Dyspnea

[Bieber]

He can survive where he's at now for quite a while if he doesn't fatigue. I would hold off intubation if I think that he has the strength for it. Maybe chbare can chime in here as I can't really back up my belief that if I intubate him I've really retarded his chances of leaving the hospital as intact as before this crisis.

I'm not nearly so concerned with adding an infection to an infection as the hospital is probably going to hose him down in IV antibiotics, but instead maintaining him and then trying to wean him from the vent.

And I wouldn't trial the CPAP first, but possibly concurrently. It will help his issues as they are, but isn't likely, to my understanding, do anything to retard the bronchoconstriction that's being signaled by the wheezing, and I'm moving forward under the assumption that that's what's trying to kill him.

I like your thought process on this one, Dwayne.

I'm going to deliver the Mag Sulphate. Let put 2g in a 100 or 250 cc bag of saline and set it to run in the first half over the next 5 mins, and the second half over the next 10 mins and see what happens.

You got it. It's being given IO. We'll give it a little bit to work its magic.

With the newly developing wheezes I'm more confident with the mag, though it seems like there's something that I'm missing there. (but going to try and play it real. In this patient, with the information in my head, this is my decision.) Plus I wonder if we won't see some benefit for the run of tachycardia that we saw earlier?

Patient's still throwing frequent PVC's but he hasn't developed any more long strings of tachycardia--for now.

So, that's my decision. CPAP, O2 titrated to 95% SPO2, Mag 2g to start, over 10+ minutes, though may increase this if his pressure holds and it seems to be giving me a decent return on my investment. Also, I'm going to go ahead and push the steroids.

You got it man. Does everyone else like the sound of this or does anyone want to try something different? Kiwi? Are you still wanting to go for the tube or do you like Dwayne's treatment plan?

You can easily administer inline nebulised medications using CPAP or BiPAP. This works with both the older Vision's and the newer V60 machines. Do we have an ABG and a chest x-ray? We can place an IO if IV access continues to be unsuccessful.

Huh. I'm not sure if our CPAP devices permit that (I'm guessing they probably do and I'm just too retarded to figure it out)--so I'll have to double check. No ABG or chest X-ray.

You got your IO.

I'm considering that the acute onset of SOB is primary a cardiovascular problem which has exasperated the patients COPD causing pulmonary edema, decreased air entry and wheezes.

Not a bad thing to consider. What does everyone else think? Is everyone set on this being a COPD exacerbation or are we still considering something else like CHF?

Nobody has mentioned the episode of paroxysmal supraventricular tachycardia the patient experienced which may be caused by a congenital heart defect such as Wolff-Parkinson-White syndrome. What also makes me think cardiac is because the patient's blood pressure is hypertensive which could indicate left ventricular dysfunction.

Does everyone agree with J306's interpretation of the episode of tachycardia? Does anyone think it's anything else?

So, I am curious, is this a true call Bieber? If so, we you able to do capnography (I ask because I see an EKG, yet no capnography though you indicate it as being shark fin like). Did you actually use percussion?

Yep. This is an actual call I ran just recently. Unfortunately, our capnography only works in conjunction to our ET tubes and combitubes, so I didn't have access to it on the call. After we're all done, I'll share with you guys what my impression and treatment was.

A patient presents with a medical history of both COPD and Congestive Heart Failure. It was mentioned that he does not have peripheral edema, which its absence is not an indicator that the problem is not pulmonary edema, as there are many causes. Since the patient presents with nocturnal dyspnea, his blood pressure is high, JVD present, I just get the feeling that that there is a pulmonary edema component. Now, I know it is not much evidence for pulmonary edema, yet I get the feel that it is. Actually, I really think that it could be a combination of both problems. Though, I do lean towards the pulmonary edema.

Awesome point about the lack of peripheral edema. There's still the possibility that this could be pulmonary edema; unfortunately we just don't seem to have much evidence in support of it at this time. Maybe if we can get her opened up a bit we'll have a better idea of which the case is!

So, I'll jump on a limb and go down the pulmonary edema route. At a minimum, I'd use Nitroglycerin and CPAP.

Everyone else seems to be behind CPAP at this point. Anyone else in favor of throwing some nitro down?

I'll give you all a new set of vitals here in a little bit. How about our transport decision? We ready to get going or do we want to sit and work him a little longer?

[chbare]

Bieber, you can always use the BVM setup for CPAP that I discussed above and attach an inline nebuliser to the BVM if you have nothing else available.

[Bieber]

Yeah, I know you can do that with our setup, I just didn't know that you could do the same with the CPAP. That's good to know, though...

[Kiwiology]

Unfortunately, a bag mask with a PEEP valve will not provide PEEP to a spontaneously breathing patient

Why is that? If they are ventilating through bag mask which is a closed circuit and that circuit has a PEEP valve on it won't they still be exhaling against the resistance of the PEEP valve?

Also, many people with acutely decompensated CHF are not fluid overloaded. This has become such an issue in my area, companies now have guidelines that require providers to calculate serum osmolarity to see if they can consider administering furosemide.

Correct, patients with cardiogenic pulmonary edema are not fluid overloaded the fluid is just in the wrong place they are in fact relatively hypovolaemic.

How are your Paramedic calculating pOsm?

A KVO rate on the IV will get him some fluid, however I dont want to make the problem worse by hosing in fluid just because I can

Do you not have the option of putting in a saline lock?

Kiwi, why do you say that the Nitro will have no effect on that?

What I should say is that his hypertension does not require treating right now, sublingual GTN will have some effect on his blood pressure obviously but that's not the same as "treating his hypertension"

Though I'm confident that Kiwi is right

I couldn't have said it better myself

I'd still like to try and avoid it if possible, and the CPAP gives us a good option for doing so.

Sigh, if only we haz teh CPAP

Edited May 27, 2012 by Kiwiology

[Bieber]

New set of vitals, post mag and CPAP:

HR: 136

RR: 24 labored

SpO2: 90%

BP: 188/100

[Mateo_1387]

How about reassessment after the treatment. What are the lung sounds now, capnography, 12 lead EKG, JVD still present, work of breathing, skin?

Deciding to treat a patient like this is tough with the dual history. I'm curious why everyone jumped on the COPD bandwagon? What signs or symptoms made you choose one over the other?

To answer my own question, I was on the pulmonary edema track because I expected a COPD exacerbation to have a lower blood pressure, especially if there is air being retained. Also, with the time the incident occurred at night, the hypertension, it makes me lean towards pulmonary edema, with COPD being a given underlying issue. Also, the run of V-tach makes me think of his heart having issues with pumping problems leading to the pulmonary edema.

Matty

EDITED to add content.

Edited May 27, 2012 by Mateo_1387

[Bieber]

Capnography and 12-lead are still the same. Lung sounds remain very diminished basally, wheezes apically. JVD's still present, skin and work of breathing are unchanged.

[Kiwiology]

This guy needs to be in the hospital, clearly whatever problem he has we're not fixing to any significant degree and we're muppeting about when we could be getting some wheels under him

I'm keen to shove an IO into his leg and intubate him, the hospital is going to do it anyway and if we have to stop on the way to do it then it's just doing nothing but delaying how long it takes him to get to the hospital

[chbare]

Kiwi, I do not want to take this too far off topic. If you want to see more about the BVM CPAP, I recommend you look at the link in my prior post. Regarding the Os calculation, we use the standard US method: (2 * (Na) + (BUN / 2.8) + (glucose / 18) + (ethanol/4.6). Additionally, I use osmolarity and osmolality synonymously in this context because the major solvent is water. I am sure somebody will call me out on that, so I will address it now.

How about the level of responseviness/consciousness? Also, do we have a temperature and what is the blood sugar? Additionally, what does the capnograph waveform look like?

I am not keen to intubate at this point. We are working hard to keep this patient's saturation at 90% and I am not sure he would tolerate an RSI procedure as well as we think. Intubation is potentially disasterous and I have to be backed into a corner before I do it. I do not feel that I am backed up enough to try a RSI at this time. Additionally, I am not going to base my current plan on what the receiving hospital might do.

[DwayneEMTP]

Still no signs of crackles in the lungs?