Presentation on theme: "The Patient with Heart Failure CPAP as an Intervention"— Presentation transcript:
1 The Patient with Heart Failure CPAP as an Intervention April 2011 CECondell Medical CenterEMS SystemSite Code #107200E -1211Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire DistrictReviewed/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’dIdentify 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’dDescribe 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 compromisedCardiac output unable to meet the demands of the body’s needsGenerally 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 diseaseHeart diseaseContributing factors to heart failureDiet - excess fluid or salt intakeHypertensionPulmonary embolismExcessive alcohol or drug usageProgression 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/organsFluid build-up causes congestion in the organs seen as edemaMay be brought on by diseased heart valves, hypertension, or some form of obstructive pulmonary diseaseOften a complication of AMIAMI – 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 pumpRight side of heart is a low pressure systemLeft 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 bloodPumps blood flow to the bodyRight side of heart less muscularPumps blood to the lungsDoes not need to be a very aggressive pump with a lot of force
12 Starling’s LawThe 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 outputWhen Starling’s Law fails, the patient is no longer able to compensateThe 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 HypertensionB/P is a measurement of force against the wall of the arteriesWhen vessels stiffen due to calcium build-up (arteriosclerosis) and plaque develops (atherosclerosis), vessels are less compliantHigher pressures are needed to pump blood through stiffer vessels
14 Right Ventricular Failure Failure of right ventricle as a forward pumpBack pressure of blood into systemic venous circulation systemCommon causesLeft ventricular failure (AMI)Systemic hypertensionPulmonary hypertensionCor 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 outFluid/pressure builds upIn right atriumBacks up into the venous systemResults in pedal/dependentedema Visible as JVD
17 Left Ventricular Failure Failure of left ventricle to function as a forward pumpBack pressure of blood into pulmonary circulationOften causes pulmonary edemaCommon causesVarious types of heart diseaseIschemia / acute MICoronary artery disease (CAD)-arteriosclerosis/atherosclerosisValve diseaseChronic hypertension - afterloadDysrhythmias
18 Progression of Left Ventricular Failure Left ventricle cannot eject all the blood delivered from the right heart via the lungsLeft atrial pressure rises and transmitted to pulmonary veins and capillariesThese high pressures force blood plasma into alveoli (ie: pulmonary edema)Oxygen capacity of lungs reducedHypoxia developsAcidosis developsMI 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 failureThink left/lungsPatient develops respiratory distress due to fluid in the lungsNote: extremely rare to have unilateral pulmonary edema; then related to unusual pathology/med hx
20 Pathophysiological Changes in Pulmonary Edema Left ventricle cannot empty effectivelyFluid moves from capillary beds into surrounding interstitial tissue alveoliFluid in alveoli impedes oxygen exchangeSurfactant lining alveoli washes outAlveoli stiffenAlveoli collapse after each breath and are harder to openLungs develop compliance, airflow obstruction, hyperinflation to workload of breathing
21 Symptoms of CHFIn the more chronic setting of right heart failure, symptoms usually related to excess fluids in organs and other body partsIn 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 edemaPeripheral edemaHepatomegalySplenomegalyJugular vein distension (JVD)AscitesWeight gainDysrhythmiasNausea/vomitingFatigueDizzinessSyncopal episodesWeaknessHepatomegaly – enlarged (engorged) liverSplenomegaly – enlarged spleenJVD – 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 breathDyspneaOrthopneaCracklesWheezingHypoxiaRespiratory acidosisChest painSweatingProductive coughBlood tinged sputumCyanosisPalpitationsDysrhythmiasHypertensionAnxiety/restlessness
24 Typical medical history pattern of patient with CHF HypertensionCardiovascular disease (CVD)Myocardial infarction (MI)Coronary artery disease (CAD)ArteriosclerosisAtherosclerosisSmokerExcessive alcohol or drug useCocaineMethamphetamineInhaled solventsPCPDietary intake excess fluids, excess saltHigh cholesterol
25 Typical home medication history pattern of patient with CHF DiureticDigoxin contractility force of the heart (inotropic)Home oxygen therapyAnti-hypertensiveACE inhibitors (end in “pril”)Beta blockers heart rate & force of contractions B/POften end in “olol”Calcium channel inhibitorsSlows movement of calcium into small muscles wrapped around blood vessels relaxing blood vessels peripheral vascular resistance relaxing blood vesselsAfterload – 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 wortEphedraGingko bilobaKavaLicoriceGinsengAconiteAlisma plantagoBearberry buchuCouch grassDandelionHorsetail rushJuniper
27 Evaluation CHF/PE COPD History n/a Dyspnea Recent hx Cough Onset B/P PneumoniaCOPDHistoryHTN, heart problemsn/aLung problemsDyspneaOrthopnea, PNDOrthopnea possibleChronic; pursed lipsRecent hxAcute weight gain, dependent edemaFever, malaiseGradual weight lossCoughFrothy sputumProductive thick greenChronic; productiveOnsetRapidGradualB/PHighNormalMedsDig, anti-HTN, diureticAntibiotic, cold prepBronchodilators, steroidsTxO2, NTG, lasix, MSO2, neb, fluidsO2, nebHTN – hypertensionPND – 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/PEPneumoniaCOPDSOBYesCoughMaybeEarly a.m.SputumFrothy pinkYellow/greenThick brownFeverNoSkinCold/clammyHot/dryNormal or duskyChest painPossibleSmoking hxUsuallyWheezingMaybe; bilateralMaybe; same side as diseaseUsually, bilateralCracklesYes; 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 findingsRecent trouble sleeping trips to the bathroom at nightOrthopnea with number of pillowsSleeping in the reclinerNew episodes of paroxysmal nocturnal dyspnea (PND) use of nitroglycerin to stop chest pain use of oxygen
31 Patient Assessment - CHF General impressionLabored respirationsAudible noisy respirationsTripod positioningFrothy sputum production work of breathing – retractions, tachypneaWheezing/crackles bilaterallyDiaphoreticChange in skin color from normSevere anxiety/restlessnessSevere hypertension may be present
33 Obtaining Breath Sounds Use flat diaphragm surface of stethoscopeRub stethoscope head between hands to warm it up before placing on patient’s skinIf audible sounds are heard, ask patient to cough gently to clear upper airwayAuscultate side to side and top to bottomAnterior: Posterior:
34 Adventitious (Extra) Breath Sounds Check for asymmetryCrackles: high pitched, continuous sounds like rubbing hair between fingersWheezes: generally high pitched, of musical qualityStridor: Harsh inspiratory wheeze indicating upper airway obstructionRhonchi: snoring or gurgling qualityAny extra sound not a crackle or wheeze is usually rhonchi
35 Decision Making –What to Do? Use critical thinking skillsDecide if patient is sick or notObtain current and past historyObtain vital signsLookSkin (wet/dry; color; temp)JVD present or notPeripheral / dependent edema presentSubtle signsListenBreath 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 skillsNot treating pulmonary edema means the body becomes more hypoxic and acidoticMiss diagnosis (ie: pneumonia) could prove lethalThis patient will arrestOnce 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.
38 Treating CHF/Pulmonary Edema Decrease myocardial workloadNo physical activity (they don’t walk to the rig)Sitting the patient upright; dangle feetAdministering oxygen – non-rebreatherCPAP to increase oxygen absorption surface of lungsMedications to preload and afterloadNitroglycerinMorphineLasix – additionally works as diureticPreload – amount of blood returning to the right side of the heartAfterload – 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 neededTreat the bacterial infectionHydrate the patientUsually found in the elderlyOften vague symptoms; use to feeling illImmune system often already weakened so mortality rate is high with this diagnosis
40 Region X SOP- Acute Pulmonary Edema Begin Routine Medical CareTake standard precautionsPerform assessmentsIdentify priority patient and make transport decisionsStay and play?Load N go?Perform routine tasksIV-O2-monitorAssessments 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 hypertensiveNitroglycerin will help reduce preload which will lower blood pressure (beneficial)Do not delay NTG dose, if no contraindications, to start the IVIf patient deteriorates before IV established, can always place an IO
42 Region X SOP- Acute Pulmonary Edema Determine if the patient is stable or unstableStability guided by status of perfusionB/P and level of consciousnessIf 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 NitroglycerinNitrate vasodilatorDecreases myocardial workloadDilates arterial and venous systems preload afterloadCarefully monitor blood pressureScreen for concomitant use of sexual enhancement drugViagra or Levitra in last 24 hoursCialis in past 48 hours
44 Stable Pulmonary Edema SOP LasixLoop diureticMoves sodium (NA+) out of blood vesselsWater follows sodiumPotassium (K+) also pulled outVasodilation effects within 5 minutesDecreases preloadDiuresis within minutesPeaks within 30 minutes
45 Stable Pulmonary Edema SOP Morphine sulfateNarcotic analgesicReduces anxietyDilates venous and arterial systems preload afterload blood pressureStimulates nausea center in the brainSlows respiratory rate in medulla
46 Region X SOP – Pulmonary Edema Medication Regimen Stable patientNitroglycerin 0.4 mg slOne every 3-5 minutes to max dose of 3Begin CPAPLasix 40 mg IVP (80 mg if taken at home)Morphine 2 mg IVP slow over 2 minutesMay repeat 2 mg every 2 minutes to max of 10mgIf wheezing, contact Medical Control for possible Albuterol neb treatment
47 CPAP Continuous positive airway pressure Delivered throughout the respiratory cycleNoninvasive ventilatory supportMost beneficial when initiated earlyMaintains airway in open position intrathoracic pressure which venous return to the heartPreload and afterload both decrease
48 Benefits of CPAP Increases amount of inspired oxygen Decreases work load of breathingReduces need for intubationIntubation requires ICCU stayIncreased exposure to risks associated with complications due to intubationIncreases overall hospital length of stay
49 Redistribution of extravascular lung water during use of CPAP Without CPAP With CPAP
51 Indications for CPAPPatient in acute pulmonary edema with stable blood pressureStable B/P = >100mmHg systolicFYI – 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 consciousnessInability of patient to protect their airway from aspirationPersistent nausea/vomitingNeed for immediate intubationHemodynamic instability (B/P<100)Note: B/P guideline will be changing to <90 with revised 2011 SOPPenetrating chest trauma
53 Medications Simultaneous With CPAP Medications should be startedNTG slThen begin CPAPThen continue medication administration as indicatedLasix – 40mg or 80mg IVPMorphine – 2 mg IVP repeated every 2 minCPAP 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 tandemLift the mask to continue administration of more NTG
55 CPAP EquipmentFixed whisper flowConnects 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
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 nebulizerMedical Control needs to give this physician’s orderContact ECRN on radioNeeds to give the ED MD a reportObtains MD’s orderRelays the response to EMSIf 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 tubingSplice Albuterol kit T piece in-lineRemove the mouthpiece and place the adaptor (used for in-line Albuterol)Connect adaptor to distal cut end of corrugated CPAP tubingRemove Albuterol corrugated tubing and connect proximal end of CPAP tubing to T piece of AlbuterolKeep Albuterol cup uprightAlbuterol kit still needs to be hooked to O2Will only be using the albuterol T piece and the medicine cup. Will need to add the adaptor found in the in-line albuterol kits.
62 Criteria to Discontinue CPAP Development of hemodynamic instabilityB/P drops below 100 systolicRevised 2011 SOP B/P level will be 90 systolicInability of patient to tolerate tight fitting maskEmergent need to intubate the patient
63 Patient Monitoring During Use of CPAP Constant reassessment required:Patient toleranceMental statusRespiratory patternRate, depth, subjective feeling of improvementBlood pressure, pulse, SaO2, EKG rhythmComplicationsGastric distension, nausea, vomiting
64 Monitoring Improvement With CPAP It’s working when:Level of distress decreasesRespiratory rate is returning toward normalPulse oximetry (SaO2) increasingPulse rate decreasing toward normalDecrease in use of accessory musclesAbility to speak in fuller sentences returning
65 Contacting Medical Control Remember:Early communication with receiving hospitalHospital needs to get their regulator for oxygen source connectionUsually not kept in each room
66 Documentation With CPAP Assessment leading your general impression to a diagnosis of pulmonary edemaCPAP level provided (10cmH2O)FiO2 provided (100%)SaO2 serial levelsVital signs over timeResponse to treatmentAny adverse reactions noted
67 So, What’s Different About BiPAP? Bi-level positive airway pressureUses 2 levels of pressureHelps move more air into lungs without need to exhale against higher pressuresCPAP is a larger & noisier machineUses extra effort to exhale and can be tiringBoth can be used for sleep apneaBiPAP easier on those with COPD and neuromuscular diseases
68 Case Scenarios Small Group and Large Group Discussions Read the presentationForm a general impressionDiscuss treatment optionsDiscuss what/how/when to reassess the patientDecide what treatment to continue or what adjustments need to be madeNote: Additional questions are asked on ppt that can be discussed during group presentations.
69 Case Scenario #1Dispatch: You are called to a 70 y/o man c/o breathing problemsHPI: Increasing shortness of breath for day despite the use of inhalersPmHx: COPD, Hypertension, and DiabetesMedications: Albuterol Inhaler, Lasix, and AspirinAllergies: PenicillinHPI: history present illnessPmHx: past medical history
70 Case Scenario #1Physical Exam: Thin white man on home oxygen breathing through pursed lips sitting in a tripod positionVital Signs: B/P 180/90; HR 120 sinus tachycardia; RR 30; SaO2 88%; LOC alert; airway patentHead & neck: Perioral cyanosis, no JVDPulmonary: Lung auscultation reveals inspiratory and expiratory wheezesExtremities: 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 supportedHistoryAppearanceLung soundsWhat 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 coughPmHx: Hypertension, DiabetesMedications: 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 patentHead & neck: Cyanosis, JVD presentPulmonary: Crackles in all lung fieldsExtremities: 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 supportedHistoryAppearanceLung soundsWhat treatment is indicated?
76 Case Scenario #2 Need to move rapidly IV-O2-monitor Minimize scene time as much as possibleIV-O2-monitorStart nonrebreather until switched to CPAPConsider AMI so obtain 12 lead EKGAny contraindications to treatment?Nitroglycerin?CPAP?Lasix?Morphine?NONONONO
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 stimuli10 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 deterioratingWhat is your treatment now?CPAP needs to be discontinuedPatient needs to be bagged and intubatedOne breath every 5-6 seconds before intubationOne breath every 6-8 seconds after intubationHold further repeats of medications usedConsider need for dopamine infusion
79 Case Scenario #3 Documentation Initial impression was acute pulmonary edemaBased on physical assessment; history; recent hospitalization for CHFTreatment was routine medical careIV – O2 non-rebreather- monitorCPAP started after ordered by Medical Control2 sets of vital signs documentedInitial 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.
83 Case Scenario #3 Documentation Discussion What went well?Recognized pulmonary edemaCPAP 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 minutesWaited for MC to order CPAP – 11 min delayNo Medical Control direction needed to initiateNo other meds given for pulmonary edemaOnly 2 sets of vital signs taken on a critical patient
85 Case Scenario #4Dispatch: You are called to a 84 year-old female c/o breathing problemsHPI: Running low grade fevers, not feeling well for 4 daysPmHx: MI, Hypertension, TIA’sMedications: Plavix, Lasix, LisinoprilAllergies: 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 patentHead & neck: Pale, no JVDPulmonary: Crackles in right lower lung fieldExtremities: 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?HistoryAppearanceLung sounds not so helpfulWhat treatment is indicated?
88 Case Scenario #4 What is your treatment now? IV-O2-monitor Fluids Faster than keep open but not a fluid challengeDiagnosis 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 restrictionsA wrong diagnosis and therefore wrong treatment approach could be harmful for both patients
90 Case Scenario #5Dispatch: You are called to a home for a 78 year-old male with severe SOBHPI: Has been getting progressively SOB past 2 days; slept in recliner last nightPmHx: MI x3; hypertension, diverticulitis, seizuresMedications: Aspirin, Hydrodiuril, Verapamil, NTG PRN, Coumadin, PhenobarbitalAllergies: 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 patentHead & neck: JVDPulmonary: Crackles mid way up lung fields bilaterallyExtremities: Cyanotic, pedal edema palpable
92 Case Scenario #5 What is your general impression? What is your treatment plan?Write a run reportInclude initial assessmentDocument treatment interventions indicatedDocument reassessment performedDiscuss as a group what needs to be included
95 BibliographyBledsoe, B., Porter, R., Cherry, R. Paramedic Care: Principles and Practices. BradyLimmer, D., O’Keefe, M. Emergency Care, 10th Edition. BradyRegion X SOP’s March 2007; Amended January 1, 2008.Variety internet websites for CPAP and pulmonary edema