27 replies to this topic

[J306]

I had a scenario the past week involving an exacerbation of emphysema which I decided to treat with Nebulized Ventolin through the CPAP mask along with Solumedrol. My instructor decided to introduce a new onset of Angina with Ishemic changes in leads II, III and aVF.

He asked me how I would treat the new onset of symptoms to which I replied I would administer 2.5mg of Morphine SIVP. He challeneged me to consider the administration of ASA and Nitro which would require me to remove the CPAP device.. I stood behind my decision to keep the CPAP device on my patient as the COPD exacerbation was the primary complaint, and there's also a risk to the patient in removing the mask once it is applied, and the angina is secondary and can be relived by the morphine.

Just curious as to what some other opinions of this would be?

Administration*

[chbare]

With elevation in said leads, you had best do additional investigating before giving preload reducing agents such as nitroglycerine. Aspirin is absolutely needed assuming no contraindications.

[J306]

Yes, absolutley would be cautious in administering nitro to a patient with inferior wall ishemia, I would have done a right sided 12-lead to get some additional views prior.. I did not give ASA because of the risk/benefit of removing the CPAP device. To be completely honest, I don't really know if it is common practice to temporarly remove the mask to give oral medications.

[chbare]

In the case of Aspirin, it's one of the only interventions available to us that actually decreases morbidity/mortality in these kinds of patients, so I think you could put up a strong argument for ASA use.

[paramedicmike]

To add to what CHBARE said, not only is ASA one of the only medications available to us to reduce morbitity and mortality, but there is some evidence to suggest that morphine makes it worse. Taking care of the pain does not end the ischemia, which is how I read your comment about angina being relieved by morphine. Morphine relieves the pain. It does not stop the damage.

Good question.

[Arctickat]

Steph asked me this too. My response was that CPAP won't be removed long enough to cause any complications when one considers the benefits from the medication.

[J306]

Yeah, I could see it being argued both ways; however, I've read that ASA has its peak effects in 6 hours which makes the immediate administration of it go down on my priority list when contrasted with removing CPAP and introducing an oral medication to a patient who is a minutes away from crashing without the CPAP.

[Arctickat]

hmmm. you sure about that peak time. Don't forget that onset is also important. Also. why do you need the CPAP in the first place? Could the respiratory problem be carcinogenic?

[J306]

Sorry, duration can be up to 6 hours, peak effects 15-120 minutes and onset 5-30 minutes.

Patient had perioral/peripheral cyanosis with R.R at 32 and 02 sats of 77%. I first started my patient on an NRB at 15lpm while auscaltating lung sounds which revealed wheezes in upper lobes with decreased to bases bilat, and no acoustic shadow or bloody sputum indicating mastocytoma/metastatic lung CA. Still quite possible though, the patient was 65 and a pack a day smoker. The patient didn't improve on 15lpm, and has history of COPD, home 02 x 5 years, I selected CPAP to try and increase the traction of the airways and decrease airway resistance by delivering 5mg ventolin through the CPAP nebulizer attachment.

Another reason I went with with CPAP is because if my patient did end up crashing and needed to be intubated, from what I've seen it is very hard to ween COPD patients off of the vent once they've been tubed.

[Curiosity]

I asked a resp tech the question about removing cpap to administer oral meds. She said they do it all the time to administer nitro to CHFers. I was told the short amount of time it takes to do this won't harm them.