The patient with Cardiac Failure by CPAP intervention

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