Pneumonia vs CHF

[goofymedc8]

Okay...my turn...

62yo male...as you guessed, a run I had recently...

CC: Shortness of Breath...

Hx: HTN; Recently underwent treatment for mild bronchitis.

HOPI: Pt relates waking up in the morning feeling just a little SOB, coughed, felt better and went about his day. Sitting down for dinner, he noticed that SOB had returned and had been getting progressively worse over the last 45-60 minutes. He denies any CP; but relates feeling "tight" across his chest.

Initial assessment/impressions: 62yo white male without hx of lung disease or cardiac hx outside his HTN. Pt is sitting upright on kitchen chair in a tripod position. His skin is pale, cool, and slightly diaphoretic. Sternocleidomastoid retractions noted. Pt is in severe respiratory distress. Central Cyanosis noted. Vitals: BP 182/106; HR 122 and regular; RR 28bpm and labored; SpO2 83% RA. Blood Glucose 152; Sinus Tach on monitor without ectopy or ST changes. Pt is normothermic. Lung sounds are markedly diminished to mid-lobe bilaterally. Very tight wheezes noted on inspiration/expiration. No pedal edema or JVD noted; Pt sleeps on two pillows a night normally for personal comfort.

Tx: 100% O2 via NRB; IVx2 (18g/20g in ACs); Cardiac Monitoring (6-lead EKG obtained) Continuous MedNeb (Albuterol x2 UD); 125mg SIVP Solu-Medrol. VS q5 minutes during emergent transport to ER. Calm reassurance as pt was very anxious.

Reassessment: BP 178/100; HR 118; RR 24...labored but cyanosis reduced significantly. SpO2 94% on 15lpm NRB. Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum. Air movement in lungs improved.

Field "diagnosis": Acute Respiratory distress secondary to pneumonia.

Now, on this run, the ER asked me why I gave Solu-Medrol when she clearly believed he was in CHF. I explained that he had no history of CHF or any pulmonary disease, just a recent bout of bronchitis which he got ATBs for. He had no pedal edema, JVD, or any other signs of CHF that you would expect. Last I checked, CHF is a secondary condition, rarely primary unless it is congenital. I really wanted to ask her why she believed it to be CHF. Did she draw a BNP level, get a CXR, or even listen to what I told her in my verbal report? But, I kept me yap shut and went about my merry way. 2 weeks later, I get pulled into the Chief's office concerning this run. That same RN wrote me up for giving the Solu-Medrol (and I did follow my protocol for acute respiratory distress). I explained to the chief my reasoning behind it and he agreed I did what protocol dictated for this pt and that it was appropriate.

Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt. My medical director reviewed that run and said that even if he was in CHF, the Solu-Medrol would not have hurt him. (BTW...he did have pneumonia, not CHF and was given Lasix anyway at the ER).

[BushyFromOz]

Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum.

Given my limited experience and relative n00b status, i'd say your nurse was being a bit of a pratt :wink:

pneumonia sounds good to me

[JeniF371]

I would say she evidently didn't listen to your report. I find that happens often, they get them and want to assess them without even listening most times. They hear the CC and do what they want when the patient gets there. ONLY good nurses listen to what has been done and will ask why and with good reasoning, will accept what has been done, and go on with their treatment of the patient.

I have a question, off topic but was just curious... for my own information. Why an IV in both AC's? Wasn't one enough? Just curious, still learning.

[akflightmedic]

Jeni,

He described a serious patient presentation. I am willing to bet his line of thought, as has been mine on a few occassions, is get the IVs while you can. If the patient is this severe, place a second line in case the first one gets yanked out or occludes.

It is never fun trying to restart an IV once the patient has decided to get worse.

Now I will critique and say ACs are last choice for me, but in all fairness it may have been all the patient had or in a crunch for time it is always easier to hit the big fat vein winking at ya...

[goofymedc8]

AK...

That was exactly my thinking...My thing is, if it's screams at me first and says "hey! Stick here!", then that's exactly where I'm gonna go...especially if they have the high potential to crump on me. I usually start IV's in the hands/forearms. Someone crumping on me or having the high possibility to, I always try to place more than one IV if I can. I'll be happy with one if that's all I can get.

As far as RNs not listening...'tis unfortunately true where I transport to. However, if the RN has a background in EMS, they tend to pay closer attention.

Thanks for the feedback!

btw...goofymedc8 is a SHE!! )

[fiznat]

To be honest, I would be highly suspicious about possible CHF with this patient as well. I have seen lots of CHFers present with lungs FULL of fluid but lacking in clinical findings like JVD and distal edema. The two do not necessarily always show up together.

-Hypertension is another warning sign for CHF, as well as "full" sounding lungs with wheezing at the top. That is very common. Rhonchi and rales are notoriously difficult to tell apart and lots of people - even doctors - get this part wrong with amazing consistency.

-Sleeping on extra pillows at night is another finding typical for CHFers, as it minimizes areas of the lung obstructed by fluid. At the same time, this would be atypical for pneumonia patients, as mucus is more viscous and will generally remain where it is regardless of body position.

-The SOB sounds like it was more of a rapid onset. This seems to suggest CHF more than pneumonia, as lungs can fill up quickly, but pulmonary infections take some time to build up.

-The patient's skin was cool. I know it is not an exact thing, but pneumonia sufferers are often hyperthermic.

The cough may have been a red herring, but who knows. Perhaps he had a little bit of both going on.

This is a tough one. It really is hard to second guess something like this without seeing the patient, hearing the lung sounds, looking at the 12 lead, etc (do you have the 12 by the way?). Like I said though, I would be VERY suspicious about failure in this patient with all of the findings you've listed above. It seems - just from what you've written - that there may be more "pro CHF" stuff than "pro pneumonia" stuff.

I dont think you did anything wrong, but I'd be interested to hear a little more of your defense as to why the seemingly CHF-sounding factors didn't sway you from your pneumonia diagnosis.

[whit72]

Fiznat wrote:

I dont think you did anything wrong, but I'd be interested to hear a little more of your defense as to why the seemingly CHF-sounding factors didn't sway you from your pneumonia diagnosis.

I agree. It sounds like classic CHF to me. What besides the productive cough, pushed you to pneumonia? Everything else seems to point to CHF.

[goofymedc8]

My defense for thinking pneumonia...He had NO JVD; NO pedal edema; had NO complaints of orthopnea; Has recently finished ATB treatment for bronchitis; and has absolutely NO hx of COPD, Asthma, or any pulmonary disease; CHF; or Heart problems outside of HTN. I pretty sure he had no flash pulmonary edema because his sputum was green/yellow/brownish and not frothy pink in nature. And from the last few flash pulmonary edema peeps I had, NONE of my treatments helped and we don't carry CPAP (yet). I can't really justify treating this pt for CHF without the hx. Please correct me if I'm wrong, but unless there is a congenital cardiac problem, CHF is USUALLY a secondary condition.

Again, as always, I am open to thoughts and constructive critiquing.

[fiznat]

Okay, just to make a few points. I'm not criticizing you, just commenting on the call and offering another opinion-- which is why I assume you posted in the first place.

-JVD and distal edema are not ALWAYS present. Their absence does not rule out CHF

-Sleeping with extra pillows is suggestive of orthopnea, even if the guy didnt specifically say it

-CHF does not depend on a history of any kind of pulmonary disease

-A lack of stated heart history does not mean that there wasn't some underline borderline failure going on. He does not need to be actually diagnosed with cardiac insufficiency before CHF becomes a possibility that you need to consider. I would ALWAYS consider CHF, "heart history" or not. Especially with this presentation.

-The color of sputum isn't very valuable, in my opinion, for diagnosis between CHF and pneumonia. ...And even still, you said yourself that he had a hx of bronchitis. What if the sputum is still some of that, while the primary problem remains CHF?

-Your recent experience with "the last few" patients who had pulmonary edema isnt very valuable, either, as far as to the worthiness of CHF treatments. This is a terrible argument. Nitro and CPAP work awesome for pulmonary edema in general. ...Just because it didnt work for your last few patients doesn't mean you shouldn't try it now.

-History isn't everything. It is true that CHF arises out of a backdrop of cardiac failure, but just because this guy hasnt actually gone to the doctor and received a diagnosis doesn't mean that it is impossible for the condition to still exist. There are plenty of people who have undiagnosed cardiac insufficiency, people who dont go to the doctor often or simply havn't gone recently. You need to go by your assessment, not by the previous assessments of other doctors. In the face of the rest of this guy's presentation, a lack of history is not enough to rule out CHF.

Just some things to think about. Like I said, I didn't see the patient though.

[WelshMedic]

Fiz,

Whilst I agree it's difficult to diagnose without seeing a pt yourself, I do think that you've made a number of subjective conclusions that are, at best, tenuous. No, JVD and distal edema aren't always present, but 9 times out of ten they are, to a greater or lesser degree present. I aslo think that History is a very important diagnostic tool in this case. It's one of the few ways that one can distinguish CHF from obstructive pulmonary disease - it's a question of asking the right questions, in my experience.

There are no absolutes in emergency medicine (or in medicine, generally) and that why it's part science and part art. Therein lies the challenge that I enjoy taking up every day. I think our colleaugue in this case used good judgement and sound clinical reasoning. That there are always exceptions to the rule is fine, but don't lose sight of the ball for the 90% that present with text-book symptoms.

WM