Right-side heart failure.

[als_medic_uk]

But it reduces capillary fluid filtration and edema formation, and hence reduces an increase of fluid.

[als_medic_uk]

Sorry CRT = Cardiac Re-synchronization Therapy, a cardiac pacemaker.

[zumjus]

I know I'm late with this post, but here is MY interp.

1. It's not RVI. RVI's almost ALWAYS are bradycardic or Hypotensive. We don't know the rate here, but it wasn't significant enough to post which leads me to believe it was normal.

2. He had a (+) hepatojugular reflex which usually indicates RHF.

3. Hx of cardiac.

Load him up with Nitro. O2 (CPAP preferred), IV, ASA, MS. Don't be afraid of the Nitro. Yeah yeah, if it's RVI you can bottom it, but those pt.s are usually hypotensive anyways. Load him with NS and give nitro nitro nitro. This pt. is not having an RVI so load him up til his BP cannot take it anymore, then give him fluid and load him up with nitro again. Don't forget the MS.

[Ridryder 911]

. Load him with NS and give nitro nitro nitro.

Congratulatios you just killed him! WTF ? Your giving fluid to a CHF patient and then using CPAP to blow it back from the alveoli ?... WHY ? would you want to drown someone ?.. You are defeating the purpose of nitrates (vessel dialtation and morphine venous pooling) by infusing fluids... duh !...poor pump failure!..... why do you think you adminster diuretics ?...

By the way late stages or progressive right sided lateral wall infarct are brady... not all right side presents in brady syndrome. I can hear Sacra shutter...

R/R 911

[zumjus]

I didn't kill him. The nitro, lasix, and CPAP are removing the fluid from his lungs so he can BREATHE!! The MS is lowering the O2 demand on his heart. The nitro is venous dilating to take pressure off of the pump and help with the fluid. The NS is just in case his BP drops. You don't give him boluses if his BP is doing good, ONLY if it drops too low for the nitro. I figured everyone would know that. When he gets to the ER they will put him on BiPAP and a nitro drip. You are right that I forgot to mention LASIX. Give him the LASIX. Have you never used CPAP? It's pretty instantaneous. If his lungs are full of fluid, then you want nitro, CPAP, lasix, and MS. He said the lowest BP was 138/80. I STILL don't buy the RVI. You are right not ALL RVIs are brady/hypotensive, but MOST of them are. You will find out after the first nitro you give. I have used this treatment several times, and have been VERY successful with it. Sacra and the education department don't seem to have a problem with it.

[flight-lp]

"Load him with NS and give nitro nitro nitro. This pt. is not having an RVI so load him up til his BP cannot take it anymore, then give him fluid and load him up with nitro again. Don't forget the MS."

Just one simple question, why would you give fluid?????????

[zumjus]

The fluid is just in case the BP drops. You don't give him fluid until his BP drops below a manageable level.

Let's pretend he IS having an RVI and his BP is high. His BP is say . . . 140/80. You give him a nitro and his BP drops to 110/50. Now here comes the balancing act where fluid is needed. Do we stop giving him nitro? No! He needs it. Do you just give him another one since his BP is above 90 systolic? No, again. He had a 30 point drop in systolic BP and you don't want to risk that again and bottom his BP out. You give him a small bolus, let's say 250 cc then give him another nitro and re-evaluate. Generally CHF'ers can handle small boluses of 1-200 cc as long as you are doing something with the fluid. Lasix, nitro, CPAP, etc. etc. etc. The point is that he NEEDS the nitrates so we need to aggressively treat these pts.

Now if he is not having an RVI, then you don't have to treat with aggressive fluid treatment. You just give him nitro nitro nitro, MS, Lasix, etc. etc. etc. Of course you don't load up a CHFer with fluid if his BP is normal or stable. That would be crazy. I guess I assumed (i know I know) that people would just know that. I think people are misinterpreting my initial treatment. I should have been more clear.

[flight-lp]

Thats how I figured you would answer. You do not "load up" a CHF'r with fluid regardless what their BP is. If they are hypotensive or in cardiogenic shock, you give them a pressor, preferably Dobutamine. While I think is nice that you are keeping such a close eye on the patients systolic BP, its really nothing more than a number. When titrating nitrates, especially in a patient with CHF, you need to keep an eye on the mean arterial pressure and look at the whole picture, not just the BP. Your ascertation is completely incorrect, "nitro, nitro, and more nitro" until the BP can "no longer handle it" and then giving fluid can and will kill your patient. Doesn't matter if it is an RVI or not. Yeah the lasix may very well eventually remove it, but why put it there in the first place. Not to mention the electrolyte depletion you are doing by continuing lasix to remove fluid that shouldn't be given in the first place. Fix whats broke, not what you break....................................

[zumjus]

Ok we are getting away from the point and this will be a never ending argument. You are putting too much emphasis on the fluid, when you won't even need the fluid for this pt. That is his problem, too much fluid. He is in Pulmonary edema and needs CPAP, nitro, Lasix, MS, ASA, and obviously O2. The fluid thing was just a "what if" scenario in case his BP somehow dropped. If his problem is hypotension to where he needs fluid, then he most likely won't be in Pulmonary Edema. I got carried away with the admin of fluid because someone brought up RVI and that is synonymous with fluid. In any case, this pt. won't need fluid. He just needs to be able to breathe right now. Can we agree on this?

Pulmonary edema Rx: O2, Nitro, CPAP/BiPAP, Lasix, ASA (if able to comply), and MS. *Remember this is Pre-Hospital.

[Asysin2leads]

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? Usually anyone who is in acute pulmonary edema has associated kidney problems from a chronic condition, such as systemic hypertension. Just wondering, I'm to tired and lazy to look it up and figure it out myself.