Pneumonia vs CHF
Posted 29 July 2007 - 04:34 AM
62yo male...as you guessed, a run I had recently...
CC: Shortness of Breath...
Hx: HTN; Recently underwent treatment for mild bronchitis.
HOPI: Pt relates waking up in the morning feeling just a little SOB, coughed, felt better and went about his day. Sitting down for dinner, he noticed that SOB had returned and had been getting progressively worse over the last 45-60 minutes. He denies any CP; but relates feeling "tight" across his chest.
Initial assessment/impressions: 62yo white male without hx of lung disease or cardiac hx outside his HTN. Pt is sitting upright on kitchen chair in a tripod position. His skin is pale, cool, and slightly diaphoretic. Sternocleidomastoid retractions noted. Pt is in severe respiratory distress. Central Cyanosis noted. Vitals: BP 182/106; HR 122 and regular; RR 28bpm and labored; SpO2 83% RA. Blood Glucose 152; Sinus Tach on monitor without ectopy or ST changes. Pt is normothermic. Lung sounds are markedly diminished to mid-lobe bilaterally. Very tight wheezes noted on inspiration/expiration. No pedal edema or JVD noted; Pt sleeps on two pillows a night normally for personal comfort.
Tx: 100% O2 via NRB; IVx2 (18g/20g in ACs); Cardiac Monitoring (6-lead EKG obtained) Continuous MedNeb (Albuterol x2 UD); 125mg SIVP Solu-Medrol. VS q5 minutes during emergent transport to ER. Calm reassurance as pt was very anxious.
Reassessment: BP 178/100; HR 118; RR 24...labored but cyanosis reduced significantly. SpO2 94% on 15lpm NRB. Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum. Air movement in lungs improved.
Field "diagnosis": Acute Respiratory distress secondary to pneumonia.
Now, on this run, the ER asked me why I gave Solu-Medrol when she clearly believed he was in CHF. I explained that he had no history of CHF or any pulmonary disease, just a recent bout of bronchitis which he got ATBs for. He had no pedal edema, JVD, or any other signs of CHF that you would expect. Last I checked, CHF is a secondary condition, rarely primary unless it is congenital. I really wanted to ask her why she believed it to be CHF. Did she draw a BNP level, get a CXR, or even listen to what I told her in my verbal report? But, I kept me yap shut and went about my merry way. 2 weeks later, I get pulled into the Chief's office concerning this run. That same RN wrote me up for giving the Solu-Medrol (and I did follow my protocol for acute respiratory distress). I explained to the chief my reasoning behind it and he agreed I did what protocol dictated for this pt and that it was appropriate.
Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt. My medical director reviewed that run and said that even if he was in CHF, the Solu-Medrol would not have hurt him. (BTW...he did have pneumonia, not CHF and was given Lasix anyway at the ER).
Posted 29 July 2007 - 04:47 AM
Given my limited experience and relative n00b status, i'd say your nurse was being a bit of a pratt :wink:
Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum.
pneumonia sounds good to me
Posted 29 July 2007 - 08:40 AM
I have a question, off topic but was just curious... for my own information. Why an IV in both AC's? Wasn't one enough? Just curious, still learning.
Posted 29 July 2007 - 10:14 AM
He described a serious patient presentation. I am willing to bet his line of thought, as has been mine on a few occassions, is get the IVs while you can. If the patient is this severe, place a second line in case the first one gets yanked out or occludes.
It is never fun trying to restart an IV once the patient has decided to get worse.
Now I will critique and say ACs are last choice for me, but in all fairness it may have been all the patient had or in a crunch for time it is always easier to hit the big fat vein winking at ya...
Posted 31 July 2007 - 03:11 AM
That was exactly my thinking...My thing is, if it's screams at me first and says "hey! Stick here!", then that's exactly where I'm gonna go...especially if they have the high potential to crump on me. I usually start IV's in the hands/forearms. Someone crumping on me or having the high possibility to, I always try to place more than one IV if I can. I'll be happy with one if that's all I can get.
As far as RNs not listening...'tis unfortunately true where I transport to. However, if the RN has a background in EMS, they tend to pay closer attention.
Thanks for the feedback!
btw...goofymedc8 is a SHE!! )
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