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Unless there's concurrent COPD exacterbation (very common) or the APE itself has induced bronchospasm which can and does happen. Sometimes, sometimes just getting afterload down will do. Very occasionally. A good portion of CHF patients actually end up DEHYDRATED. It's not usually a fluid overload problem so much as a distributional and hydrostatic pressure issue. Invasive vs non-invasive PPV Nitrates and ACE inhibitors actually do a FAR better job of changing the pressure gradients and treating the true cause behind a CHF exacterbation . If found to be fluid overloaded via diagnostics, than yes the patient needs to be diuresed. Other times they may actually need fluid. We just discussed this on another board and came to the conclusion with the help of a couple of very smart RRTs that this does not provide CPAP as there is no "continuous" part to it. What your actually doing is increasing the WOB. Remember, APE and decompensated heart failure are usually afterload issues, NOT fluid overload. High dose nitrates are the treatment of choice. However, if there is wheezing (not rales mistaken for wheezing) than that's indicative of bronchospasm and albuterol should be used to relieve the bronchospasm.

Service dogs are trained not to be aggressive - they know their job is not protection by aggression. I can't say "never will happen" but I do feel that the chances are incredibly slim. If the EMS provider has a fear of dogs, they should realize that their fear is exactly that - it is theirs,.... if it interferes with patient care, they need to address it, and if that means calling in a second crew to transport the patient and their dog, then do it. Your phobia, pride, or embarassment need to come second to doing what is best for the patient.

Reglan (and droperidol, for that matter) fell from popularity due to their respective black box warnings. Which may or may not have been fairly applied depending on who you talk to. Phenagren has some nasty side effects including phlebitis and a tendency to give older folks dystonic reactions (I've seen elderly patients pretty well flip their wig post phenagren, not sure why it seems to effect the elderly so badly). Xopenex is an expensive drug that does basically what albuterol does. It is more beta 2 specific than albuterol, but it's still under patent so that specifity comes at a price.Used primarily to prevent long-term sympathetic stimulation in people who don't need it and in kids who have behavioral problems in Ventolin. Ipatropium on the other hand is a great addition to any drug box as it helps with acute broncospastic events from an entirely different angle. Valium actually has the longest half life if all the agents listed. It's also the "weakest". I personally like midazolam simply because of the IN admin option and the tendency to induce anterograde amnesia, as usually when we're giving it something unpleasant is happening. Lorazapam is a perfectly ok agent and has less hemodynamic effects than midaz. IV NTG is the bees knees IF you have a pump. It's not a drip you can eyeball. It's also about a hundred bucks a bottle, so it's not the cheapest stuff ever. I've personally probably hung a few gallons of the stuff and through urban, suburban, rural and HEMS have never had an issue with the glass bottle other than Minimed pumps throwing a fit over sucking minute amounts of air. If your really worried about it, get a Koozie, cut a hole in the bottom for the bottle neck and carry the NTG in there. Works like a charm. Hopefully this was helpful.

You really need to take each encounter for its own merits. If the dog is aggressive in any way I cant take it with me, as I know that if the situation in the back with the pt the dog is going to react. I would have to ask the owner to make arrangements to get the dog to him in the hospital. Ok lets take this to another level Mike. I personally do not have any fear of dogs, so it unlikely I would leaving a service dog behind, but what if you afraid of dogs. There are alot of people that are terrified of dogs, and a big german shepherd can be intimidating to someone with fears.

Firstly Welcome: Some pretty broad statements here. I would dispute that statement. You may find that around 46% of CHF patients have associated COPD, the study by singer is suggestive that is an increase in mortality with the use of "albuterol" in the CHF with no pre-existing COPD. In the combined COPD / CHF (the 46 % club) the mortality was decreased, other studies footnoted in this link may help. http://www.medcontrol.com/omd_pub/bronchodilator_and_chf.pdf Could you explain in your statement that all CPAP is PEEP, can one positively say that a PEEP valve on a BVM (spring loaded valve) is true PEEP ? Squeezing the bag will apply PEEP most interesting, as I thought (as in your statements above) that PEEP was Positive "END" expiratory pressure, not PIP Peak Inspiratory Pressures. (the squeeze part) When you stated "fluid around the heart" as I always though that was called an effusion ? Are there any other choices if diuretics or other rx used in your practice perhaps that are potassium sparing ? Furosemide is being looked at with a more critical eye these days in CHF. Are there no J receptors triggered to respond when pulmonary oedema is present, this leading to an increase in hypoxia and that Bronchospasm in the CHF patient never occurs, as a result. http://en.wikipedia.org/wiki/Juxtacapillary_(J)_receptors Taken from an RT book (Dr. Creed) As one can see there is quite a bit of controversy in the medical field regarding the use of bronchdialators in CHF. cheers