Right-side heart failure.

[pigginsick]

I think you may be right CHF seems a goos guess with all that edema going about. You don't mention whether your patient was experiencing chest pain. The problem with Lasix is that it takes 20 to 40 mins to be effective, a good longer term help but won't do much for your patient in the short term. The Nitro would of course dilate the blood vessels thereby reducing somewhat the work load of the heart. You don't mention wether your service carries a CPap ventilator but if not using a BVM with oxygen at 15 ltrs would offer postive pressure ventilation for your patient. This would certainly help with breathing and would force some of the fluid from your opatients lungs. Thsi is a method of immediate relief for the patient that I have used many times with good results. Of course all the other support services was also offered as you did. Hope this may give you another point of view.

NREMT-P in SC

[THE_DITCH_DOCTOR]

By the way, speaking as the staff RT here, , a CPAP unit is not a ventilator. Yes, CPAP is a mode of ventilation but it technically does not ventilate the patient. A BiPAP unit is akin to a pressure ventilator because you can set an inspiratory time and pressure, over the EPAP setting. If push comes to shove (you have NO other choice) you can actually ventilate an apneic patient using some BiPAP machines (either non-invasively (by mask) or after the patient is intubated; but the machine MUST have a time setting in order to set the RR), you can not ventilate an apneic patient with CPAP.

For the benefit of those who don't work with ventilators or CPAP and BiPAP on a regular basis, CPAP has one pressure setting- measured in cmH20. BiPAP (bilevel positive airway pressure) has two settings- for instance 12/5, also measured in cmH20. The first number is the inspiratory positive airway pressure (the maximum pressure being delivered (akin to the systolic pressure in BP readings) and the second number is the EPAP- expiratory positive airway pressure) is the same thing physiologically as CPAP. It is the lowest pressure that occurs during the cycle with a level of 0 indicating ambient (atmospheric pressure).

EPAP or CPAP is also the same thing as positive end expiratory pressure (PEEP) which is a term used in other modes of mechanical ventilation).

Also Pigginsick, have you read any of the studies stating that atrial fib is a relative contraindication to the use of CPAP, as the increase in intrathoracic pressure that accompanies CPAP usage can impair venous return and can drop cardiac output, thereby decreasing BP. It's not a reason to withhold needed care, just a very good reason to be cautious and not overly aggressive.

[buddha]

Why are you guys making this so difficult??? The answers are simple, if you don't get caught up in the "what if's".

First, look at why you are at the patient's side. You are there for SOB. What do you know about the patient? Onset acute and worsening during last few hours. SPO2 90% ambient - which is not a crisis at the moment. Put the patient on 12 lpm via nrb. Rales halfway up = acute pulmonary edema. Peripheral edema, ascites, and JVD noted = right sided failure. Right sided failure is secondary to LV failure, and when most patients suffer coronary syndromes such as A-fib or AMI they experience some degree of LV failure. Why? Because the left side has the highest workload and therefore demands the most oxygen. Treating the syndrome will usually eliminate pulmonary edema. The right sided failure, however, always remains in some degree. Now think about the possibilities in this patient. Yes, he's in A-fib, but is it symptomatic?? Not with a reasonably controlled rate and decent BP. A-fib is not the cause of this patient's current problem. Why does everyone need a 12 lead?? Think about the obvious - yes, an RVI can cause peripheral edema. Yes, NTG is bad for the RVI patient. Remember that RVI many times presents bradycardias and heart blocks (cuz the conduction system is on the right). Remember also that if you are still suspicious of RVI, you can see all you need to see with your three lead monitor. The ECG parameters to identify AMI are ST elevation greater than 1 mm in two or more anatomically connected leads - therefore, you can look at lead ll and lead lll to pretty much rule out RVI.

Forget the symptoms of right sided failure and treat what you need to. Give the NTG first, because it is quick acting and should provide near immediate relief. Secure a line and give your 80 mg lasix, which will take a while longer to work ( try to time it so the patient doesn't have to pee until you get them inside the ER). Who cares if his feet are swollen as long as he can breathe??

[Ace844]

Why are you guys making this so difficult??? The answers are simple, if you don't get caught up in the "what if's".

First, look at why you are at the patient's side. You are there for SOB. What do you know about the patient? Onset acute and worsening during last few hours. SPO2 90% ambient - which is not a crisis at the moment. Put the patient on 12 lpm via nrb. Rales halfway up = acute pulmonary edema. Peripheral edema, ascites, and JVD noted = right sided failure. Right sided failure is secondary to LV failure, and when most patients suffer coronary syndromes such as A-fib or AMI they experience some degree of LV failure. Why? Because the left side has the highest workload and therefore demands the most oxygen. Treating the syndrome will usually eliminate pulmonary edema. The right sided failure, however, always remains in some degree. Now think about the possibilities in this patient. Yes, he's in A-fib, but is it symptomatic?? Not with a reasonably controlled rate and decent BP. A-fib is not the cause of this patient's current problem. Why does everyone need a 12 lead?? Think about the obvious - yes, an RVI can cause peripheral edema. Yes, NTG is bad for the RVI patient. Remember that RVI many times presents bradycardias and heart blocks (cuz the conduction system is on the right). Remember also that if you are still suspicious of RVI, you can see all you need to see with your three lead monitor. The ECG parameters to identify AMI are ST elevation greater than 1 mm in two or more anatomically connected leads - therefore, you can look at lead ll and lead lll to pretty much rule out RVI.

Forget the symptoms of right sided failure and treat what you need to. Give the NTG first, because it is quick acting and should provide near immediate relief. Secure a line and give your 80 mg lasix, which will take a while longer to work ( try to time it so the patient doesn't have to pee until you get them inside the ER). Who cares if his feet are swollen as long as he can breathe??

"Buddah,"

With all due respect IMHLO it is essential to assess and consider the possibility that this episdoe of CHF and clinically symptomatic Right sided Heart failure wasn't caused by a RV MI, if you give NTG to a patient who has this you will take away what little "pre-load" that they have keeping them alive, their BP will bottom out and they may possibly soon after arrest on you....just some food for thought...

Hope this helps,

Ace844

[1EMT-P]

1. ABC's - BVM Assist with high flow 02 + Nasal Airway

2. Established IV of NS

3. Placed Pt on Monitor

4. Administered # 4 81 MG Chewable ASA

5. Contacted Medical Command

[buddha]

Like I said before, Ace. If you are antsy, or suspect RVI, looking at your three lead monitor in leads ll and lll can almost certainly rule that out. ST elevations greater than 1 mm in two or more antomically connected leads = AMI. RVI presents in leads ll, lll, and avf. ST elevations are ST elevations regardless of what machine you are using.

[kevkei]

If you only have a three lead, you could do MCL 4R (V4R). That would be more effective than only II and III.

[mediccjh]

Did V4R....nutin'.

No CP...why give ASA?

[vs-eh?]

No CP...why give ASA?

Query cardiac event. You could rationalize it easily. Do you give ASA for suspected CHF without CP?

[Ace844]

Like I said before, Ace. If you are antsy, or suspect RVI, looking at your three lead monitor in leads ll and lll can almost certainly rule that out. ST elevations greater than 1 mm in two or more antomically connected leads = AMI. RVI presents in leads ll, lll, and avf. ST elevations are ST elevations regardless of what machine you are using.

"Buddah,"

I understand and know how and where RVMI shows ST elevation on a 3 and multilead printout/monitor, but thanks for the refresher. I still stand by my earlier post on why i would be VERY CAUTIOUS about giving a patient with clinically significant Right sided failure with an acute presentation NTG for the reasons posted. This is why usually if a hospital gives "nitrates" in a situation similar to this they use Nitroprusside as the agent of choice, for 3 reasons. 1.) It's easy to titrate to desired effect 2.)It's short acting 3.) It has the same therepeutic benefits as Tardil/NTG .... As always your protocols, med availability, and practice environment, as well as Milage may vary...

Out here,

Ace844