Dyspnea

[DwayneEMTP]

...Patient's daughter and DPOA is on scene and requesting that the minimum amount of invasive treatments be performed to stabilize her father. With that in mind, do you want to continue with the IO and intubation, Ben?...

I think that at this point the I/O and intubation might be the least invasive, though we've not pushed the Epi. I know that that is a risky move with this patient, but I don't believe terribly so. The Epi may give us some more lung access which may give his heart a break.

I wonder about some Mag in this patient? It doesn't sound as if the lungs are retarded secondary to matter but to constriction. I have no idea what kind of an idea this is for this patient.

If she has his POA for medic decisions then I think that it's appropriate and ethical to explain that if we intubate his odds of being successfully removed from the vent at a later time are very questionable. Of course, if we don't, his odds of reaching the hospital alive are diminished. What kind of hospital will we reach in a half hour? Serious care, or bandaid station?

I was on a call very much like this as a student. The patient was familiar to the medic, the daughter was adamant that her father would want to be allowed to die if he couldn't survive without invasive/pharmacological measures. She didn't have current paperwork but the medic and I loaded him into the ambulance, I bagged him until he died enroute to the ER. (And yeah, we reported the fact that he died in the ambulance.) Nothing else was done per the daughters wishes.

If this daughter has the verifiable right to make life and death decisions for her father then no other decisions can really be made until she's completely informed to the best of our ability to do so.

[Kiwiology]

We could try adrenaline and it is indeed part of local guidance for COPD exacerbation

The point about him being difficult to wean off the ventilator later is an excellent point, I didn't think of that

It's also struck me that his SPO₂ is abysmally low, but many COPD patients have a very low SPO₂, do we know what it is normally?

Like I said before, at this moment in time he is not "actively dying" (at end of life) so it's up to the daughter to decide really, I think it's the best option for right now and if he dies a day later in ICU then so be it, I mean until he is actively dying I think there is at least some moral obligation to work on him; if he was on palliative care or something it'd be different

Edited May 26, 2012 by Kiwiology

[nypamedic43]

Since the daughter is so indecisive about what to do and is stating that she wants the minimal done....how about CPAP?? His problem is oxygenation. His SPO2 will dip a little more on the CPAP before it gets better however he will be getting more o2 with the CPAP. Its non invasive, which is what the daughter wants. It needs to be done like...5 minutes ago or he will be going into arrest. We've already thrown everything we can at him minus meds. If we can turn him around on CPAP...awesome. And we still have the option of intubating if it doesnt work.

[Bieber]

I think that at this point the I/O and intubation might be the least invasive, though we've not pushed the Epi. I know that that is a risky move with this patient, but I don't believe terribly so. The Epi may give us some more lung access which may give his heart a break.

I wonder about some Mag in this patient? It doesn't sound as if the lungs are retarded secondary to matter but to constriction. I have no idea what kind of an idea this is for this patient.

I think some mag would be a great option for this patient, and one that comes with a lot less strain on his already irritable heart!

If she has his POA for medic decisions then I think that it's appropriate and ethical to explain that if we intubate his odds of being successfully removed from the vent at a later time are very questionable. Of course, if we don't, his odds of reaching the hospital alive are diminished. What kind of hospital will we reach in a half hour? Serious care, or bandaid station?

Great point on the risks of intubation and ventilation... It sounds like this patient might already have an infection, do we want to risk adding a vent acquired infection on top of that?

The hospital has an appropriate ICU and respiratory department. They're no trauma center, but they can handle most anything medical.

It's also struck me that his SPO₂ is abysmally low, but many COPD patients have a very low SPO₂, do we know what it is normally?

Great question! Nursing staff has no clue, but the daughter states that he usually runs in the low to mid 90's.

Since the daughter is so indecisive about what to do and is stating that she wants the minimal done....how about CPAP?? His problem is oxygenation. His SPO2 will dip a little more on the CPAP before it gets better however he will be getting more o2 with the CPAP. Its non invasive, which is what the daughter wants. It needs to be done like...5 minutes ago or he will be going into arrest. We've already thrown everything we can at him minus meds. If we can turn him around on CPAP...awesome. And we still have the option of intubating if it doesnt work.

Not a bad idea, but do we want CPAP or PPV with a BVM along with nebulized albuterol? He seems to be doing better with the BVM, although we've only gotten one albuterol treatment in so far.

After Dwayne and Kiwi combine their skills of persuasion, the daughter finally concedes and says "do what you have to". You've got your green light to do what you think is necessary up to the point where the patient codes. Now, with everything we know in mind, what do we want to do?

Quick recount:

HR: 137 (160's during second bout of the same tachycardia as before, this time lasting only a couple of seconds)

RR: 24 labored

BP: 192/108

SpO2: 87%

Treatment so far:

PPV via BVM with x1 albuterol treatments administered so far.

No IV access at this time.

So far, here's what's been suggested for our next move:

*Epinephrine. Things to consider: age, myocardial irritability, hypertension. Risk/benefit?

*Magnesium sulfate. Things to consider: less cardiac stress. No IV access.

*CPAP. Things to consider: no ability to give nebulized treatments through it. May increase oxygenation, however with the airways closed up so much, do we want to try and open those first or concurrently?

*RSI/Intubation. Things to consider: risk of vent-acquired infection. May be more invasive than the patient would want. Can bag in nebulized treatments through it; may increase oxygenation status.

Do we want to get a steroid on board? We've got about 25 minutes to the nearest hospital, which means the patient may start to experience some of the effects by the time of transfer of care.

Great responses, everyone, really well thought out.

Addendum: Also, have we come to a consensus on what we think we're dealing with here?

[Kiwiology]

If he has a chest infection most steroids are immunosuppressants so not something I'd use

I've got no experience with CPAP or magnesium sulfate as neither are used here

I am still very keen to intubate him

[Eydawn]

I wondered when someone was going to get to CPAP... in an old COPD'r, forcing those airways open can do more than waiting for bronchodilators to creep down incrementally... give a dose, 10% opens... give a dose, 15% opens... too much time that we don't have. It will also treat pulmonary edema if that's what we have going on here. If we're closed down enough, you may not hear anything until things get opened up a little more. I might trial 10 minutes of CPAP and then give a neb, if no improvement seen initially with the CPAP continue with nebs as we transport...

To be honest, and to dive off on a tangent here, if the patient has had 911 called for them, chances are good the nurse has looked at them in the last 15-20 minutes. Most CNA's aren't allowed to make the call, a nurse does. Sure, she may not have seen him in the 3-4 hours prior, but she may have report from her underlings, and I'll bet you she looked at him and said "aw shit" before calling 911. Just saying. Since I actually worked long term care and all.

But, the answer should never be "this isn't my patient"- that's what the charting from the previous few days are for. "I'm not sure, but let me peek through his charting really quick and get a picture of what's been going on if I can. Give me 3 minutes." Anyway, back to treating the poor bastard...

Wendy

CO EMT-B

[Kiwiology]

Like I said we don't have CPAP here in NZ so hmm I'm not sure, it could be of benefit from a physiologic standpoint

[DwayneEMTP]

He can survive where he's at now for quite a while if he doesn't fatigue. I would hold off intubation if I think that he has the strength for it. Maybe chbare can chime in here as I can't really back up my belief that if I intubate him I've really retarded his chances of leaving the hospital as intact as before this crisis.

I'm not nearly so concerned with adding an infection to an infection as the hospital is probably going to hose him down in IV antibiotics, but instead maintaining him and then trying to wean him from the vent.

And I wouldn't trial the CPAP first, but possibly concurrently. It will help his issues as they are, but isn't likely, to my understanding, do anything to retard the bronchoconstriction that's being signaled by the wheezing, and I'm moving forward under the assumption that that's what's trying to kill him.

I'm going to deliver the Mag Sulphate. Let put 2g in a 100 or 250 cc bag of saline and set it to run in the first half over the next 5 mins, and the second half over the next 10 mins and see what happens.

With the newly developing wheezes I'm more confident with the mag, though it seems like there's something that I'm missing there. (but going to try and play it real. In this patient, with the information in my head, this is my decision.) Plus I wonder if we won't see some benefit for the run of tachycardia that we saw earlier?

So, that's my decision. CPAP, O2 titrated to 95% SPO2, Mag 2g to start, over 10+ minutes, though may increase this if his pressure holds and it seems to be giving me a decent return on my investment. Also, I'm going to go ahead and push the steroids.

What does anyone think about inhaled steroids or Epi for this guy?

Like I said we don't have CPAP here in NZ so hmm I'm not sure, it could be of benefit from a physiologic standpoint

Screw physiological, from a psychological point of view it makes me feel better, and that's the important thing...

[chbare]

You can easily administer inline nebulised medications using CPAP or BiPAP. This works with both the older Vision's and the newer V60 machines. Do we have an ABG and a chest x-ray? We can place an IO if IV access continues to be unsuccessful.

[J306]

I'm considering that the acute onset of SOB is primary a cardiovascular problem which has exasperated the patients COPD causing pulmonary edema, decreased air entry and wheezes.

Nobody has mentioned the episode of paroxysmal supraventricular tachycardia the patient experienced which may be caused by a congenital heart defect such as Wolff-Parkinson-White syndrome. What also makes me think cardiac is because the patient's blood pressure is hypertensive which could indicate left ventricular dysfunction.

I agree with the application of CPAP as long as we're sure we've ruled out spontaneous pneumothorax. However, I agree that giving a bronchodialator to TX the wheezes beforehand would be the best option. If the patient does not improve post nebulized albuterol and CPAP, incubation is definitely indicated.