Albuterol use while ruling out CHF vs Respitory complication

[ccmedoc]

Portly means rotund, fat, round in shape... it's an older descriptive term. I like that word!

Wendy

Yeah, I know. I was being facetious....Thanks for the hep though..

Its still funny :wink:

[jwraider]

Sorry guys was going off what I could remember in my head the call was about 4 weeks ago and I was an observer/doing emt skills as part of medic school (pre-internship to get 911 experience).

He was average weight to skinny not fat for sure. (or portly!) So if you are differentiating between emphysema and chronic bronchitis he appeared emphysema like. I can't remember his color or moisture level or temp sorry!

The audible "vocal sound" was a grunt I guess ... I don't know if thats the right adjective but it points to the right line of thinking.

I agree, get a better assessment done before treating , there were 6 people on scene so enough to have everything done fast.

Again sorry I don't remember his meds or exact Hx at this point other than the medic asking if he had "COPD"... The PT was asked about CP multiple times and admitted to having some on the way out to the ambulance which made things more complicated.

In my county nitro is often administered before IV access. For example on a CP call you'll see 02,a quick 12 lead/BP,then Nitro/aspirin and then transport where an IV is done and possibly morphine. I've only seen one IV on scene for routine ALS medical calls and that was the FD who had arrived 5 mins before us.

Anyone else have an idea of how long albuterol should take to have an effect or is it just too variable?? If thats the case what is the best onset time you've scene ?

[tniuqs]

Gee wraider, no need for an apology dude, your learning and looks like you are really applying yourself, kudos as this is only your 27th post so a great start, hey your senario made ME think !

The dang internet ate my first post and I forgot to incude this in the next try .... shame on squint!

The audible "vocal sound" was a grunt I guess ... I don't know if thats the right adjective but it points to the right line of thinking.

Perhaps the sounds you heard were an attempt at "Purse Lip" breathing, although we observe this grunting in the stressed infant and called "grunting respirations" we also observe this with the COPD card holding club members. It is an attempt to generate intrinsic or auto PEEP, aka positive end expiratory pressure" this increases pressure within the terminal alvolus, in an attempted to:

1- Drive O2 into the aveolar/ capillary membrane, it is an intrinsic manouver that overcomes the osmotic vs hydrostatic pressures (in CHF)

2- This expiratory pressure tends to hold the terminal airways open ( COPD) and allows for improved CO2 removal with the " decrease of elasticity " of those terminal bronchioles.

The Whole point of that CPAP machine in fact, quite please to hear you have that option, sounds as if you are working with a progressive provider.

3- Make mental note next call to observe accesory muscle usage as well, supraclavicular indrawing and intercostal indrawing, all signs that your patient is circling the drain and has pooped out, and may need to "chew" on plastic soon, ie the dreaded ETT for the COPDer, as most don't wean well off the Ventilator, non-invasive Positive Pressure Devices are staying off the tube for many these days.

cheers and happy oxygenating !

[tniuqs]

Argh: missed the allocated time for edit, I bet that AZCEP will add his comments regarding the use of nitro before a IV Line .... hmmm not in my hood.

[AZCEP]

Just to satisfy you tniuqs.

The "common" use of NTG prior to IV access is a good way to become complacent with doing something that carries a significant amount of risk. There are occasions when it happens, and it is reasonable to do so. Doing it as "routine", is fraught with problems.

If you are thinking through a scenario, and the NTG comes first while someone else is establishing your line so be it. I just wouldn't make a habit of the practice.

Grunting is a bit more active than pursed lips, in my experience. Typically if the patient is producing a grunt, they are trying very hard to prevent their distal bronchi/alveoli from collapsing. Pursed lips tend to not be quite as sick, and can be turned around fairly quickly. The description you give pushes me to think this patient was having a fluid problem rather than an obstructive one.

[tniuqs]

Just to satisfy you tniuqs.

WHAT ? :shock:

Thats all .... :twisted:

j/k :thumbright:

[john_boston]

I know it's an EMS stereotype and of course I do not know you one bit (so don't take this too personally), but I can't help but cringe at an EMT or paramedic spelling the word respiratory "respitory".

[MSDeltaFlt]

jwraider,

Having COPD Exacerbation and CHF at the same time is not that uncommon. Give a neb, or don't give a neb; it really boils down to the breath sounds. Not the audible sounds. You must put your stethescope on the patient and actually LISTEN. Listen to all lung fields: front, back and side. Listen for Rales. Where do you hear them? Where do they stop? Are there any Wheeze? Where? Musical wheeze? Coarse wheeze? Do you hear any Rhonchi? Where? How about any air exchange? Do you hear any? Or do you hear nothing but the crappy breath sounds forementioned?

If they're full of fluid, I'm not going to give a neb. Giving a neb in fluid filled lungs is an excersize in futility IMHO.

Hope this helps.