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Pneumonia vs CHF

Posted · Report post

Okay...my turn...

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).

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Posted · Report post

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.

Given my limited experience and relative n00b status, i'd say your nurse was being a bit of a pratt :wink:

pneumonia sounds good to me

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Posted · Report post

I would say she evidently didn't listen to your report. I find that happens often, they get them and want to assess them without even listening most times. They hear the CC and do what they want when the patient gets there. ONLY good nurses listen to what has been done and will ask why and with good reasoning, will accept what has been done, and go on with their treatment of the patient.

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.

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Posted · Report post

Jeni,

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...

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Posted · Report post

AK...

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!! :o)

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Posted · Report post

To be honest, I would be highly suspicious about possible CHF with this patient as well. I have seen lots of CHFers present with lungs FULL of fluid but lacking in clinical findings like JVD and distal edema. The two do not necessarily always show up together.

-Hypertension is another warning sign for CHF, as well as "full" sounding lungs with wheezing at the top. That is very common. Rhonchi and rales are notoriously difficult to tell apart and lots of people - even doctors - get this part wrong with amazing consistency.

-Sleeping on extra pillows at night is another finding typical for CHFers, as it minimizes areas of the lung obstructed by fluid. At the same time, this would be atypical for pneumonia patients, as mucus is more viscous and will generally remain where it is regardless of body position.

-The SOB sounds like it was more of a rapid onset. This seems to suggest CHF more than pneumonia, as lungs can fill up quickly, but pulmonary infections take some time to build up.

-The patient's skin was cool. I know it is not an exact thing, but pneumonia sufferers are often hyperthermic.

The cough may have been a red herring, but who knows. Perhaps he had a little bit of both going on.

This is a tough one. It really is hard to second guess something like this without seeing the patient, hearing the lung sounds, looking at the 12 lead, etc (do you have the 12 by the way?). Like I said though, I would be VERY suspicious about failure in this patient with all of the findings you've listed above. It seems - just from what you've written - that there may be more "pro CHF" stuff than "pro pneumonia" stuff.

I dont think you did anything wrong, but I'd be interested to hear a little more of your defense as to why the seemingly CHF-sounding factors didn't sway you from your pneumonia diagnosis.

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Posted · Report post

Fiznat wrote:

I dont think you did anything wrong, but I'd be interested to hear a little more of your defense as to why the seemingly CHF-sounding factors didn't sway you from your pneumonia diagnosis.

I agree. It sounds like classic CHF to me. What besides the productive cough, pushed you to pneumonia? Everything else seems to point to CHF.

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Posted · Report post

My defense for thinking pneumonia...He had NO JVD; NO pedal edema; had NO complaints of orthopnea; Has recently finished ATB treatment for bronchitis; and has absolutely NO hx of COPD, Asthma, or any pulmonary disease; CHF; or Heart problems outside of HTN. I pretty sure he had no flash pulmonary edema because his sputum was green/yellow/brownish and not frothy pink in nature. And from the last few flash pulmonary edema peeps I had, NONE of my treatments helped and we don't carry CPAP (yet). I can't really justify treating this pt for CHF without the hx. Please correct me if I'm wrong, but unless there is a congenital cardiac problem, CHF is USUALLY a secondary condition.

Again, as always, I am open to thoughts and constructive critiquing.

:o

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Posted · Report post

Okay, just to make a few points. I'm not criticizing you, just commenting on the call and offering another opinion-- which is why I assume you posted in the first place.

-JVD and distal edema are not ALWAYS present. Their absence does not rule out CHF

-Sleeping with extra pillows is suggestive of orthopnea, even if the guy didnt specifically say it

-CHF does not depend on a history of any kind of pulmonary disease

-A lack of stated heart history does not mean that there wasn't some underline borderline failure going on. He does not need to be actually diagnosed with cardiac insufficiency before CHF becomes a possibility that you need to consider. I would ALWAYS consider CHF, "heart history" or not. Especially with this presentation.

-The color of sputum isn't very valuable, in my opinion, for diagnosis between CHF and pneumonia. ...And even still, you said yourself that he had a hx of bronchitis. What if the sputum is still some of that, while the primary problem remains CHF?

-Your recent experience with "the last few" patients who had pulmonary edema isnt very valuable, either, as far as to the worthiness of CHF treatments. This is a terrible argument. Nitro and CPAP work awesome for pulmonary edema in general. ...Just because it didnt work for your last few patients doesn't mean you shouldn't try it now.

-History isn't everything. It is true that CHF arises out of a backdrop of cardiac failure, but just because this guy hasnt actually gone to the doctor and received a diagnosis doesn't mean that it is impossible for the condition to still exist. There are plenty of people who have undiagnosed cardiac insufficiency, people who dont go to the doctor often or simply havn't gone recently. You need to go by your assessment, not by the previous assessments of other doctors. In the face of the rest of this guy's presentation, a lack of history is not enough to rule out CHF.

Just some things to think about. Like I said, I didn't see the patient though.

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Posted · Report post

Fiz,

Whilst I agree it's difficult to diagnose without seeing a pt yourself, I do think that you've made a number of subjective conclusions that are, at best, tenuous. No, JVD and distal edema aren't always present, but 9 times out of ten they are, to a greater or lesser degree present. I aslo think that History is a very important diagnostic tool in this case. It's one of the few ways that one can distinguish CHF from obstructive pulmonary disease - it's a question of asking the right questions, in my experience.

There are no absolutes in emergency medicine (or in medicine, generally) and that why it's part science and part art. Therein lies the challenge that I enjoy taking up every day. I think our colleaugue in this case used good judgement and sound clinical reasoning. That there are always exceptions to the rule is fine, but don't lose sight of the ball for the 90% that present with text-book symptoms.

WM

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Posted · Report post

Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt.

I believe the nurse was grilling you due to one of the side effects of solu-medrol being sodium/fluid retention. I also believe that the Methylprednisolone treatment, given the respiratory distress with this symptomology, was correct. The immediate effects would be beneficial and the sodium/water retention could be addressed with Furosemide, which you alluded to in your post, and observation. This patient would most likely me admitted after this episode anyway...The nurse had no right to question your differential Dx or treatment, as your responsibility is to the patient. The physicians on shift ultimately dictate your treatments, not the nurses. Any question of treatment should come from the doctor as she has no more of a right to diagnose than you do as a medic.IMHO...

She's gettin a little big for her britches... :o

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Fiznat...

I'm sorry if my last post seemed a bit sharp, which is not my intent at all...I read your post and did take it to heart. It certainly bids a re-look on my part to make certain my understanding of the pathos is as it should be. I never EVER take offense to constructive critiquing, which you were kind enough to give. Another perspective on a call like this can only serve to broaden my own understanding of the pathos of these patients.

Again Fiz...THANKS!!

:D

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haha hey man dont worry about it at all. I've taken my fair share of grilling here as well-- I understand how ya feel. As long as in the end we all learn something and nobody's feathers get *too* ruffled. :wink:

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I think this nurse should mind her own business. Until she learns to read an x-ray or give medications independent of direct verbal order, she can take her (incorrect, by the way) Monday-morning-quarterbacking and shove it someplace that can't be reached by a tube.

The patient had bronchospasm as evidenced by wheezes. This is caused by an inflammatory process, whether by asthma, COPD, RAD, pneumonia, or fluid overload. A single dose of solu-medrol in this patient who is critically ill will not do any appreciable harm, or at least the risks are far outweighed by the potential benefits to this imminently deteriorating state.

This nurse has quite a bit of gall to write you up and question your field treatment of CHF, particularly when the patient didn't have CHF. Staffing must be pretty good at that hospital if she's got time to jump your s&it AND write you up with your supervisor.

Punt this to the medical director. He or your supervisor should get into contact with the hospital's EMS coordinator on this.

'zilla

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The patient had bronchospasm as evidenced by wheezes. This is caused by an inflammatory process, whether by asthma, COPD, RAD, pneumonia, or fluid overload. A single dose of solu-medrol in this patient who is critically ill will not do any appreciable harm, or at least the risks are far outweighed by the potential benefits to this imminently deteriorating state.

I agree with you that the nurse needs to back off. ...But about this inflammatory process, I would like to clarify.

Correct me if I am wrong of course, but I didnt think that wheezing in CHF is related to an inflammatory process. I was sure that the so-called "cardiac wheeze" is different from other wheezes in that it comes from partial fluid obstructions rather than bronchospasm and inflammation.

Assuming that this was CHF (which may or may not be true), then wouldn't it be advisable to allow routine CHF treatments to work before we go after an inflammatory pathology? Solu-Medrol takes quite a while to work in the body IIRC, while nitrates, loop diuretics, CPAP, broncodialators, etc work fairly quickly. Why not give them a shot first and see...

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Correct me if I am wrong of course, but I didnt think that wheezing in CHF is related to an inflammatory process. I was sure that the so-called "cardiac wheeze" is different from other wheezes in that it comes from partial fluid obstructions rather than bronchospasm and inflammation.

Assuming that this was CHF (which may or may not be true), then wouldn't it be advisable to allow routine CHF treatments to work before we go after an inflammatory pathology? Solu-Medrol takes quite a while to work in the body IIRC, while nitrates, loop diuretics, CPAP, broncodialators, etc work fairly quickly

In the assessment it was stated that there was no pedal edema or JVD appreciated. If this patient had a long progression of the difficulty in breathing, a CHF pt. would most likely present with a fair amount of dependant edema, and most probably have some periorbital edema to show. Without a CXR and other diagnostics it would be, and was, prudent to follow the assessment and think some inflammatory etiology was present. As Doczilla pointed out, one dose of steroids will not do appreciable harm to this critical pt, and most likely will help. Risk vs. benefit ...benefit in this circumstance. Fluid in the airways will cause an inflammation in and of itself. The symptomology of the progression, cough, no edema, sleeping throughout the night, episodic nature of the dyspnea, no cardiac history and history of recent bronchial infection all strongly support an inflammatory process leading to any fluid in the airways, not the reverse (fluid leading to inflammation). The big picture says non-cardiogenic, the treatment was accurate and prudent given the circumstances, I believe....

Again I go back to discarding any and all comments given you by this arrogant nurse...Maybe she is in need of some remedial training in regards to respiratory ailments?? Not the best example of nurse professionalism..I'm embarrassed for her!! :oops:

.

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I agree with your treatment given the patient's history & physical exam. If she had CHF I would expect her to have some edema. Plus given the fact that her sputum is a greenish or yellowish color.

I don't think the nurse was right to question your assessment or treatment... What made her think that it was CHF? Did she do a Basic Metabolic Panel, Chest X-Ray, Ecg or Pro-BNP?

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Full respects to nurses but it seems it's always easier for them to make a judgement on what is going on when they are sitting in their cushy hospital. I can almost guarantee you it would have been a lot different if she had been on there on scene with you.

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When a nurse disagrees with something I've done for the patient, I usually ask why. If she seems like she'd take my question as confrontational, I'll add "so I know next time". The conversation that follows usually leads to a finding a miscommunication earlier in the report and it works out OR I learn something new and know for next time OR it ends up being a problem with a protocol I had to follow and not an actual mistake. But at least next time you come in, they at least (hopefully) remember you're not a moron even if you make mistakes and are interested in patient discussions.

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Posted · Report post

With any pneumonia you want to be cautious about using immunosuppressive doses of glucocorticoids/corticosteroids.

Was the pt. febrile?

I agree with the above posts also in regards to open communication, however sometimes nurses or other paramedics are not as receptive to the other side of the story as one would think.

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Was the pt. febrile?

I dont think he was. Read in the original post, she stated the pt was normothermic..

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Ah, Thank you. Sounds like a tough call on the decision then.

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