Albuterol use while ruling out CHF vs Respitory complication

[jwraider]

I recently participated in a call and the medic used albuterol while trying to decide if the PT was experiencing CHF or exacerbation of COPD.

I was left wondering if using albuterol (which could have side effects of increased HR or HTN) before ruling out CHF is bad?

Would those sidefx just be a minor relative contraindication because of severe respitory distress??

He also said that he decided to move to CPAP because the breathing treatment was not working after about... 1 minute into the treatment... In your experience how long does albuterol really take to take effect (my drug sheet says 5 minutes)

Thanks!

The call if you're interested:

65 y/o male pt difficulty breathing found in tripod position making vocal sounds on expiration. (HX of COPD)

Initial lung sounds are absent or diminished (medic basically couldn't hear anything)

SP02 on RA 74%

Medic places PT on NRB... and requests a breathing treatment be started.

PT placed on monitor and BP taken (treatment started 30 seconds prior).... 165/108. Medic says "hmmmm.. might be CHF"

PT taken to rig and we get CPAP ready. Medic goes to admin Nitro but PT states he took Viagra about 8 hours ago (Nitro spray was at the mouth not sure how the medic kept from pulling the trigger!)

Code3 transport and about 5 mins into it above treatment is having a positive effect. PT had poor IV access so morphine never got onboard.

MD diagnosis was exacerbation of COPD.

[DwayneEMTP]

Great question.

I'm not busting your chops here, but what do you mean by vocal sounds? If it was the sounds of the patient’s lungs, surely the medic could hear something?

Or do you mean he was making purposeful sounds secondary to his distress or the like that perhaps masked his lung sounds preventing decent auscultation?

And is there any chance that you can be more specific about the patient's general appearance? Skin color, accessory muscle use, general physical condition?

Where there any meds/med history available? Home O2 use?

All of the above would be important, but I would work hard for the lung sounds.

CHF would not be an absolute contraindication for albuterol. Treatment is going to be based on your differential diagnosis, which will be based on the physiology involved, which will be strongly suggested by your signs/symptoms...is he choking (FBAO/Bronchiole constriction), or drowning (Pulmonary edema/MI/CHF), or being smothered (COPD/Pneumo)? See what I mean?

These aren't the only options, but the ones that you're most likely familiar with as a basic.

And on this patient? Get your IV access. No matter what, find it. It should have been a priority based on his condition. Should have had it before administering nitro if at all possible (especially if you’re going to administer it with Viagra… :wink: ). Almost regardless of which ailment he’s suffering from, there is the possibility of creating a significantly more positive outcome for this man, but that ability is severely limited without IV access.

Also, there are times when you have to make the best of some bad choices. In this patient, you need to get him to breath, right? It’s possible that assaulting his heart becomes a necessary evil temporarily to make that happen. I'm certainly not saying that's the case here, only that we don't always have the "single system involvement" answer that we'd like.

I like the way you’re thinking!

Dwayne

[AZCEP]

Dwayne makes some good points about being clear with your description of the situation.

By "vocal sounds" are you describing grunting at the end of exhalation? A bit different, but important to a differential. The appearance of the patient is relatively important as well. What do they look like? Gray? Mottled? Cyanotic? Diaphoretic? Flushed? All of these add information to what you are dealing with, and can make narrowing the differential a bit easier.

I will say that the respiratory component of the situation needs aggressive management, and a standard SVN treatment is not going to be very effective with this patient's inability to move much air on their own. Because you don't describe the patient history, this could be any number of things. Was this patient on Viagra for ED, or pulmonary HTN? That by itself would alter the direction of management.

The single blood pressure you describe does not make a good case for CHF. A patient that can't breathe will have an elevated pressure as a response to the problem. CPAP is probably a good call, but more information would be appreciated.

[Dustdevil]

Also, there are times when you have to make the best of some bad choices.

Speaking of bad choices, waiting until after initiating any kind of therapeutics before taking your first blood pressure would rate at the very top of that list. You don't make it clear whether you were an actual team member in this scenario, or just an observer. But either way, please don't let that become a habit with you. That would be epic FAILURE.

[akroeze]

I agree with Dust, you should get V/S before you initiate any treatment.

The ONLY exception I can possibly think of for this is a patient in severe anaphylaxis. I may not wait for a full set of V/S plus monitor before giving them Epi.

[tniuqs]

Some excellent points here.

Just to recap:

65 y/o Male

WT ? skinny or portly?

Chronology of Onset ? C/C ... called for SOB or Chest pain ?

On meds (only mention of Viagra) any beta blockers on board ?

V/S Mod Hypertension, no mention of tachycardia or ECG strip ?

I do like the position found "Tripod" and "Silent Chest" ...this is painting a very clearly picture to me pointing down the COPD trail, confirmed by you closeing statement so its really easy on this one to be a couch quarterback.

Another question was the Pulse Ox Coorelating as this is huge with me ... was the Patient Hypoxia or are we just treating a number ... anything less that 77% and coorelating is truely life threating, btw it will give you a pulse rate too.

Beta 2 adrenergics, ie Albuterol in Yall speak: is a relative contraindicated but in fact some MDs will use this with suspected CHF due to the theory that improved oxgenation may assist with Hypoxia for possible in CHF or MI the Gang. The idea being .... bronchodilation = improved oxygenation, granted not if pulse is clipping along at the "do we need to electivly weld level" ?

That said onset of Albuterol in most literature is ~ 5 minutes and peak effects within 15 minutes.

Query do you have or carry Atrovent ? FEV1 in the COPD demographic indicate that Atrovent is very benificial, but don't let in get into the eyes of a glaucoma patient if possible.

I to must emphasize the importance of v/s, color, and skin moisture level, assessment (s) prior to any treatment, even with the CPAP, as this should be considered a drug as well, V/S pre and post as preload on the heart is seriously affected possibly far more so than with albuterol, the set CPAP level should be included with information presented.

That said I do like your post but a :

Thoughout presentation from the Get Go .... makes you look like a REAL PRO.

hey thats catchy yea think ?

cheers

[ccmedoc]

WT ? skinny or portly?

I don't know why this struck me as funny, is that a medical term??

[tniuqs]

I don't know why this struck me as funny, is that a medical term??

This is the new EMY city "improved" politically correct medical term, you didn't get the memo .... again ?

The veterinarian termanology would be porky, but that's on VET city.

[Eydawn]

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

Wendy

[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: