Difficulty Breathing

[FireEMT2009]

Hey guys,

Been a while but I got a good one for you.

You are dispatched to a residence at 0300 for a patient having difficutly breathing. Upon arrival, you find an 88 year old female in the tripod position in bed, with severe respiratory distress. Patient states that she cannot breath. Patient has audible wheezing.

And.....GO!

[Kiwiology]

PMHx?

Meds?

HPI?

O/E (ROS)?

Obs?

At first glance lets give her some salbutamol and ipratropium while we gather more information.

If she is very, very hypoxic and near arrest then forego the nebules and just give her high flow oxygen (NRB 15 LPM) +/- parenteral adrenaline

[J306]

Accessory muscle use?

Perioral cyanosis?

Hx of asthma or CHF?

Let's get our partner to get a r/a 02 sat as we're auscaltating lung sounds down the back, what do we hear?

Any associated tightness to the chest, or pain on inspiration?

Lets get ETC02 reading, get her on an NRB 15 lpm, switch the reservoir for a combivent neb canister and continually monitor how she responds.

[FireEMT2009]

PMHx?

Meds?

HPI?

O/E (ROS)?

Obs?

At first glance lets give her some salbutamol and ipratropium while we gather more information.

If she is very, very hypoxic and near arrest then forego the nebules and just give her high flow oxygen (NRB 15 LPM) +/- parenteral adrenaline

Atrial Fibrillation, HTN, PAD.

Plavix, Lisinopril, Lopressor, and Coumadin

She was awoken with the difficulty breathing and wheezes.

Accessory muscle use?

Perioral cyanosis?

Hx of asthma or CHF?

Let's get our partner to get a r/a 02 sat as we're auscaltating lung sounds down the back, what do we hear?

Any associated tightness to the chest, or pain on inspiration?

Lets get ETC02 reading, get her on an NRB 15 lpm, switch the reservoir for a combivent neb canister and continually monitor how she responds.

She has some accessory muscle usage in her neck

No perioral cyanosis yet.

No Asthma or CHF hx.

RA O2 of 88%

Wheezing noted throughout all lung fields, has some diminihed breath sounds in the bases.

No CP, during inspriation, or exhalation. No CP.

ETCo2 of 45

Would you like to start a neb treatment now? If so what med, or meds would you like to have in the nebulizers, and would you like vitals first?

[J306]

I'd like to hold off on the nebs, continue the high flow 02 until we can be sure this is not a case of Cardiac Asthma. If our assessment suggests Cardiac Asthma, neb tx's may worsen the condition. Trepopnea present? Any pedal edema? How is her mental status, any dizziness/fatigue? Has she recently been experiencing increased SOB on exertion? Cough? s1, s2 audible?

Let's continue high flow 02 as stated above, get a set of vitals including temp, get a 3 lead than 12 lead looking for signs of recent infarct/ischemia or hypertrophy.

Is her breathing worse off when laying down? Has she been taking her meds regularly?

[chbare]

Since we are monitoring CO2, what is the morphology of the waveform? Has this ever occurred before? If so, what was the cause, how was it treated and what was the outcome (did the patient require intubation)?

[FireEMT2009]

I'd like to hold off on the nebs, continue the high flow 02 until we can be sure this is not a case of Cardiac Asthma. If our assessment suggests Cardiac Asthma, neb tx's may worsen the condition. Trepopnea present? Any pedal edema? How is her mental status, any dizziness/fatigue? Has she recently been experiencing increased SOB on exertion? Cough? s1, s2 audible?

Let's continue high flow 02 as stated above, get a set of vitals including temp, get a 3 lead than 12 lead looking for signs of recent infarct/ischemia or hypertrophy.

Is her breathing worse off when laying down? Has she been taking her meds regularly?

No trepopnea.

There is some pedal edema in the feet, but none noted in the hand. Her mental status is alert, bu she does appear to be beginnig to tire out with her breathing. She states that she has been experiencing some SOB upon exertion but she figured it was normal. She has had a cough with frothy sputum. S1 and S2 are audible with no gallop.

She states that she cannot lay down it puts her in severe panic. And she has been taking them regularly.

High flow O2 has been applied with some relief of difficulty breathing, O2 Sat has only come up to 89%. Her respiration rate is around 60.

Since we are monitoring CO2, what is the morphology of the waveform? Has this ever occurred before? If so, what was the cause, how was it treated and what was the outcome (did the patient require intubation)?

Morphology: Rectangle, not "shark fin"/

This is the first time this has ever occured.

[Kiwiology]

12 lead ECG +/- right sided ECG +/- posterior leads?

Hmm ... as I understand with "cardiac asthma" (wheeze from constriction of irritated bronchioles due to pulmonary edema) there is usually a degree of crackle and wheeze.

Are there crackles?

If there are no crackles and her ECG has no signs of ischaemia, infarction or wide complex tachycardia I'd give her some salbutamol and ipratropium.

If so then I guess we could try one spray of GTN and see how that went

Regardless, let's get her on the way to hospital.

Current status is two - urgent/needs to be seen by a Doctor within 10 minutes of arrival.

[mobey]

Okay: I'm on the "High pressure Pulmonary edema" train.

Just want a HR and BP and temp to solidify my assessment.

Either way, CPAP goes on now.

Get a line in her and once the pressure comes back hypertensive give her a Nitro (OK that was a little arrogant)

In the mean time, squirt the Salbutamol MDI in the cpap a few times. There is a balance between relieving spasm to maximize ventilation/oxygenation, and irritating the heart with excess salbutamol.

I'll also give her 1.0mg Ativan SL if that BP comes back high. I like to treat the intrinsic catecholamine dump from the source.

of course all this is based on vitals = tachycardia with hypertension and afebrile.

12 lead ECG +/- right sided ECG +/- posterior leads?

Hmm ... as I understand with "cardiac asthma" (wheeze from constriction of irritated bronchioles due to pulmonary edema) there is usually a degree of crackle and wheeze.

Are there crackles?

Ya kiwi that is correct. The problem is, sometimes you cant hear the crackles through the wheezes, or differentiate good enough until it is too late. With a RR of 60 and signs of fatigue I am as aggressive as they come if I suspect flash edema. I have had 3 people die in my ambulance ever...... and they were all high pressure pulmonary edema patients.

All the ECG's are important, if this is an acute MI, we may thrombolize it. If the A-Fib is gotten out of control again, she may need rate control, but if we don't get her resp status temporized none of that would matter.

[J306]

and thennnnn?