Dyspnea

[systemet]

All right, folks, here's the epic conclusion to this scenario!

Thanks for the awesome scenario. Well presented!

By the way, I called those bouts of tachycardia V-tach, based on their similar morphology to the PVC's the patient was throwing and because I've never seen anybody go in and out of PSVT like that and I considered the rhythm most likely due to ventricular irritability secondary to the hypoxia.

I think it's VT. I think another option is a.flutter, but the rate seems a little off for that, I think there's retrograde P waves, which, if correct, rules out a.flutter. It could also be junctional w/ aberrancy. It's really hard to measure the QRS sometimes from just the limb leads.

-Magnesium Sulfate: This we don't have by standing order but I could have called for, and I wish I had. I think I may have briefly considered it but for one reason or another didn't go back to the idea. I wish I had now, and maybe it would have helped turn the patient around quicker.

I think this is a reasonable thing to do, but from what I remember, the evidence, while weak, is much better for mag in asthma versus COPD. I might try and do a lit search if I have time.

Anecdotally, it seems like mag either works really well, or does nothing. Not sure why. I think sometimes the change in patient condition is just coincidental, and can be put down to higher FiO2 and beta-agonist / anticholinergic, and also that people really like to give mag, because it makes them feel like they're doing something.

-CPAP: Chris, I owe you for making me feel stupid about this one, and again for teaching me something. I really didn't think you could connect a nebulizer to CPAP (maybe because previously we've been so anti-CPAP for non-pulmonary respiratory disease), but now that I know, you can bet I'll be using this in the future. I still think that PPV via BVM was a good second best, but it definitely would have given me a chance to get more done if I hadn't been bagging the patient all the way in and it might have been more beneficial to them as well.

A couple of questions here, perhaps chbare can help --- (1) How good is the evidence for CPAP in reactive and/or obstructive airway disease? I can understand that it might prevent some dynamic airway collapse, but it seems like the underlying pathophysiology is very different versus CHF, (2) Would some sort of bilevel support be better here, with a lower PEEP, but a higher inspiratory support?

As for the rhythm, i've seen runs of both PSVT and V-tach in the field which both converted themselves back to NSR. I personally thought it resembled SVT but I may be mistaken. What do you guys think?

Regarding this --- I think you're leaning towards SVT because the axis is normal and the complexes are upright in II, III, aVF. When you see textbook examples of VT, they normally give you something with a nice indeterminate axis, that looks nice and wide in the limb leads. But, of course, VT can have any axis, and look nice and positive, when it wants to.

It's hard in this example to decide where the QRS begins and ends (in my opinion), and would be easier with a 12-lead with multiple options from which to measure. But if you look at the ECG, it does look suspiciously wide, but it's a bit of a judgment call.

It could well be SVT, I just personally think VT is a little more likely. It's also the safer clinical decision --- if you're not sure, and if you're sure, you want to be really sure, it's better to assume VT. That's not to suggest that we should just give up every time we see something wide, just that we should bias ourselves in the direction of VT for the safety of our patients.

[TicTok]

On the topic ECG, I automatically decided it was VTACH as only one lead was presented and it is very broad. It would have been interisting to know if any canon wave were present during the episode. Regardless though, it does not really matter wheather it was was non sustained VTACH or a PSVT with aberancy, it was a warning sign and not the pathological cause.

External juguler vein canulation is still classed most times as a peripheral line as it is superficial so to say. Yes I do agree that the neck is involved and if it bleeds there may be complications if not closely monitored and tamponaded if extravasation occurs. In South Africa we seem to use it more often than I.O. canulation in adults, probably due to the extreme price of the equipment needed for I.O. here. I have a fair amount of experiance with EJ canulation and am comfortable with the skill. This patient needed iv access and the risks (also taking chronic meds into account) dont outway the benifit of a large bore line (14G my needle of choice in almost all EJ canulations) with an often increased patency over time. I do however suspect that this is anecdotal and teaching in our system. I also find it less distresing to the patient when explaining what is coming........

We have an awesome MandM group here who take responsibilaty for or actions with out arguments and being guarded. You Sir Bieber have achieved this in the most unpredictable place. Well done too you. It was well presented. I think I will visit farrrrr more often if this becomes a trend. Thanks to all. It was an awesome read.

[chbare]

There is evidence that supports using non invasive ventilation on these patients. Particularly, NIV has been shown to decrease the need for intubation and overall mortality and cost of care in acute COPD exacerbations. Some companies are starting to include COPD in their protocols. I cannot answer the CPAP versus BiPAP question. Both seem to work; however, air trapping and the development of auto PEEP are concerns and should not be ignored.

If you want to blow some money, check out a book called Egan's Fundamentals of Respiratory Care. I believe the recent edition is at ten. These questions are addressed in this book and you even have AARC guidelines that can be referenced.

[Bieber]

I think it's VT. I think another option is a.flutter, but the rate seems a little off for that, I think there's retrograde P waves, which, if correct, rules out a.flutter. It could also be junctional w/ aberrancy. It's really hard to measure the QRS sometimes from just the limb leads.

Yeah, I agree, I wish I had gotten a 12-lead but it seemed like I just didn't have enough hands to get everything done that I wished I had.

I think this is a reasonable thing to do, but from what I remember, the evidence, while weak, is much better for mag in asthma versus COPD. I might try and do a lit search if I have time.

Anecdotally, it seems like mag either works really well, or does nothing. Not sure why. I think sometimes the change in patient condition is just coincidental, and can be put down to higher FiO2 and beta-agonist / anticholinergic, and also that people really like to give mag, because it makes them feel like they're doing something.

That seems to be what I've heard too as far as it either working great or not working at all. I've never used it myself, though our new protocols will have it by standing order so hopefully I'll get the chance to in the near future.

A couple of questions here, perhaps chbare can help --- (1) How good is the evidence for CPAP in reactive and/or obstructive airway disease? I can understand that it might prevent some dynamic airway collapse, but it seems like the underlying pathophysiology is very different versus CHF, (2) Would some sort of bilevel support be better here, with a lower PEEP, but a higher inspiratory support?

From what I've heard CPAP works pretty good on COPD, although I do think that BiPAP might be more beneficial to help prevent air trapping.

TicTok, thanks so much for participating man! It was great to get the perspective of someone working in a completely different EMS environment than what I'm used to and I know enough about South Africa and EMS there to know that you guys are some of the best out there and run critical calls on an extremely frequent basis. Thanks for giving your input and for sharing some of your kind words. As far as the EJ goes, I would tend to agree with you--I just wanted you to share your reasoning aloud for everyone to see where you were coming from. Thanks again man!

Chris, thanks for sharing a bit more on NIV and for the book reference. If I ever get some free cash floating around I'll definitely have to check it out.

Kiwi... don't lie, bro, you were totally hard for this scenario. Lol.

Dwayne, as always, thanks for bringing your knowledge and experience to this scenario. You really made me think about things I could have done differently and made me realize some areas of weakness that I'll work to avoid next time. To answer your question, I definitely think that presenting these scenarios is just as much if not more helpful than participating in them. In the heat of a call it can be hard to avoid getting that tunnel vision and going over calls is a great way to learn from them and to improve the next time around.

You guys were amazing! Thanks again! I go back to work on Tuesday and hopefully I'll have some more scenarios to post soon.

[chbare]

I am not sure BiPAP would be more effective. The evidence does not point to that consistently. It's actually somewhat lacking for COPD patients. We do know that NIV (CPAP or BiPAP) does appear to be effective in patients with acute COPD exacerbation. There have been CHF studies that demonstrate faster improvement in BiPAP groups; however, the BiPAP groups had a higher incidence of myocardial infarction. I am not sure you could even consider applying this to COPD patients however.

A rule of thumb that is more anecdotal that I was taught in respiratory school was CPAP is good at assisting with oxygenation while BiPAP is good for assisting with ventilation. I am sure significant crossover exists however. In addition, the difference between IPAP and EPAP in BiPAP is known as pressure support (PS). PS can help overcome certain types of airway resistance, so a weak argument could exist for favouring BiPAP. The literature is still somewhat limited and certainly not definitive toward one modality or the other IMHO.

With that said, I choose CPAP in this case simply because the EMS crew probably did not have the ability to provide BiPAP or it's generic analogues. If the crew had a high tech ventilator shuch as the LTV 1200, they could in fact have provided the analogue of BiPAP by setting the ventilator up in NIV and setting PS and PEEP or setting the analogue of BiPAP. Either way, the job could be accomplished. That is essentially what BiPAP is. PS above PEEP is the IPAP and PEEP is the EPAP. Simply put, PS by it's self is nothing more than what I call 1/2 PEEP/CPAP or pressure during inspiration only.

Edit: "."

Edited May 29, 2012 by chbare

[Bernhard]

Great scenario, just read the whole thread, unfortunately too late to participate. Especially great since I had a very similar case recently and this made me think a lot over it again (89 y/o female, known COPD and CHF, home oxygene used - we applied CPAP and it significantly increased SpO2 soon).