Right-side heart failure.

[Ridryder 911]

I agree he needs to breathe, however one needs to understand V/Q. For the patient to breath we have to treat the etiology of the problem.. fluid and start diuresis as soon as possible. CPAP works great, if the patient is not worn out or there is not an obstruction problem Again, CPAP can usually only be used in the first few minutes when the shift from right to left side. Intubation, with PEEP and continuation of diuresis with nitrate or even a low dose of Dopamine to increase renal perfusion and messenteric dilation.

Be safe,

R/R 911

[zumjus]

I agree 100% with the diuresis and nitro. Intubation . . . yes in extreme cases. You are right CPAP is good for a starter (at the begining) but then BiPAP after that. The Docs around here have the thought, and I agree, that if we have to intubate these pts. then we have already gotten behind the game. Don't get me wrong, I do agree with intubation with PEEP, but only if the other less invasive strategies don't work, or the pt. is too far along. Of course if the pt. was too worn out for the CPAP, then we would intubate, but I've seen some pretty tired pts. get immediate relief from CPAP and get their "strength" back to breathe. Unfortunately the scenario presented was not that detailed as to how tired the pt. was or anything like that.

"we have to treat the etiology of the problem.." of course we do. I would hope we ALWAYS try to do that. Unfortunately pre-hospital we are limited in what we can do. Sometimes you have to treat the s/s first before you can move onto the etiology. A lot of time we can only treat the results of the disease process so that the hospital doesn't have to worry about that and start with actually treating the core of the problem. But that's another discussion not relevant to this posting.

[Doczilla]

Not having used hypertonic solution solution, my question is what type of effects does it have on the kidneys, and would this be a reason not to use it?

Hypertonic saline will draw water into the vascular container, expanding circulating volume and worsening the fluid overload on the heart. For this reason, CHF patients often find themselves in trouble if they do not watch their salt intake. Some just can't resist that piece of ham. Renal insufficiency or renal failure compounds this problem, since these patients cannot get rid of excess volume or excess salt easily. CHF and renal insufficiency/failure often go hand in hand. Renal failure patients in acute CHF pose a particular problem for prehospital and ER providers since you can't really remove the fluid. You can reduce preload with nitrates and improve pump function with dobutamine or dopamine, but dialysis is the only way to get the fluid off.

There are a handful of absolute indications for dialysis:

1) electrolyte disturbance that is severe and/or refractory to treatment

2) metabolic acidosis/alkalosis that is severe and/or refractory to treatment

3) fluid overload that is refractory to treatment

4) BUN >90

5) Poisoning with certain substances, such as aspirin, methanol, or ethylene glycol

Low doses of dopamine (the "renal dose" of 2mcg/kg/min) hasn't been shown to do much to improve outcome, so it's a practice that has fallen out of favor. There are some old school docs who still cling to it, but their numbers are dwindling.

Good kidneys are very forgiving of salt intake. A young otherwise healthy person's BP doesn't usually flutuate too much even with large salt loads taken orally (mmmmm.... canned soup). At first, the kidney senses the increased salt concentration. Thinking that you're dehydrated, it retains more water expanding the blood volume. This increases the pressure on the kidney and flow through the glomerulus, increasing filtration, dumping the excess volume. The volume will normalize within hours, and when combined with the compensating effects of vasoconstriction/dilation and pump variability, the BP doesn't move too much. In a person with hypertension, atherosclerosis, or preexisting heart disease, the vessels can't compensate for the increased volume, and hypertension and/or CHF results.

'zilla

[kevkei]

I think someone needs to review the pathophysiology of RHF.

[Ace844]

I think someone needs to review the pathophysiology of RHF.

I second that, and will add and request you read the "teaching point's" threads on Respiratory physiology, Heart Failure and cardio phys as well as the other threads here, next after that kindly buy or borrow Lilly's Pathophysiology of heart disease. After that, then come back and re-debate your point, though I strongly suspect you'll have found your wrong and agree with us...

Hope this helps,

ACE844

[zumjus]

You all crack me up. 8)

[spgmedic]

Did this PT have COPD? If not I would have tried CPAP for the SOB and try to move some of that fluid out.

[zumjus]

You can use CPAP for SOB on COPD pt's too. CPAP would be highly recommended. Rule of thumb is that is your interventions aren't working, then go for the CPAP.

[spgmedic]

You have to be careful with COPD

[Ridryder 911]

Can you say BLEB ?!

R/R 911