Acute CHF & Aortic Disasters
Upcoming SlideShare
Loading in...5
×
 

Acute CHF & Aortic Disasters

on

  • 1,694 views

 

Statistics

Views

Total Views
1,694
Views on SlideShare
1,055
Embed Views
639

Actions

Likes
0
Downloads
14
Comments
0

1 Embed 639

http://onscene1097.com 639

Accessibility

Categories

Upload Details

Uploaded via as Apple Keynote

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Time for a case discussion. \nThink about what your response to this patient will be. \n\nCheck if they know ambulance codes.\n(note: change of modes to maintain interest)\n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n

Acute CHF & Aortic Disasters Acute CHF & Aortic Disasters Presentation Transcript

  • Acute CHF & Aortic Disasters Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC 1
  • WHY HOLD THE LASIX?AMR 713 Victorville85 y/o male SOB x 1 day 3-4 word dyspnea Warm to touch Cough Pedal edema 2
  • Acute SOB 66 y/o man presents with acute sob developing over the last 8 hoursHistory of HTN, and tobacco useDiaphoretic, normal mental statusAfebrile, HR 110, BP 180/110, RR30, pulse ox. 86% Lungs crackles, JVD, pedal edema 3
  • Acute SOBWhat is the optimal treatment in the next 5-10minutes? ! A. morphine ! B. Lasix ! C. Morphine + lasix 4
  • Acute SOBWhat is the optimal treatment in the next 5-10minutes? ! A. ! B. ! C. 5
  • Acute Pulmonary EdemaPreload…tries to fill lungsLV Function…emptys heartAfterload…size of hose to empty heart 6
  • Acute Pulmonary EdemaWhat do you do if the Bathtub is overflowing?Turn off water….PreloadPump it out…LV Function 7
  • Preload Reduction MS Lasix Nitrates 8
  • Morphine as Preload Reducer Disadvantges May increase catecholiminesRespiratory depressionDirect myocardial depressant…decreased SVNo good evidence that it is a central preloadreducer 9
  • Morphine Swan StudiesPreload increasedWorsening cardiac index 10
  • LasixIncreased catecholine output… activatesrenin..angiotensin system early onDieuresis is delayed…at least 90 minutesDecrease stroke volume and cardiac output dropIncreases afterload 11
  • Nitroglyercin Better than morphine or lasix for preloadreductionSafer than morphine or lasixRapid effective iniation of treatment 12
  • Ace Inhibitors Reduces afterload & some preload benefitsWorks within 15 minutesDecreases intubation and ICU admission ratesCombined ith NTG exceeds benefit of eitheralone 13
  • WHY HOLD THE LASIX? Top Articles in 2006  Evaluation of Prehospital use of Furosemide in patients with Respiratory Distress  Use of Lasix prior to adequate preload and afterload reduction can be harmful Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197 14
  • WHY HOLD THE LASIX? Lasix given improperly up to 30% of the time Patients that received lasix and/or morphine had increased mortality 2.2 to 22% Use of NTG not associated with worse outcome even if given inappropriately! ! Wuerz (Ann Emerg Med 1992)
  • What about CPAP or BIPAP?Non-Invasive Positive Pressure VentilationIn an Austrialian meta-analysis 23 trials were reviewedThey found that when either CPAP or BiPAP were usedthere was decreased mortalityDecreased need for mechanical ventilation Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163 16
  • SOB & Funny looking T-WavesAMR 145 40 y/o female CC- general weakness & SOB DM, HTN, ESRD on dialysis 3x wk. Sinus rhythm with peaked T-waves 17
  • Acute SOB & Renal FailureMedic 314 57 y/o female w/ acute resp distress Unable to speak Retractions, JVD, no pedal edema ESRD Bp 250/150 HR 140 RR 30’s SATS 80-90’s 18
  • Case #137 y/o man presents in respiratory distressHistory of HTNMissed last 2 dialysis sessionsExam is consistent with pulmonary edema,severe hypoxia (pulse ox 80%)Initial EKG… 19
  • Initial EKG 20
  • Case # 1Only mild improvement with NRB maskDecision made to intubate Etomidate SuccinylcholineRhythm changes, interpreted as VT… 21
  • Case # 1The patient is given a bolus of lidocaine and hisrhythm changes to… 23
  • Case # 1 24
  • Ventricular Tachycardia Wide complex regular rhythm No obvious pqrs association Heart Rate must be >= 120 If HR < 120 BPM, consider Hyperkalemia Type IA medication toxicity (incl. TCA & Cocaine toxicity Reperfusion arrhythmias (AIVR) 25
  • Ventricular TachycardiaWhat’s the problem why don’t just go ahead and treatwith lidocaine, procainimide, amniodarone…V- Tach Mimics Treatment of slow “VT” may induce asystole Mclean, et al (Ann Emerg Med, 2000) WCT due to hyperkalemia misdiagnosed as VT 26
  • 61 year-old man withpalpitations and
  • 79 year-old man; 45 minutes after receiving thrombolytic therapy for acute myocardial
  • 6. Answer
  • 52. 62 year-old man with renal failure complains of dyspnea and orthopneaafter missing his last two hemodialysis sessions
  • 52. Answer…
  • 52.Answer
  • Heart BlocksBlocks are like relationships 1st Degree 2nd Degree Mobitz I “Wenckebach” 2nd Degree Mobitz II 3rd Degree Block- complete disassociation 34
  • The Electrical Pacemakers
  • Home
  • Home 12. Answer
  • Home 42. Answer
  • Home Third Degree Heart Block
  • 57. 54 year-old man with five days of anorexia, nausea, and vomiting
  • 57. Answer
  • 68. 41 year-old man with weakness after missing hemodialysis
  • 68. Answer
  • 69. 45 year-old woman with left chest and arm pain and dyspnea
  • 69. Answer
  • 69. Answer
  • 79. 68 year-old man unconscious with blood pressure 108/60
  • 89. 44 year-old chronic alcoholic with persistent vomiting, becomes unresponsive during the ECG
  • 89. Answer
  • 100. 26 year-old woman with history renal failure, reports nausea and generalized weakness
  • V Tach Mimics- SummaryBeware Slow V Tach HR < 120 BPM Consider hyperkalemia, TCA OD, AIVR Avoid Lidocaine and other antidysrhythmics When in doubt try HCO3 53
  • THANK YOU Questions?You can contact me at: