Is this a cardiac patient or not?

[46Young]

Ummm ... that is kinda stretching it, I don't think you wish debate that.

Ones Ears are far better at that diagnosis.

Not really meaning to shred and the red wine did put things out of sequence, but could you expound on that a bit I am not following ?

Lasix has it place and really should not have a "drug" reputation persay. Lets not forget that one needs a mean b/p of at least 70 to 80 for whatever dosage of furosemide is needed to make that filter operational.

Quoting a MD I worked with a Dr. Marchashamer ... TO PEE IS TO BE.

In ICU we called dopamine "poor man's lasix" + inotropic and increases renal perfusion.

Did forget that even M/S has minor diuretic renal action useful in LVF.

There was another tool in the bag sorry, my bad, I just felt compelled to finish that sentence.

Zactly ... not bad for a bucket head medic

Regarding ETCO2, of course I would rely primarily on L/S. If I heard some wheezing but the pt was moving a decent amount of air, I would hold off on a neb and see if I could help the pt with CPAP and nitrates. The ETCO2 capnography could help me monitor how they're moving air, not to mention their capnometry, which will assist me (along with other aspects of my ongoing assessment) in deciding if my therapies are not working, and intubation will be necessary Episodes of CHF/APE can have a concurrent COPD exacerbation.

When I said we don't treat CHF, I meant that the prehospital goal is not to address their peripheral edema; we're treating rales and maybe wheezing presumed to be caused by a weak left ventricle. Are they having an MI? Did their BP spike, causing a 100% occlusion somewhere in the coronary vasculature? Is the afterload too much to effectively overcome due to a rise in BP? Do they need a bolus to increase preload if they're in cardiogenic shock from inaqdequate output from the RV? What I meant is that if the pt has significant peripheral edema, it's not a prehospital goal(at least not here) to treat that directly with a diuretic. There are other treatments that are far more effective. We can give lasix, but that's at the bottom of my list of considerations.

If the pt had a BP of 80 or less, I wouldn't be thinking about lasix, and not because renal perfusion shunts away at around that pressure. I would be addressing their cardiogenic shock at that point. Maybe a fluid bolus for the rt, or pressors for the left, generally speaking, among other things. I'm not going to be going renal doses of dopamine, I'll probably be running it at 10-20 mcg/kg/min.

I've been using CPAP since 2005, when we got them to use for a trial in NYC (only been a bucket head since 2008).

My bad, I forgot about rural EMS, which can txp upwards of an hour, easy.

Edited February 20, 2011 by 46Young

[Kiwiology]

CHF is not fluid overload, the fluid is in the wrong place

*smashes head on wall

CHF is not fluid overload, the fluid is in the wrong place

*smashes head on wall

[crotchitymedic1986]

I am sorry, I did not mean that you should not treat the patient prehospitally as you normally would, Just pointing out it was CHF and not some other rare disease that only "House" could figure out.

[mobey]

I am sorry, I did not mean that you should not treat the patient prehospitally as you normally would, Just pointing out it was CHF and not some other rare disease that only "House" could figure out.

I will take this "dodge" of all my questions to mean: "I was wrong, High doses of lasix alone is not indicated in the presented case"

[crotchitymedic1986]

I will take this "dodge" of all my questions to mean: "I was wrong, High doses of lasix alone is not indicated in the presented case"

No, I imagine that if the OP ever comes back and tells us what treatment the patient received in the hospital, it will include high doses of Lasix.

[Paramagic]

No, I imagine that if the OP ever comes back and tells us what treatment the patient received in the hospital, it will include high doses of Lasix.

The treatment he received in hospital is somewhat of a moot point. As has been pointed out (with accompanying head smashing ) acute cardiogenic pulmonary edema is a problem of fluid in the wrong place, not too much fluid in total. The treatment should be nitrates and CPAP.

However, depending on how long the patient required positive pressure ventilation, it is entirely possible that they did receive furosemide in hospital. This is not necessarily because they were fluid overloaded in the inital stages, but because positive pressure ventialtion is known to cause SIADH after 24 hours or so, making diuresis necessary.

Furosemide in the early stages of a sympathetic mediated acute cardiogenic pulmonary edema is an evil, evil drug.