Differential Diagnosis

[medic001918]

She is unable to lift her tongue to the roof of her mouth (either through communication, nerve damage or the fact that she is hypoxic) so NTG is out, we dont have CPAP nor PEEP, so thats out too. I could have tried using a BVM as a PEEP, but i went for more benign treatment since at this point she was awake and aware.

Could you have used NTG paste? It's a viable option for the patient that can't follow commands.

I agree with others that lasix probably wasn't the best course of treatment for this patient. I would have pursued a different course or treatment based on the picture you painted for us. A patient that is unresponsive secondary to hypoxia (such as in late stages of failure) would not have a sat of 98%, and would not generally be normotensive. I'm curious, was she tachy? If so, how tachy was she?

An aspiration pneumonia can present with a sudden onset. The story you present doesn't make me immediately think of CHF. It sounds like there's more to the story than what's being presented. The best treatment for this patient would be conservative, as any form of pneumonia is one that dehydration could worsen and provide additional complications for the patient.

tniuqs provided a great analysis of the call based on what you've presented. Review his information, follow up on the patient with the ED and find out what it was. And most of all, learn from this call.

Shane

NREMT-P

[ERDoc]

OVB I feel your pain. The first SOB patient I ever had as an ALS provider was much like this, with a similar result.

The only differences were his pressure was much lower but he had the classic CHF rales that you could hear down the hall. I had seen many CHF patients as a Basic, and this one was screaming CHF at me. No history that would've normally pointed me towards failure, but I went there anyway.

To my credit though, so did the ER MD. I had given and 40mg lasix enroute and the doc ordered another 80 before he was even off our stretcher, followed later by CPAP, which the patient was less than compliant with. I followed up several days later (with the ER MD), and found out that the DX was in fact pneumonia.

ERDoc- in my case, with an assessment seems most likely pneumonia with a low pressure (90's) would a fluid bolus be something to consider, or do we want to avoid that and just try to maintain him as is? I ask because many of the pneumonia patients I tend to see are on their way downhill towards fullblown sepsis, and once I'm satisfied that it's not CHF I'd like to be able to do something for them, but I've been hesitant with fluids do to everything they've already got going on. Plus, on occasion, there is still the nagging doubt of whether it IS CHF or not. I have gotten 200x better at differentiating though.

Someone bordering on septic needs fluids. A pt in full sepsis can require liters of fluids in order to fill the space created by vasodilation. Obviously if they have a history of CHF you need to be careful, but that fluid is more likely to fill your increased peripheral capacitance before it will dump into the lungs. The ICU guys can worry about that, if they don't get the fluids they will not make it to that point. I have put almost 12 liters of fluid into a septic pt over 3 hours and still started them on pressors. In sepsis the key is antibiotics and then fluids. I would recommend giving so much fluid in the ambulance, but it is a good idea to start a hypotensive pt with a low BP some fluids.

[VentMedic]

A little tracheal suctioning preferably NT (with an NPT in place if available for comfort) after hyperoxygenating with the NRBM would determine the quality of secretions as for as pulmonary edema or aspiration in some cases. It would also clear the airway somewhat to hear breath sounds better. All gurgling, rhonchi and crackles sound misleading until you take out the excess noise. It may not be pneumonia at this point in time but will be soon.

Pts with difficulty moving or nursing home pts are usually positioned side to side. Thus aspiration tend toward LLL or RML. Supine pts aspirate toward upper lobes. If pt aspirates while chest is vertical (while eating) then RLL. LLL is also more likely to have atelectasis making it very prone to pneumonia. Pts who are losing control of their airway and swallow ability will have some combination of all lobes involved.

CPAP in a pt that has lost muscle tone in the oropharynx is not recommended. The continuous positive pressure will lead to further aspiration of oral secretions and possible occlusion of the airway. The pt should still have some control over their own airway for safe usage of CPAP/BIPAP.

A little BLS before ALS.

[tniuqs]

"ERDoc"

I agree with all of your points. However, aspiration pneumonia most commonly occurs in the RLL. The reason being is that the left mainstem has a sharper angle off the trachea than the right, so it is a more direct path to the RLL. This is also why most inhaled objects end up in the RLL. Then again, those north of the border may have a different anatomy.

Oh sure, pick on the dumb Kanukistanian challenged by snow, ice and trying to find a doorbell on those damn igloos! :oops: Yes in this case (from the commentary and reported ascultation) more likely a LLL aspiration, but your point well presented the Right Mainstem is far more a favourite route for "peas and carrots".

VentMedic enlightens us with the "chronic, bed-ridden" patient and most excellent comentary, yes, the BLS approach of suctioning with an Trumpet tube would (most likely) have been my first option as well, yet again, well stated the armchair quarter back is always correct post play!

BUT the thing in VentMedics World "rumoured" is that when he flushes the Toilet Bowl it circles the OTHER WAY ?....

I have no problems playing Monday morning quarterback for any call that someone has a question about, but, as tnuiqs stated, be honest with what you are thinking and hoping to accomplish. Say straight out, "I had this call and got a major attitude from the nurse. I think I'm right, but let me know what you think." Just be prepared to hear that you might be wrong. If you are looking for opinions on what happened and what the diagnosis is, you've come to the right place. If you are looking for someone to make you feel better and tell you that you were right when you might have been wrong, you have come to the wrong place.

This point is also well made ( I failed political sensitivity training 101) far more diplomatic, so in conclusion, patient presentation a systematic approach and the possibilitys that one can not be 100% correct all the time was attempted by Overactive Brain, so + 5 on the Dust devil scale as this was a great teaching post, it refreshed my under active brain as well!

Overactive Brain does post some great stuff and a very valued member on EMT city, hope I wasn't TOO harsh.

OveractiveBrain:

Talking to my partner who said a pulmonologist Doc told him that a paramedic in the field will be unable to differentiate a pneumonia from edema due to resonance and a generally untrained ear. While early pneumonia may be localized and audible in one field, the chances are slim. Now i think thats crap, because pneumonia should sound different, but its still something I consider.

This point: I must whole heartedly agree ! and it clearly demonstrates your willingness to learn and not accept a pre-concieved status quo notions.....I think its crap too.....perhaps "that" MD.... as specialists do thrive on this elitism idea. Perhaps this pulmonologist should get off his opinionated ass and do more teaching as well..... :twisted:

Gosh darn good thing WE have the very respected ERDoc and his daily (almost) comitment to this board.

ps Just in passing Overactive Brain...if the opportunity ever presents itself again, ask to review the CXRay this is a great learning experiance even though it can be most humbling at times, (I have been!) The difference between a Good medic and a Great one is never let bedside personality differences cloud your learning, my personal experiance has been that one recieves way more brownie points from ER staff when one is open minded.

cheers

[ERDoc]

That pulmonologist is a tool. Anyone can learn to listen to lungs sounds. Will we ever be able to discriminate the minute differences he is able to detec? No, probably not, but do we need to? No, probably not. Pneumonia is generally easy to differentiate from pulm edema, especially in your otherwise health person. Pneumonia will usually present with decreased sounds over a specific area when compared to the other fields. You may also hear some rales/rhonchi. Pulm edema will usually be more diffuse and will start at the bases and work their way up. Obviously the more comorbidities they have the more sounds you may have to differentiate. Also the more adiposely enhanced they are the more difficult they will be to assess. Pulmonologists have developed a special skill that helps them to be able to better assess the pt. It's called looking at the chest xray/CT scan first. Tniuqs, thanks for the praise and reminding me that I have no outside life.

Seriously, I like coming here. You guys are all down to earth and afterall, EMS is where I started as one of the v-words (no, not that v-word. I started as a volunteer). It think it is important to

[OVeractiveBrain]

Sorry ive been away for so long.

So some info i may have left out in the original post, that Ill reiterate that led down the path of Pulmonary Edema.

For Pulmonary Edema

Why I jumped to CHF:

-That percolating sound upon spontaneous respiration of 'im full of fluid' heard without a scope as you walk up to her. It was only really after the intervention that i was curious as to whether i had made the right decision (left cleared, right didnt) *

-Relatively fast onset (basically overnight)

-afebrile

contributing factors:

-pt improvement (easier to breathe, better color, less sluggish, though still pretty lethargic) after lasix

-no "cardiac hx" but she does have HTN

-(retrospective) improvement in lung sounds (particular left) in the semi fowlers position, and increased pulse ox post intervention

Against Pulmonary Edema, why i second guessed:

-Predisposing condition

-Normal ECG (no rotation, no ACS, no hypertrophy, nothing cardiac on the monitor nor 12-lead to suggest a cause of CHF)

-No Hx indicative of CHF, Hx of pneumonia

*ERDoc's comment about right side having higher incidence of pn

To some of the other comments:

-She wasnt dehydrated nor septic; oral mucosa was wet, there was no tenting of skin, and she was afebrile. I wasnt really concerned about electrolytes at that point either, as her pressure was fine and she had been normal and functioning until that day.

-CPAP would have been great, but the closest thing ive got is manual PEEP (a BVM with some positive pressure on release). I had considered it when I first got to her, since she was unresponsive with spontaneous respirations. Once we managed to extricate her (all the while on 15LPM NRB) she came around a bit. Since i had other things I had to manage (and i was traveling down the route of CHF, question of pn) i decided not to dedicate my time to convincing her it would be worth while for me to force air into her lungs.

-I really would have liked to give NTG. Again, all we have is the spray, and her neurologic disorder cause her to be unable to lift the tongue and open her mouth. Something to do with a change of meds for pain in her face. Yes, i could have ripped open her mouth and sprayed it in prior to giving the lasix, but since the dose of lasix was so low and I had access (we have to have access prior to NTG admin) i went for what was easier for me.

-I wasnt going to take a conservative approach either. Some one found with a GCS of about 9 who improves with 02 but was still sluggish with poor presentation with a transport time of about 20 minutes or longer warrants some intervention. I guess Im really not describing her presentation well enough to justify my actions. Also, I wrote the initial post with the tone of "crap, did I do somethign wrong" instead of "this is what i did but that stupid nurse thought i was wrong," so im not suprised people are finding out of favor with my intervention. My saving grace is the paramedic in back with me agreed, so Im not all worried, just interested in what people have to say.

In any case, im sure this will initiate a new barrage of posts, but I appreciate the feedback, harsh or not. But dont worry, you cant insult me. And if you did, id just report you to an admin. Just Kidding. No Im Not. Yes I am. Kidding.

The real point of the post, what I was tryign to get to, was not "whether i did the right thing" but more along the line of "have you had aspiration pneumonia present as a possible CHF" and "can some one without any cardiac findings at a paramedic level be suffering from edema."

[OVeractiveBrain]

So I had the same patient again today, one week later, 3 days after being discharged with aspiration pneumonia. Guess what she still has? Whoops...