This document outlines the objectives and procedures for EMS providers regarding heart failure and the use of CPAP as an intervention. It details definitions, causes, symptoms, assessment techniques, and treatment protocols for patients with congestive heart failure and pulmonary edema. Additionally, it covers medication management, CPAP set-up, benefits, and clinical decision-making processes.

1. 1
The Patient with Heart
Failure
CPAP as an Intervention

2. 2
Objectives
Upon successful completion of this module, the EMS
provider will be able to:
 Define heart failure and congestive heart
failure.
 Identify causes of heart failure.
 Identify symptoms of heart failure.
 Identify patterns of medical history related to
the patient with heart failure.
 Identify current home medications typically
taken by the patient with congestive heat
failure.

3. 3
Objectives cont’d
 Identify the difference between the patient with
congestive heart failure and pneumonia.
 Identify the assessment of the patient with
congestive heart failure.
 Identify the proper procedure for assessing breath
sounds.
 Identify treatment goals and options for congestive
heart failure following Region X SOP’s.
 Define CPAP as used by EMS for the patient with
pulmonary edema.

4. 4
Objectives cont’d
 Describe how CPAP will benefit the patient with
pulmonary edema.
 State indications, contraindications and
medications used with CPAP.
 Describe the process of setting up the CPAP
device.
 Describe the process of adding in-line Albuterol
with CPAP.
 Describe patient assessment while delivery
CPAP.
 State components to document when using
CPAP.

5. 5
Objectives cont’d
 Demonstrate the set up of CPAP.
 Demonstrate the set-up of regular and
in-line Albuterol.
 Demonstrate adding in-line Albuterol
with CPAP.
 Actively participate in case scenario
discussion.
 Successfully complete the post quiz with a
score of 80% or better.

6. 6
What is Heart Failure?
 A clinical syndrome
 Heart’s mechanical performance (ie:
pumping action) is compromised
 Cardiac output unable to meet the demands
of the body’s needs
 Generally divided into backward
ventricular failure (right heart failure) and
forward ventricular failure (left heart
failure)
 Can be of a chronic or acute nature

7. 7
Heart Failure
 Variety of causes
 Valve disease
 Heart disease
 Contributing factors to heart failure
 Diet - excess fluid or salt intake
 Hypertension
 Pulmonary embolism
 Excessive alcohol or drug usage
 Progression of an underlying disease

8. 8
What is CHF?
 Congestive heart failure = CHF
 Condition of excess build-up of fluid in the
lungs and/or other body parts/organs
 Fluid build-up causes congestion in the
organs seen as edema
 May be brought on by diseased heart
valves, hypertension, or some form of
obstructive pulmonary disease
 Often a complication of AMI

9. 9
Fluid build-up in CHF may be
pulmonary, peripheral, sacral, or ascites

10. 10
Understanding CHF
 A failure of the pumping action of the heart
 Heart is a 2 sided pump
 Right side of heart is a low pressure
system
 Left side of heart is a high pressure
system

11. 11
Heart as a Pump
 Left side of heart muscular
 Needs to overcome pressure in the arteries to
push/pump blood
 Pumps blood flow to the body
 Right side of heart less muscular
 Pumps blood to the lungs
• Does not need to be a very aggressive
pump with a lot of force

12. 12
Starling’s Law
 The more the myocardial muscle is
stretched, the greater the force of
contraction (the greater the recoil)
 Greater the preload (amount of blood
returned to the right heart), the farther the
myocardium is stretched and the more
forceful a contraction that results leading to
an increased cardiac output
 When Starling’s Law fails, the patient is
no longer able to compensate

13. 13
Hypertension
 B/P is a measurement
of force against the wall of the arteries
 When vessels stiffen due to calcium build-
up (arteriosclerosis) and plaque develops
(atherosclerosis), vessels are less
compliant
 Higher pressures are needed to pump
blood through stiffer vessels

14. 14
Right Ventricular Failure
 Failure of right ventricle as a forward
pump
 Back pressure of blood into systemic
venous circulation system
 Common causes
 Left ventricular failure (AMI)
 Systemic hypertension
 Pulmonary hypertension
 Cor pulmonale – heart
disease due to pulmonary
disease
(ie; effects of COPD)

15. 15
Progression of Right Heart Failure
 Right ventricle cannot eject all of the blood
out
 Fluid/pressure builds up
• In right atrium
Backs up into the venous system
Results in pedal/dependent
edema
 Visible as JVD

16. 16
Right
Sided
Heart
Failure -
A
Systemic
Picture

17. 17
Left Ventricular Failure
 Failure of left ventricle to function as a forward
pump
 Back pressure of blood into pulmonary circulation
 Often causes pulmonary edema
 Common causes
 Various types of heart disease
• Ischemia / acute MI
• Coronary artery disease (CAD)-
arteriosclerosis/atherosclerosis
• Valve disease
• Chronic hypertension -  afterload
• Dysrhythmias

18. 18
Progression of
Left Ventricular Failure
 Left ventricle cannot eject all the blood
delivered from the right heart via the
lungs
 Left atrial pressure rises and transmitted
to pulmonary veins and capillaries
 These high pressures force blood plasma
into alveoli (ie: pulmonary edema)
 Oxygen capacity of lungs reduced
 Hypoxia develops
 Acidosis develops

19. 19
Pulmonary
Edema
 Severest form
of congestive
heart failure
 Left ventricular forward failure
 Think left/lungs
 Patient develops respiratory distress due to
fluid in the lungs
 Note: extremely rare to have unilateral pulmonary
edema; then related to unusual pathology/med hx

20. 20
Pathophysiological Changes in
Pulmonary Edema
 Left ventricle cannot empty effectively
 Fluid moves from capillary beds into
surrounding interstitial tissue  alveoli
 Fluid in alveoli impedes oxygen exchange
 Surfactant lining alveoli washes out
 Alveoli stiffen
 Alveoli collapse after each breath and are harder to
open
 Lungs develop  compliance,
airflow obstruction, hyperinflation
  to workload of breathing

21. 21
Symptoms of CHF
 In the more chronic setting of right heart
failure, symptoms usually related to
excess fluids in organs and other body
parts
 In the more acute left heart failure,
symptoms usually related to excess fluid in
the lungs and therefore respiratory
distress

22. 22
Signs and Symptoms
Right Heart Failure
 Dependent edema
 Peripheral edema
 Hepatomegaly
 Splenomegaly
 Jugular vein
distension (JVD)
 Ascites
 Weight gain
 Dysrhythmias
 Nausea/vomiting
 Fatigue
 Dizziness
 Syncopal episodes
 Weakness

23. 23
Signs and Symptoms
Left Heart Failure
 Shortness of breath
 Dyspnea
 Orthopnea
 Crackles
 Wheezing
 Hypoxia
 Respiratory acidosis
 Chest pain
 Sweating
 Productive cough
 Blood tinged sputum
 Cyanosis
 Palpitations
 Dysrhythmias
 Hypertension
 Anxiety/restlessness

24. 24
Typical medical history pattern of
patient with CHF
 Hypertension
 Cardiovascular
disease (CVD)
 Myocardial infarction
(MI)
 Coronary artery
disease (CAD)
 Arteriosclerosis
 Atherosclerosis
 Smoker
 Excessive alcohol or
drug use
 Cocaine
 Methamphetamine
 Inhaled solvents
 PCP
 Dietary intake excess
fluids, excess salt
 High cholesterol

25. 25
Typical home medication history
pattern of patient with CHF
 Diuretic
 Digoxin
  contractility force of
the heart (inotropic)
 Home oxygen therapy
 Anti-hypertensive
 ACE inhibitors (end in “pril”)
 Beta blockers
•  heart rate & force
of contractions  B/P
• Often end in “olol”
 Calcium channel
inhibitors
• Slows movement of
calcium into small
muscles wrapped
around blood
vessels relaxing
blood vessels
•  peripheral
vascular resistance
relaxing blood
vessels

26. 26
Herbal remedies that may be harmful
when mixed with heart failure
 St. John’s wort
 Ephedra
 Gingko biloba
 Kava
 Licorice
 Ginseng
 Aconite
 Alisma plantago
 Bearberry buchu
 Couch grass
 Dandelion
 Horsetail rush
 Juniper

27. 27
Evaluation CHF/PE Pneumonia COPD
History HTN, heart
problems
n/a Lung problems
Dyspnea Orthopnea,
PND
Orthopnea
possible
Chronic;
pursed lips
Recent hx Acute weight
gain, dependent
edema
Fever, malaise Gradual
weight loss
Cough Frothy
sputum
Productive thick
green
Chronic;
productive
Onset Rapid Gradual Gradual
B/P High Normal Normal
Meds Dig, anti-HTN,
diuretic
Antibiotic, cold prep Bronchodilators,
steroids
Tx O2, NTG,
lasix, MS
O2, neb, fluids O2, neb

28. 28
Separating Signs/Symptoms
Symptom CHF/PE Pneumonia COPD
SOB Yes Yes Yes
Cough Maybe Yes Early a.m.
Sputum Frothy pink Yellow/green Thick brown
Fever No Yes No
Skin Cold/clammy Hot/dry Normal or dusky
Chest pain Possible Maybe No
Smoking hx Possible Possible Usually
Wheezing Maybe;
bilateral
Maybe; same
side as disease
Usually,
bilateral
Crackles Yes; bilateral Maybe; same
side as disease
No

29. 29
A Note…
“Old geezers don’t become new
wheezers!”
 COPD develops over a long period of time. If
an elderly person does not have a history of
COPD and they are suddenly wheezing, think
a cardiac problem or pulmonary edema.
Assume the worst,
hope for the best

30. 30
Patient Assessment - CHF
 Acute findings
 Recent trouble sleeping
•  trips to the bathroom at night
• Orthopnea with  number of pillows
• Sleeping in the recliner
• New episodes of paroxysmal nocturnal
dyspnea (PND)
•  use of nitroglycerin to stop chest pain
•  use of oxygen

31. 31
Patient Assessment - CHF
 General impression
 Labored respirations
 Audible noisy respirations
 Tripod positioning
 Frothy sputum production
  work of breathing – retractions, tachypnea
 Wheezing/crackles bilaterally
 Diaphoretic
 Change in skin color from norm
 Severe anxiety/restlessness
 Severe hypertension may be present

32. 32
Patient Assessment - CHF
 Signs and symptoms pulmonary edema
 Tachypnea
 Orthopnea
 PND
 Noisy labored respirations
 Fine crackles/rales
 Wheezing – “cardiac asthma”
 Coarse crackles/rhonchi larger airways
 Coughing with frothy blood tinged sputum

33. 33
Obtaining Breath Sounds
 Use flat diaphragm surface of stethoscope
 Rub stethoscope head between hands to
warm it up before placing on patient’s skin
 If audible sounds are heard, ask patient to
cough gently to clear upper airway
 Auscultate side to side and top to bottom
 Anterior: Posterior:

34. 34
Adventitious (Extra) Breath
Sounds
 Check for asymmetry
 Crackles: high pitched, continuous sounds
like rubbing hair between fingers
 Wheezes: generally high pitched, of musical
quality
 Stridor: Harsh inspiratory wheeze indicating
upper airway obstruction
 Rhonchi: snoring or gurgling quality
 Any extra sound not a crackle or wheeze
is usually rhonchi

35. 35
Decision Making –What to Do?
 Use critical thinking skills
 Decide if patient is sick or not
 Obtain current and past history
 Obtain vital signs
 Look
 Skin (wet/dry; color; temp)
 JVD present or not
 Peripheral / dependent edema present
 Subtle signs
 Listen
 Breath sounds

36. 36
Making the Right Decision
 Does the medical history include
cardiovascular disease?
 Does the physical examination/patient
assessment paint a picture of CHF?
 Use critical thinking skills
 Not treating pulmonary edema means the
body becomes more hypoxic and acidotic
 Miss diagnosis (ie: pneumonia) could prove
lethal
 This patient will arrest

37. 37
Treatment Goals for CHF
 Decrease myocardial workload
 Decrease oxygen demand
 Decrease fluid retention
 Correct hypoxia
 Correct acidosis

38. 38
Treating CHF/Pulmonary
Edema
 Decrease myocardial workload
 No physical activity (they don’t walk to the
rig)
 Sitting the patient upright; dangle feet
 Administering oxygen – non-rebreather
 CPAP to increase oxygen absorption surface
of lungs
 Medications to  preload and afterload
Nitroglycerin
Morphine
Lasix – additionally works as diuretic

39. 39
Treatment Goals for Pneumonia
 Supply supplemental oxygen as needed
 Treat the bacterial infection
 Hydrate the patient
• Usually found in the elderly
• Often vague symptoms; use to feeling ill
• Immune system often already weakened
so mortality rate is high with this diagnosis

40. 40
Region X SOP- Acute
Pulmonary Edema
 Begin Routine Medical Care
 Take standard precautions
 Perform assessments
 Identify priority patient and make transport
decisions
• Stay and play?
• Load N go?
 Perform routine tasks
• IV-O2-monitor

41. 41
What About the IV and
Nitroglycerin?
 Region X Medical Directors discussion:
 Majority of patients in pulmonary edema will be
hypertensive
 Nitroglycerin will help reduce preload which will
lower blood pressure (beneficial)
 Do not delay NTG dose, if no contraindications,
to start the IV
• If patient deteriorates before IV established,
can always place an IO

42. 42
Region X SOP- Acute
Pulmonary Edema
 Determine if the patient is stable or
unstable
 Stability guided by status of perfusion
B/P and level of consciousness
 If stable, the patient can receive more
aggressive care including medications and
procedures (ie: CPAP)
 If unstable, Medical Control needs to
coordinate degree of care provided in the
field (ie: meds and CPAP)

43. 43
Region X SOP- Acute
Pulmonary Edema - Stable
 Nitroglycerin
 Nitrate vasodilator
 Decreases myocardial workload
• Dilates arterial and venous systems
•  preload
•  afterload
 Carefully monitor blood pressure
 Screen for concomitant use of sexual
enhancement drug
• Viagra or Levitra in last 24 hours
• Cialis in past 48 hours

44. 44
Stable Pulmonary Edema SOP
 Lasix
 Loop diuretic
 Moves sodium (NA+) out of blood vessels
• Water follows sodium
• Potassium (K+) also pulled out
 Vasodilation effects within 5 minutes
• Decreases preload
 Diuresis within 20-30 minutes
 Peaks within 30 minutes

45. 45
Stable Pulmonary Edema SOP
 Morphine sulfate
 Narcotic analgesic
• Reduces anxiety
 Dilates venous and arterial systems
•  preload
•  afterload
•  blood pressure
 Stimulates nausea center in the brain
 Slows respiratory rate in medulla

46. 46
Region X SOP – Pulmonary Edema
Medication Regimen
 Stable patient
 Nitroglycerin 0.4 mg sl
• One every 3-5 minutes to max dose of 3
 Begin CPAP
 Lasix 40 mg IVP (80 mg if taken at home)
 Morphine 2 mg IVP slow over 2 minutes
• May repeat 2 mg every 2 minutes to max of 10mg
 If wheezing, contact Medical Control for
possible Albuterol neb treatment

47. 47
CPAP
 Continuous positive airway pressure
 Delivered throughout the respiratory cycle
 Noninvasive ventilatory support
 Most beneficial when initiated early
 Maintains airway in open position
  intrathoracic pressure which  venous
return to the heart
 Preload and afterload both decrease

48. 48
Benefits of CPAP
 Increases amount of inspired oxygen
 Decreases work load of breathing
 Reduces need for intubation
 Intubation requires ICCU stay
• Increased exposure to risks associated
with complications due to intubation
• Increases overall hospital length of stay

49. 49
Redistribution of extravascular lung
water during use of CPAP
Without CPAP With CPAP

50. 50

51. 51
Indications for CPAP
 Patient in acute pulmonary edema with
stable blood pressure
 Stable B/P = >100mmHg systolic
 FYI – with revised 2011 SOP’s, blood
pressure levels will be shifting to systolic
of 90 as a consistent guideline throughout
the SOP’s

52. 52
Contraindications for CPAP
 Decreased or altered level of consciousness
 Inability of patient to protect their airway from
aspiration
 Persistent nausea/vomiting
 Need for immediate intubation
 Hemodynamic instability (B/P<100)
 Note: B/P guideline will be changing to <90 with
revised 2011 SOP
 Penetrating chest trauma

53. 53
Medications Simultaneous With
CPAP
 Medications should be started
 NTG sl
 Then begin CPAP
 Then continue medication administration as
indicated
 Lasix – 40mg or 80mg IVP
 Morphine – 2 mg IVP repeated every 2 min
CPAP will buy time for the medications to work

54. 54
Did you know…
It is not either / or
(CPAP or meds)
CPAP works WITH medications
in tandem
Lift the mask to continue administration of
more NTG

55. 55
CPAP Equipment
 Fixed whisper
flow
 Connects to
your oxygen
source

56. 56
O2 Tank Duration
Approximate time at 30% FIO2
D tank 30 min.
E tank 50 min.
M tank 253 min.
H tank 508 min.
*based on 50 psi output

57. 57
CPAP
Circuit
Set-up
Package
includes:
Mask
Tubing
Head
strap
CPAP
valve
Air
entrainment
filter
Filter
CPAP
valve

58. 58
Most patients need a lot of coaching to
initially tolerate the tight fitting mask

59. 59
If The Patient is Wheezing
 Contact Medical Control to consider an
order for Albuterol via nebulizer
 Medical Control needs to give this
physician’s order
 Contact ECRN on radio
• Needs to give the ED MD a report
• Obtains MD’s order
• Relays the response to EMS
 If Albuterol is given, monitor for cardiac
side effects (ie: tachycardia)

60. 60
In-line Albuterol Set-up with
CPAP
 Cut the CPAP corrugated tubing as close to patient
as possible in smooth area of tubing
 Splice Albuterol kit T piece in-line
 Remove the mouthpiece and place the adaptor (used for
in-line Albuterol)
 Connect adaptor to distal cut end of corrugated CPAP
tubing
 Remove Albuterol corrugated tubing and connect
proximal end of CPAP tubing to T piece of Albuterol
 Keep Albuterol cup upright
 Albuterol kit still needs to be hooked to O2

61. 61
CPAP With In-line Albuterol Set-up

62. 62
Criteria to Discontinue CPAP
 Development of hemodynamic instability
 B/P drops below 100 systolic
• Revised 2011 SOP B/P level will be 90 systolic
 Inability of patient to tolerate tight fitting
mask
 Emergent need to intubate the patient

63. 63
Patient Monitoring During Use
of CPAP
 Constant reassessment required:
Patient tolerance
Mental status
Respiratory pattern
Rate, depth, subjective feeling of
improvement
Blood pressure, pulse, SaO2, EKG rhythm
Complications
Gastric distension, nausea, vomiting

64. 64
Monitoring Improvement With
CPAP
 It’s working when:
 Level of distress decreases
 Respiratory rate is returning toward normal
 Pulse oximetry (SaO2) increasing
 Pulse rate decreasing toward normal
 Decrease in use of accessory muscles
 Ability to speak in fuller sentences returning

65. 65
Contacting Medical Control
 Remember:
 Early communication with receiving
hospital
 Hospital needs to get their regulator for
oxygen source connection
• Usually not kept in each room

66. 66
Documentation With CPAP
 Assessment leading your general
impression to a diagnosis of pulmonary
edema
 CPAP level provided (10cmH2O)
 FiO2 provided (100%)
 SaO2 serial levels
 Vital signs over time
 Response to treatment
 Any adverse reactions noted

67. 67
So, What’s Different About BiPAP?
 Bi-level positive airway pressure
 Uses 2 levels of pressure
 Helps move more air into lungs without need
to exhale against higher pressures
 CPAP is a larger & noisier machine
 Uses extra effort to exhale and can be tiring
 Both can be used for sleep apnea
 BiPAP easier on those with COPD and
neuromuscular diseases

68. 68
Case Scenarios
Small Group and Large Group
Discussions
 Read the presentation
 Form a general impression
 Discuss treatment options
 Discuss what/how/when to reassess the
patient
 Decide what treatment to continue or what
adjustments need to be made
 Note: Additional questions are asked on ppt that can be
discussed during group presentations.

69. 69
Case Scenario #1
 Dispatch: You are called to a 70 y/o man
c/o breathing problems
 HPI: Increasing shortness of breath for
1 day despite the use of inhalers
 PmHx: COPD, Hypertension, and
Diabetes
 Medications: Albuterol Inhaler, Lasix, and
Aspirin
 Allergies: Penicillin

70. 70
Case Scenario #1
 Physical Exam: Thin white man on home
oxygen breathing through pursed lips sitting in a
tripod position
 Vital Signs: B/P 180/90; HR 120 sinus
tachycardia; RR 30; SaO2 88%; LOC alert;
airway patent
 Head & neck: Perioral cyanosis, no JVD
 Pulmonary: Lung auscultation reveals
inspiratory and expiratory wheezes
 Extremities: Cyanotic, no pedal edema

71. 71
Case Scenario #1
 What is your general impression?
 Are assessment findings stronger for
exacerbation of COPD or for acute
pulmonary edema?
 COPD supported
 History
 Appearance
 Lung sounds
 What treatment is indicated?

72. 72
Case Scenario #1
 IV – O2, monitor
 Albuterol nebulizer started:
• 5 min Vital Signs: B/P 160/90; HR 130; RR 24;
SaO2 92%, LOC Alert; lung sounds unchanged
• 10 min Vital Signs: B/P 120/90; HR 120, RR,
24, SaO2 92%, LOC Alert; lung sounds less
prominent wheezing; subjectively patient
breathing easier

73. 73
Case Scenario #2
 Dispatch: 65 y/o woman c/o of shortness
of breath
 HPI: 1 week history of progressive
dyspnea with exertion. Unable to lay
down flat without shortness of breath, no
chest pain or cough
 PmHx: Hypertension, Diabetes
 Medications: Lasix, Atenolol, and
Glucaphage

74. 74
Case Scenario #2
 Physical Exam: 260 lb woman sitting in
recliner.
 Vital Signs: B/P 160/80; HR 140 sinus
tachycardia; RR 30; SaO2 78%, LOC
follows commands; airway patent
 Head & neck: Cyanosis, JVD present
 Pulmonary: Crackles in all lung fields
 Extremities: Cyanotic, 3+ pedal edema

75. 75
Case Scenario #2
 What is your general impression?
 Are assessment findings stronger for
exacerbation of COPD or for acute pulmonary
edema?
 Pulmonary edema supported
 History
 Appearance
 Lung sounds
 What treatment is indicated?

76. 76
Case Scenario #2
 Need to move rapidly
 Minimize scene time as much as possible
 IV-O2-monitor
 Start nonrebreather until switched to CPAP
 Consider AMI so obtain 12 lead EKG
 Any contraindications to treatment?
 Nitroglycerin?
 CPAP?
 Lasix?
 Morphine?
NO
NO
NO
NO

77. 77
Case Scenario #2
 After CPAP started:
 5 min Vital Signs: B/P 100/60; HR 100; RR
24; SaO2 84%; LOC: responds to verbal
stimuli
 10 min Vital Signs: B/P 60/40; HR 30; RR
6; SaO2 60%; LOC unresponsive

78. 78
Case Scenario #2
 What is your general impression now?
 Patient is deteriorating
 What is your treatment now?
 CPAP needs to be discontinued
 Patient needs to be bagged and intubated
• One breath every 5-6 seconds before intubation
• One breath every 6-8 seconds after intubation
 Hold further repeats of medications used
 Consider need for dopamine infusion

79. 79
Case Scenario #3 Documentation
 Initial impression was acute pulmonary edema
 Based on physical assessment; history;
recent hospitalization for CHF
 Treatment was routine medical care
 IV – O2 non-rebreather- monitor
 CPAP started after ordered by Medical
Control
 2 sets of vital signs documented
 Initial vital signs (B/P 170/98 – 92 – 32)
 Second reading at the hospital

80. 80
Case Scenario #3 Comments
Documented
 Upon arrival patient found sitting upright,
agitated, complaining of chest pain and
difficulty breathing. Audible congested
breathing standing next to patient. Unable to
complete a full sentence. Bilateral pedal
edema noted. Began oxygen via
nonrebreather. IV started. Moved patient to
ambulance. Medical Control contacted and
ordered CPAP to be started. Patient becoming
more agitated. After 5 minutes, SaO2
increasing. Patient stated breathing was
becoming easier.

81. 81
Case Scenario #3 Documentation
cont’d
 Patient transported sitting upright.
Continued CPAP during entire call.
Transported patient into ED on portable O2
with CPAP continued.

82. 82
Case Scenario #3 Documentation
cont’d
 Pt contact: 0954
 Depart scene: 1025
 “Drugs”
 0959 - Oxygen - 15 l – non-rebreather
 1001 – 0.9 NS 1000ml – TKO – IV
 1005 – CPAP /oxygen – 15l – CPAP mask
 “`Cardiac rhythm”
 0958 – sinus
 1035 - sinus

83. 83
Case Scenario #3 Documentation
Discussion
What went well?
 Recognized pulmonary edema
 CPAP used with positive patient response

84. 84
Case Scenario #3 Documentation
Discussion
 What could be improved upon?
 Long on-scene time (0954 – 1025 -31 mins)
 Delay in initiating O2 therapy – 5 minutes
 Waited for MC to order CPAP – 11 min delay
• No Medical Control direction needed to initiate
 No other meds given for pulmonary edema
 Only 2 sets of vital signs taken on a critical
patient

85. 85
Case Scenario #4
 Dispatch: You are called to a 84 year-old
female c/o breathing problems
 HPI: Running low grade fevers, not feeling
well for 4 days
 PmHx: MI, Hypertension, TIA’s
 Medications: Plavix, Lasix, Lisinopril
 Allergies: Iodine, shellfish

86. 86
Case Scenario #4
 Physical Exam:
 Vital Signs: B/P 142/80; HR 96 sinus
rhythm; RR 28; SaO2 92%, LOC follows
commands; airway patent
 Head & neck: Pale, no JVD
 Pulmonary: Crackles in right lower lung
field
 Extremities: Pale, pedal pulses palpable

87. 87
Case Scenario #4
 What is your general impression?
 Are assessment findings stronger for
acute pulmonary edema or pneumonia?
 Pneumonia supported?
 History
 Appearance
 Lung sounds not so helpful
 What treatment is indicated?

88. 88
Case Scenario #4
 What is your treatment now?
 IV-O2-monitor
 Fluids
• Faster than keep open but not a fluid
challenge
 Diagnosis confirmed at the hospital with
chest x-ray and labs

89. 89
Case Scenario #4
 Patients with pneumonia need fluids
 Patients with congestive heart failure need
fluid restrictions
 A wrong diagnosis and therefore wrong
treatment approach could be harmful for
both patients

90. 90
Case Scenario #5
 Dispatch: You are called to a home for a 78
year-old male with severe SOB
 HPI: Has been getting progressively SOB past 2
days; slept in recliner last night
 PmHx: MI x3; hypertension, diverticulitis,
seizures
 Medications: Aspirin, Hydrodiuril, Verapamil,
NTG PRN, Coumadin, Phenobarbital
 Allergies: none

91. 91
Case Scenario #5
 Physical Exam:
 Vital Signs: B/P 172/96; HR 110 sinus
tachycardia; RR 36; SaO2 88%, LOC follows
commands; extremely anxious; airway patent
 Head & neck: JVD
 Pulmonary: Crackles mid way up lung fields
bilaterally
 Extremities: Cyanotic, pedal edema palpable

92. 92
Case Scenario #5
 What is your general impression?
 What is your treatment plan?
 Write a run report
 Include initial assessment
 Document treatment interventions indicated
 Document reassessment performed
 Discuss as a group what needs to be
included

93. 93

94. 94

95. 95
Bibliography
 Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care: Principles and Practices. Brady. 2009.
 Limmer, D., O’Keefe, M. Emergency Care, 10th
Edition. Brady. 2005.
 Region X SOP’s March 2007; Amended
January 1, 2008.
 http://whisperflow.respironics.com/
 www.emsworld.com
 Variety internet websites for CPAP and
pulmonary edema