1. Acute CHF & Aortic
Disasters
Troy W. Pennington DO, MSHPE, FAAEM
EMS Director- ARMC
1

2. WHY HOLD THE
LASIX?
AMR 713 Victorville
85 y/o male SOB x 1 day
3-4 word dyspnea
Warm to touch
Cough
Pedal edema
2

3. 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

4. Acute SOB
What is the optimal treatment in the next 5-10
minutes?
! A. morphine
! B. Lasix
! C. Morphine + lasix
4

5. Acute SOB
What is the optimal treatment in the next 5-10
minutes?
! A.
! B.
! C.
5

6. Acute Pulmonary Edema
Preload…tries to fill lungs
LV Function…emptys heart
Afterload…size of hose to empty heart
6

7. Acute Pulmonary Edema
What do you do if the Bathtub is overflowing?
Turn off water….Preload
Pump it out…LV Function
7

8. Preload Reduction
 MS
 Lasix
 Nitrates
8

9. Morphine as Preload
Reducer
 Disadvantges
 May increase catecholimines
Respiratory depression
Direct myocardial depressant…decreased SV
No good evidence that it is a central preload
reducer
9

10. Morphine Swan Studies
Preload increased
Worsening cardiac index
10

11. Lasix
Increased catecholine output… activates
renin..angiotensin system early on
Dieuresis is delayed…at least 90 minutes
Decrease stroke volume and cardiac output drop
Increases afterload
11

12. Nitroglyercin
 Better than morphine or lasix for preload
reduction
Safer than morphine or lasix
Rapid effective iniation of treatment
12

13. Ace Inhibitors
 Reduces afterload & some preload benefits
Works within 15 minutes
Decreases intubation and ICU admission rates
Combined ith NTG exceeds benefit of either
alone
13

14. 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

15. 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)

16. What about CPAP or
BIPAP?
Non-Invasive Positive Pressure Ventilation
In an Austrialian meta-analysis 23 trials were reviewed
They found that when either CPAP or BiPAP were used
there was decreased mortality
Decreased need for mechanical ventilation
Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163
16

17. SOB & Funny looking
T-Waves
AMR 145
40 y/o female CC- general weakness & SOB
DM, HTN, ESRD on dialysis 3x wk.
Sinus rhythm with peaked T-waves
17

18. Acute SOB & Renal
Failure
Medic 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

19. Case #1
37 y/o man presents in respiratory distress
History of HTN
Missed last 2 dialysis sessions
Exam is consistent with pulmonary edema,
severe hypoxia (pulse ox 80%)
Initial EKG…
19

20. Initial EKG
20

21. Case # 1
Only mild improvement with NRB mask
Decision made to intubate
Etomidate
Succinylcholine
Rhythm changes, interpreted as VT…
21

23. Case # 1
The patient is given a bolus of lidocaine and his
rhythm changes to…
23

24. Case # 1
24

25. 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

26. Ventricular
Tachycardia
What’s the problem why don’t just go ahead and treat
with 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

27. 61 year-old man with
palpitations and

29. 79 year-old man; 45 minutes after receiving
thrombolytic therapy for acute myocardial

30. 6. Answer

31. 52. 62 year-old man with renal failure
complains of dyspnea and orthopnea
after missing his last two hemodialysis
sessions

32. 52. Answer…

33. 52.
Answer

34. Heart Blocks
Blocks are like relationships
1st Degree
2nd Degree Mobitz I “Wenckebach”
2nd Degree Mobitz II
3rd Degree Block- complete disassociation
34

35. The Electrical Pacemakers

36. Home

37. Home
12. Answer

38. Home
42. Answer

39. Home
Third Degree Heart
Block

40. 57. 54 year-old man with five days of
anorexia, nausea, and vomiting

41. 57. Answer

42. 68. 41 year-old man with weakness
after missing hemodialysis

43. 68. Answer

44. 69. 45 year-old woman with left chest
and arm pain and dyspnea

45. 69. Answer

46. 69. Answer

47. 79. 68 year-old man unconscious with
blood pressure 108/60

49. 89. 44 year-old chronic alcoholic with
persistent vomiting, becomes
unresponsive during the ECG

50. 89. Answer

51. 100. 26 year-old woman with history
renal failure, reports nausea and
generalized weakness

53. V Tach Mimics-
Summary
Beware Slow V Tach HR < 120 BPM
Consider hyperkalemia, TCA OD, AIVR
Avoid Lidocaine and other antidysrhythmics
When in doubt try HCO3
53

54. THANK
YOU
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