve Filter

58 Most patients need a lot of coaching to initially tolerate the tight fitting mask

59 If The Patient is Wheezing
Contact Medical Control to consider an order for Albuterol via nebulizer Medical Control needs to give this physician’s order Contact ECRN on radio Needs to give the ED MD a report Obtains MD’s order Relays the response to EMS If Albuterol is given, monitor for cardiac side effects (ie: tachycardia)

60 In-line Albuterol Set-up with CPAP
Cut the CPAP corrugated tubing as close to patient as possible in smooth area of tubing Splice Albuterol kit T piece in-line Remove the mouthpiece and place the adaptor (used for in-line Albuterol) Connect adaptor to distal cut end of corrugated CPAP tubing Remove Albuterol corrugated tubing and connect proximal end of CPAP tubing to T piece of Albuterol Keep Albuterol cup upright Albuterol kit still needs to be hooked to O2 Will only be using the albuterol T piece and the medicine cup. Will need to add the adaptor found in the in-line albuterol kits.

61 CPAP With In-line Albuterol Set-up

62 Criteria to Discontinue CPAP
Development of hemodynamic instability B/P drops below 100 systolic Revised 2011 SOP B/P level will be 90 systolic Inability of patient to tolerate tight fitting mask Emergent need to intubate the patient

63 Patient Monitoring During Use of CPAP
Constant reassessment required: Patient tolerance Mental status Respiratory pattern Rate, depth, subjective feeling of improvement Blood pressure, pulse, SaO2, EKG rhythm Complications Gastric distension, nausea, vomiting

64 Monitoring Improvement With CPAP
It’s working when: Level of distress decreases Respiratory rate is returning toward normal Pulse oximetry (SaO2) increasing Pulse rate decreasing toward normal Decrease in use of accessory muscles Ability to speak in fuller sentences returning

65 Contacting Medical Control
Remember: Early communication with receiving hospital Hospital needs to get their regulator for oxygen source connection Usually not kept in each room

66 Documentation With CPAP
Assessment leading your general impression to a diagnosis of pulmonary edema CPAP level provided (10cmH2O) FiO2 provided (100%) SaO2 serial levels Vital signs over time Response to treatment Any adverse reactions noted

67 So, What’s Different About BiPAP?
Bi-level positive airway pressure Uses 2 levels of pressure Helps move more air into lungs without need to exhale against higher pressures CPAP is a larger & noisier machine Uses extra effort to exhale and can be tiring Both can be used for sleep apnea BiPAP easier on those with COPD and neuromuscular diseases

68 Case Scenarios Small Group and Large Group Discussions
Read the presentation Form a general impression Discuss treatment options Discuss what/how/when to reassess the patient Decide what treatment to continue or what adjustments need to be made Note: Additional questions are asked on ppt that can be discussed during group presentations.

69 Case Scenario #1 Dispatch: You are called to a 70 y/o man c/o breathing problems HPI: Increasing shortness of breath for day despite the use of inhalers PmHx: COPD, Hypertension, and Diabetes Medications: Albuterol Inhaler, Lasix, and Aspirin Allergies: Penicillin HPI: history present illness PmHx: past medical history

70 Case Scenario #1 Physical Exam: Thin white man on home oxygen breathing through pursed lips sitting in a tripod position Vital Signs: B/P 180/90; HR 120 sinus tachycardia; RR 30; SaO2 88%; LOC alert; airway patent Head & neck: Perioral cyanosis, no JVD Pulmonary: Lung auscultation reveals inspiratory and expiratory wheezes Extremities: Cyanotic, no pedal edema

71 Case Scenario #1 What is your general impression? COPD supported
Are assessment findings stronger for exacerbation of COPD or for acute pulmonary edema? COPD supported History Appearance Lung sounds What treatment is indicated?

72 Case Scenario #1 IV – O2, monitor Albuterol nebulizer started:
• 5 min Vital Signs: B/P 160/90; HR 130; RR 24; SaO2 92%, LOC Alert; lung sounds unchanged • 10 min Vital Signs: B/P 120/90; HR 120, RR, 24, SaO2 92%, LOC Alert; lung sounds less prominent wheezing; subjectively patient breathing easier

73 Case Scenario #2 Dispatch: 65 y/o woman c/o of shortness of breath
HPI: 1 week history of progressive dyspnea with exertion. Unable to lay down flat without shortness of breath, no chest pain or cough PmHx: Hypertension, Diabetes Medications: Lasix, Atenolol, and Glucaphage

74 Case Scenario #2 Physical Exam: 260 lb woman sitting in recliner.
Vital Signs: B/P 160/80; HR 140 sinus tachycardia; RR 30; SaO2 78%, LOC follows commands; airway patent Head & neck: Cyanosis, JVD present Pulmonary: Crackles in all lung fields Extremities: Cyanotic, 3+ pedal edema

75 Case Scenario #2 What is your general impression?
Are assessment findings stronger for exacerbation of COPD or for acute pulmonary edema? Pulmonary edema supported History Appearance Lung sounds What treatment is indicated?

76 Case Scenario #2 Need to move rapidly IV-O2-monitor
Minimize scene time as much as possible IV-O2-monitor Start nonrebreather until switched to CPAP Consider AMI so obtain 12 lead EKG Any contraindications to treatment? Nitroglycerin? CPAP? Lasix? Morphine? NO NO NO NO

77 Case Scenario #2 After CPAP started:
5 min Vital Signs: B/P 100/60; HR 100; RR 24; SaO2 84%; LOC: responds to verbal stimuli 10 min Vital Signs: B/P 60/40; HR 30; RR 6; SaO2 60%; LOC unresponsive

78 Case Scenario #2 What is your general impression now?
Patient is deteriorating What is your treatment now? CPAP needs to be discontinued Patient needs to be bagged and intubated One breath every 5-6 seconds before intubation One breath every 6-8 seconds after intubation Hold further repeats of medications used Consider need for dopamine infusion

79 Case Scenario #3 Documentation
Initial impression was acute pulmonary edema Based on physical assessment; history; recent hospitalization for CHF Treatment was routine medical care IV – O2 non-rebreather- monitor CPAP started after ordered by Medical Control 2 sets of vital signs documented Initial vital signs (B/P 170/98 – 92 – 32) Second reading at the hospital

80 Case Scenario #3 Comments Documented
Upon arrival patient found sitting upright, agitated, complaining of chest pain and difficulty breathing. Audible congested breathing standing next to patient. Unable to complete a full sentence. Bilateral pedal edema noted. Began oxygen via nonrebreather. IV started. Moved patient to ambulance. Medical Control contacted and ordered CPAP to be started. Patient becoming more agitated. After 5 minutes, SaO2 increasing. Patient stated breathing was becoming easier.

81 Case Scenario #3 Documentation cont’d
Patient transported sitting upright. Continued CPAP during entire call. Transported patient into ED on portable O2 with CPAP continued.

82 Case Scenario #3 Documentation cont’d
Pt contact: 0954 Depart scene: 1025 “Drugs” Oxygen - 15 l – non-rebreather 1001 – 0.9 NS 1000ml – TKO – IV 1005 – CPAP /oxygen – 15l – CPAP mask “`Cardiac rhythm” 0958 – sinus sinus

83 Case Scenario #3 Documentation Discussion
What went well? Recognized pulmonary edema CPAP used with positive patient response

84 Case Scenario #3 Documentation Discussion
What could be improved upon? Long on-scene time (0954 – mins) Delay in initiating O2 therapy – 5 minutes Waited for MC to order CPAP – 11 min delay No Medical Control direction needed to initiate No other meds given for pulmonary edema Only 2 sets of vital signs taken on a critical patient

85 Case Scenario #4 Dispatch: You are called to a 84 year-old female c/o breathing problems HPI: Running low grade fevers, not feeling well for 4 days PmHx: MI, Hypertension, TIA’s Medications: Plavix, Lasix, Lisinopril Allergies: Iodine, shellfish

86 Case Scenario #4 Physical Exam:
Vital Signs: B/P 142/80; HR 96 sinus rhythm; RR 28; SaO2 92%, LOC follows commands; airway patent Head & neck: Pale, no JVD Pulmonary: Crackles in right lower lung field Extremities: Pale, pedal pulses palpable

87 Case Scenario #4 What is your general impression?
Are assessment findings stronger for acute pulmonary edema or pneumonia? Pneumonia supported? History Appearance Lung sounds not so helpful What treatment is indicated?

88 Case Scenario #4 What is your treatment now? IV-O2-monitor Fluids
Faster than keep open but not a fluid challenge Diagnosis confirmed at the hospital with chest x-ray and labs

89 Case Scenario #4 Patients with pneumonia need fluids
Patients with congestive heart failure need fluid restrictions A wrong diagnosis and therefore wrong treatment approach could be harmful for both patients

90 Case Scenario #5 Dispatch: You are called to a home for a 78 year-old male with severe SOB HPI: Has been getting progressively SOB past 2 days; slept in recliner last night PmHx: MI x3; hypertension, diverticulitis, seizures Medications: Aspirin, Hydrodiuril, Verapamil, NTG PRN, Coumadin, Phenobarbital Allergies: none

91 Case Scenario #5 Physical Exam:
Vital Signs: B/P 172/96; HR 110 sinus tachycardia; RR 36; SaO2 88%, LOC follows commands; extremely anxious; airway patent Head & neck: JVD Pulmonary: Crackles mid way up lung fields bilaterally Extremities: Cyanotic, pedal edema palpable

92 Case Scenario #5 What is your general impression?
What is your treatment plan? Write a run report Include initial assessment Document treatment interventions indicated Document reassessment performed Discuss as a group what needs to be included



95 Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care: Principles and Practices. Brady Limmer, D., O’Keefe, M. Emergency Care, 10th Edition. Brady Region X SOP’s March 2007; Amended January 1, 2008. Variety internet websites for CPAP and pulmonary edema

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