Case Study: Respriatory Distress - Fluid or Mucus? EKG+ABG!

[fiznat]

O/A

Dispatched priority 1 for SOB. On arrival find 95 y/o female semi fowler's in bed on 2lpm n/c in significant respiratory distress. You notice a significantly increased work of breathing, tachypenia at 40rpm. She is alert and responsive, but baseline demented and hard of hearing. ...A poor historian at best who cannot fully answer your questions. She nods yes when asked about SOB, and will say not much else other than "hurry up, hurry up."

The nursing home technicians (I now refuse to use the word "nurse" for these people. Call them NHTs.) state that there was an acute onset of these symptoms approxamately 1/2 hour before you arrived. This seems questionable because it was mentioned that the patient was only found in this condition because the NHT was coming into the same room for something else. So, unknown onset of symptoms but perhaps it was acute. Patient last seen normal 6 hours ago (this is in the middle of the night).

The NHTs state that the patient is a new admit to them, and they are unfamiliar with the medical history. They "think" she has CHF, but they don't know. They are able to produce a list of medications, though, which helps:

HX

Rx: Lasix (20), Lopressor, Lorazepam, Ambien

Hx: HTN/CHF, Dementia

NKDA

VS

BP: 182/76

HR: 140

RR: 40, labored

SPO2: 82%

ETCO2: 59

Assess

Alert, responsive. PEARRL. Skin very hot to touch/pink/dry. Lung sounds with harsh, rhonchi-sounds about all fields. Difficult to determine rhonchi vs rales but you lean towards rhonchi. Upper airway clear. No JVD, no distal edema. ABD soft/non-tender. Pt demonstrates +PMS/CSM x 4 extremities. Rapid trauma assessment is neg. for DCAPBTLS. Venous BGL is 96.

EKG

Tx

Patient is sat up straight, placed on 15lpm NRB, IV established. Pt given 0.4mg NTG SL spray. Tpt --> ED. Enroute patient notes no change in SOB. SPO2 noted to increase to 100%, no other changes noted.

Discuss

I had a hard time making a decision as far as pneumonia vs. CHF with this patient. On one hand, the "acute onset," hypertension, and history seem to point to CHF. On the other, the hot skin, and probable rhonchi suggest pneumonia. I gave NTG only and held off on the Lasix because I was unsure. I thought briefly about a neb treatment, but I worried about giving beta-agonists to a tachycardic patient with ischemic changes.

At the hospital they burnt off an I-Stat. I got a copy for you guys:

(Here is a good website to help with reading ABGs: http://www.the-abg-site.com/about.htm)

So yeah, hot skin for sure. 102.5 freakin degrees. Also looks like a compensated respiratory acidosis. ...Borderline metabolic acidosis there, though, as the HCO3 is at the very high end of normal (top range is 26). I wouldn't be surprised if there was a metabolic component to the acidosis as well, although who knows.

The doc was pretty busy so I didn't get a chance to talk in depth with him about it, but it looked like they were leaning towards a pneumonia diagnosis. They sent off a BNP test to check, though, which I never got to see the results for. I will follow up if I can.

Anyways, wondering what you guys think. Ask questions if I left anything out. Also let me know if the images are too big.

[hammerpcp]

I think you definitely should have checked for a Babinski reflex.

Otherwise you did good. I probably would have guessed at the pneumonia as a working dx from the get go, mostly because of the skin. Did she have any hx of cough or sputum? Oh, I forgot she was in a NH so yo probably wouldn't know.

Anyhoo, ntg wont hurt, beta agonist may or may not have helped, although it may have been a good idea to try it, and lasix definitely wouldn't help and is not reversible so good call holding off on it.

Several ER docs I have come into contact with recently during my training have mentioned that the differential dx between COPD and CHF is often a very difficult one and that they would not rely on a clinical dx alone. They do the blood work and the chest x-ray before administering anything. So don't sweat it man.

Beta 2 agonist though. Hmmmm....I understand your concern with the cardiac side effects but it may have been worth a go. I just learned a wicked awesome way to nebulize meds while ventilating with a BVM.

[chbare]

Do you have access to any lab findings? I would love to see the WBC and a manual differential at a minimum. In addition, a chemistry 12, coagulation studies, cardiac enzymes and lactate level would be nice. A chest X-Ray would also assist us in the diagnosis. The presentation is quite suspicious for hyperdynamic sepsis. The patient may have underlying cardiac and or respiratory problems; however, the findings point toward sepsis.

Take care,

chbare.

[scott33]

Good thorough job.

If I was to stick my neck out...

Age + Nursing home + dementia + fever + tachycardia = sepsis

But look a bit more closely at her 12-lead (irrespective of what is written). She appears to have an anterior hemiblock and a RBBB. That is a bifacicular block in my book, and could definitely account for the SOB.

This woman is not well.

Keep hold of the EKG, its a good teaching reference.

[fiznat]

You guys seem to be pretty sure it was pneumonia, but what about the other findings that point towards CHF? Significant hypertension, a history of the same, acute onset of the symptoms... Those are all pretty strong factors that suggest CHF.

I was worried about this call because the factors that I had that pointed towards pneumonia were fairly subjective. The lungs sounded more like rhonchi than rales, but honestly in my limited experience it was borderline. The skin FELT hot to the touch, but she was under a bunch of blankets and we don't carry thermometers.

In contrast, the factors pointing towards CHF were objective. High BP, history, etc. Looking back it seems that I made the right choices, but to be honest this was a really tough one. I could have very easily gone the wrong way and really messed this patient up.

[chbare]

I am not telling you that the patient does not have cardiac or respiratory issues; however, the signs are quite suggestive for sepsis as well. The tachycardia, fever, and elevated blood pressure can idicate hyperdynamic sepsis. If you can obtain follow up information, we may be able to learn allot more about the patient.

Take care,

chbare.

[fiznat]

Yeah I work tomorrow 1500-2300, I'll try to get follow-up info if I can.

It shouldn't alter the discussion that much though. This is still an EMS forum, and most of us are going to be without lab results and chest x-rays when we meet these kinds of patients in the field. I'll get that info anyways though. It should prove interesting.

[chbare]

I would not expect the work up to alter our discussion. If anything, the results of the work up and the patients subsequent course will only help us put the big picture together and perhaps fully appreciate the extent of her problems and the implications of the therapies that we have considered.

Take care,

chbare.

[OVeractiveBrain]

I was going CHF the whole way until the hot skin. Ronchi, Rales, lets just say theres junk. Her history is very strong for CHF given the obviously uncontrolled hypertension and numerous risk factors for cardiac disease.

While I do think AMS+Old+Hot+Ronchi = infection, hypertension, history and a probably demented base line do not put it straight down the infection field. The presence of fever, however, pretty much guarantees infection, even if it is not her primary problem. I was shooting for pneumonia, too, by the end of the call. Coming from home with a fairly useless history and fairly useless "primary caregiver" makes the assessment difficult.

To be honest, Ive seen very few patients with active acute pulmonary edema. It is a constant source of anxiety for me, since it is the only thing I have trouble diagnosing. I had trouble clarifying what Rales really were and find myself going down the CHF path when it isnt necessary. It has also been a source of a number of posts on this site.

Basically, I accept the diagnosis of CHF under two conditions. (1) They are pink and frothy and my god is it hard to see the chords and wow do you need suction and (2) Hypertensive Diabetic with Lasix, Beta-Blocker, orthopnic, at a party where they just drank 5 beers because they just turned ninety and you can hear them gurgling.

Obviously I am exaggerating, but too few times I have actually caught some one in acute pulmonary edema. One strong case stands out in my mind (23 year old dialysis patient that skipped dialysis on friday and drank friday and saturday). Otherwise there is just always another differential. This is true more so in the elderly elderly, and especially in the instance of neurodegenerative disorders (MS, Alz, Dementia, etc.).

So, while this lady had a strong history indicative of CHF, in my book, in the absence of the Murse's call for labs (which are usually arriving when we are bringing in our NEXT patient), the fact that there could be another differential means that it probably isnt CHF. I like to personally carry 3 possible working differentials at any one time, weeding out the options with assessments and history. CHF, if it is one, is usually the case when the others have been ruled out.

Overactive

P.S. Man do I miss being on the road every day.

[fiznat]

To be honest, Ive seen very few patients with active acute pulmonary edema. It is a constant source of anxiety for me, since it is the only thing I have trouble diagnosing. I had trouble clarifying what Rales really were and find myself going down the CHF path when it isnt necessary. It has also been a source of a number of posts on this site.

I agree dude. I freaking hate lung sounds. Perhaps it is inexperience, but I constantly fear coming into the ED with a patient I have decided has rhonchi and then have the MD/RNs turn around and say "uh, no. That's big time rales-- how did you not notice that??" The two are hard to tell apart, and despite other associated signs + symptoms (like we see in this case), often the truth is still far from obvious. I suppose this is why tests such as BNP, chest x-rays, labs, etc exist. ...Because the basic signs + symptoms are very often not enough to tell.