shortness of breath/ chest pain

[Aussieaid]

Just some points to consider: Pt has a history of MI and ventolin has been known to cause MI even in pt's with no known cardiac history. Beta blockers are given in both AMIs and CHF so giving ventolin is going to have the exact opposite effect. If the pt has had no relief from his own ventolin (albuterol) and develops crushing chest pain with further ventolin with a history of angina and MI's would it not make sense that perhaps the treatment is causing the problem? Do you think that possibly his breathing difficulties could have been caused by CHF? Wheezing in the bases versus throughout all the lung fields makes me think more CHF than asthma not that you can't have it in both but looking at the whole picture I would be leaning towards cardiac. (By the way "cardiac asthma" = CHF) Perhaps the dust was coincidental or it could have triggered SOB with already developing CHF. What were his SpO2 levels? Do you have 12 lead capability? It could also have been an asthma attack and they developed an MI from the ventolin. If they were above 90% and not improving with the ventolin and it was causing chest pain perhaps it would be prudent to stop the ventolin, continue providing O2 (possible CPAP if you have it) and treat the chest pain. Or treat the chest pain and if he deteriorates instead of improving (with his respiratory status) then restart the ventolin once his heart rate has decreased and chest pain improved.

I wasn't there and don't have the whole picture but just remember that some of our treatments can actually cause more damage if we are mistreating something. Pain is an indication of a problem and it can be to your detriment if you ignore it. Tachycardia in an MI can increase the ischemia and area of infarction. You were on the right track of reassessing with changes in patient condition and in questioning if your treatment was actually causing more harm. Keep on with the critical thinking!

Remember "First do no harm!"

(Sorry I know you have already answered a couple of the questions but I had typed this all out and thought it was posted but it didn't save. So am reposting without editing because I am too lazy!!!)

Edited December 1, 2010 by Aussieaid

[rock_shoes]

The breath sounds are audible wheezes bilateral to the bases. The patient describes the chest pain as "Crushing", The pt just tells you that he had an MI two years ago and has been prescribed Nitro, but has never had to use it before. The patient tells you that his Asthma is brought on by dust and that he had been cleaning out his basement when he started to find it hard to breathe.

Just for clarity. The patient exhibited bilateral wheezes apices to bases prior to any treatment. Is that correct? Did the patient present with any specific s/s of CHF? Peripheral oedema, rales/ronchi on auscultation, ect.? What is the patient’s medication profile? Is it suggestive of a more chronic cardiac condition than the previous MI and infrequent angina?

The town I am working in does not have ALS, so it is up to us PCPs to deal with this kind of situation. That is my thinking as well, is that the B1 effects from the Ventolin could be causing him to have chest pain, but on the other hand the chest pain could be causing his SOB.

The number one history question here is “when did the chest pain start exactly?” Did it start before or after the ventolin treatment was initiated? Is the CP as a result of the B1 effects of the ventolin, the increased work of breathing associated with an asthma attack, the reduced blood oxygen levels associated with an asthma attack or some combination of everything? If everything started with an asthma exacerbation you have to treat the cause of the event. If you only treat the chest pain this patient still can’t breathe. If he can’t breathe his problems will only continue.

[rock_shoes]

Just for a little more relevant background information.

Cardiac asthma in elderly patients: incidence, clinical presentation and outcome

[Richard B the EMT]

I'm BLS, and the department and state DOH protocols I work under only allow me Albuterol via O2 administration set.

What is Ventolin? I don't recall hearing my ALS teams using it?

[rock_shoes]

I'm BLS, and the department and state DOH protocols I work under only allow me Albuterol via O2 administration set.

What is Ventolin? I don't recall hearing my ALS teams using it?

Sorry Richard. Sometimes we Canucks forget drug names that are specific to us. Ventolin is Albuterol.

Ventolin

[Kiwiology]

It's very simple, either

- the chest pain is of cardiac etiology or you are highly suspicious that it is of cardiac origin, or

- it's a side effect of the salbutamol and nothing to worry about

In theory positive chrono and inotropic effect and myocardial oxygen defecit could be possible due to the beta dernergic properties of the salbutamol but its probably not likely.

Edited December 1, 2010 by kiwimedic

[Eydawn]

So, Kiwi- what do you do? Treat as if cardiac d/t index of suspicion, or monitor as a potential side effect until you get to definitive care?

This is why it sucks not being able to use all the tools to gather all your info... a 3 lead or 12 lead would be HIGHLY useful here... unless the side effect cardiac pain also causes EKG changes... does that happen with albuterol tx?

Wendy

CO EMT-B

[uglyEMT]

OK Im BLS but will give it a shot being the 3 or 12 lead is out and ALS is not possible.

This sounds like an asthma attack and the chest pain is being brought on by the increased work load and the decreased O2 in his blood. I would give the Albuterol (Ventolin) as per my SOPs (for me it is pts own meds administered per prescription directions). One nitro pill would not hurt in this situation as long as there is no contraindications (ie to low of a BP). Continue to monitor the chest pain but agressively treat the SOB. I would get O2 onboard at 15lpm via NRB as long as this guy is above 10 breaths a minute. If he is below 10 I would start bagging, again still at 15lpm. Is CPAP available? If yes get him on it, if not load and go and give high flow O2 as much as possible. If the ventolin isnt releaving the SOB and his lungs are weezes top to bottom then it could turn into respitory failure quickly (depending on how long he has been in this distress).

Continue to monitor the CP. Any changes in the level of pain? Is it getting better or worse? Is it radiating anywhere? Thats an important question, is it radiating anywhere. If its just crushing and in the chest only it could be a side effect of the SOB and just a distracting symptom. If it is radiating then it could be a sign of an MI and needs treatment. As you stated no ALS, no 3 or 12 lead, so he is a load and go if it is an impending MI and your level of care will not be sufficent unfortunatly so get him to higher level of care ASAP.

All in all I would say continue treating the SOB while monitoring the CP for any changes. Load and go and get this person to a higher level of care.

[Richard B the EMT]

Just mentioning, under FDNY and NY State protocols, the only drugs BLS crews carry are chewable baby aspirin (85 Mg), albuterol, glucose paste, and oxygen. We are allowed to "assist" a patient in taking the patient's own nitro, after the "rights" are followed.

[WolfmanHarris]

Holy crap, never realized how much I've come to depend on ECG until now. I won't worry too much about it though, plenty of non-STEMI's out there.

I know this was a college scenario so we're working on a piece of fiction here, but I'd be curious about initial HR, RR and BP. On all my SOB calls I've gotten in the habit of adding ETCO2 into the mix to take a look at the waveform.

Dive back into the Hx. Some people have a weird perception of pain. Yes the crushing CP occurred following ventolin administration, but did anything feel out of the ordinary in the chest prior to that?

How did the lungs sound after the initial ventolin treatment? Were I to hear increased wheezes or crackles then I'd start considering CHF.

Given his history, I am inclined to lean more towards cardiac ischemia brought on by the asthma and ventolin treatment.

Of course this is where it gets a bit stickier. Has the Pt. ever had asthma complications with ASA usage? Under my Medical Directive NTG is contraindicated when the Pt. has no prior NTG use w/o a line established.

I can tell why this one was used in school for you. Forces the student to make a decision and operate in that grey area where so many Pt.'s fall.