The Patient with Heart Failure

Transcript The Patient with Heart Failure

The Patient with Heart Failure CPAP as an Intervention

April 2011 CE Condell Medical Center EMS System Site Code #107200E -1211 Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P 1

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.

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.

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.

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.

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 6

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 7

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 8

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

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 10

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 11

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 12

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 13

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) 14

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 15

Right Sided Heart Failure A Systemic Picture

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 Dysrhythmias  afterload 17

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 18

Pulmonary Edema

 Severest form of congestive heart failure  Left ventricular forward failure  Think

eft/

ungs  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 19

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 20

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 21

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 22

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 23

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 24

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 25

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 26

Evaluation CHF/PE History

HTN, heart problems

Dyspnea Recent hx Cough Onset

Orthopnea, PND Acute weight gain, dependent edema Frothy sputum Rapid

B/P Meds Tx

High Dig, anti-HTN, diuretic O 2 , NTG, lasix, MS

Pneumonia

n/a Orthopnea possible Fever, malaise Productive thick green Gradual Normal Antibiotic, cold prep O 2 , neb, fluids

COPD

Lung problems Chronic; pursed lips Gradual weight loss Chronic; productive Gradual Normal Bronchodilators , steroids O 2 , neb 27

Symptom SOB Cough Sputum Fever Skin Chest pain Smoking hx Wheezing Crackles

Separating Signs/Symptoms

CHF/PE

Yes

Pneumonia

Yes

COPD

Yes Maybe Frothy pink No Yes Early a.m.

Yellow/green Thick brown Yes Cold/clammy Hot/dry No Normal or dusky Possible Maybe No Possible Maybe; bilateral Possible Maybe; same side as disease Yes; bilateral Maybe; same side as disease Usually Usually, bilateral No 28

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

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 30

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 31

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 32

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: 33

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 34

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 35

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 36

Treatment Goals for CHF

 Decrease myocardial workload  Decrease oxygen demand  Decrease fluid retention  Correct hypoxia  Correct acidosis 37

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   Nitroglycerin preload and afterload  Morphine  Lasix – additionally works as diuretic 38

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 39

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-O 2 -monitor 40

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 41

Region X SOP- Acute Pulmonary Edema

 Determine if the patient is

stable unstable

or    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) 42

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 43

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 44

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 45

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 46

CPAP



ontinuous

ositive

irway

ressure  Delivered throughout the respiratory cycle  Noninvasive ventilatory support 

Most beneficial when initiated early

 Maintains airway in open position   intrathoracic pressure which  return to the heart venous  Preload and afterload both decrease 47

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 48

Redistribution of extravascular lung water during use of CPAP

Without CPAP With CPAP 49

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 51

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 52

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

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 54

CPAP Equipment

 Fixed whisper flow  Connects to your oxygen source 55

O

Tank Duration

 Approximate time at 30% FIO 2 D tank E tank M tank H tank 30 min.

50 min.

253 min.

508 min.

*based on 50 psi output 56

CPAP Circuit Set-up

Package includes:  Mask  Tubing  Head strap  CPAP valve  Air entrainment filter CPAP valve Filter 57

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

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) 59

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 O 2 60

CPAP With In-line Albuterol Set-up

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 62

Patient Monitoring During Use of CPAP

 Constant reassessment required:  Patient tolerance  Mental status  Respiratory pattern  Rate, depth, subjective feeling of improvement  Blood pressure, pulse, SaO 2 , EKG rhythm  Complications  Gastric distension, nausea, vomiting 63

Monitoring Improvement With CPAP

 It’s working when:  Level of distress decreases  Respiratory rate is returning toward normal   Pulse oximetry (SaO 2 ) increasing Pulse rate decreasing toward normal  Decrease in use of accessory muscles  Ability to speak in fuller sentences returning 64

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 65

Documentation With CPAP

 Assessment leading your general impression to a diagnosis of pulmonary edema  CPAP level provided (10cmH 2 O)  FiO 2 provided (100%)  SaO 2 serial levels  Vital signs over time  Response to treatment  Any adverse reactions noted 66

So, What’s Different About BiPAP?



-level

ositive

irway

ressure  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 67

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.

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 69

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; SaO airway patent 2 88%; LOC alert; 

Head & neck:

Perioral cyanosis, no JVD 

Pulmonary:

Lung auscultation reveals inspiratory and expiratory wheezes 

Extremities:

Cyanotic, no pedal edema 70

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?

Case Scenario #1



IV – O 2 , monitor



Albuterol nebulizer started:

• 5 min Vital Signs: B/P 160/90; HR 130; RR 24; SaO 2 92%, LOC Alert; lung sounds unchanged • 10 min Vital Signs: B/P 120/90; HR 120, RR, 24, SaO 2 92%, LOC Alert; lung sounds less prominent wheezing; subjectively patient breathing easier 72

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 73

Case Scenario #2



Physical Exam:

260 lb woman sitting in recliner. 

Vital Signs:

B/P 160/80; HR 140 sinus tachycardia; RR 30; SaO 2 78%, LOC follows commands; airway patent 

Head & neck:

Cyanosis, JVD present 

Pulmonary:

Crackles in all lung fields 

Extremities:

Cyanotic, 3+ pedal edema 74

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?

Case Scenario #2

 Need to move rapidly  Minimize scene time as much as possible  IV-O 2 -monitor  Start nonrebreather until switched to CPAP  Consider AMI so obtain 12 lead EKG  Any contraindications to treatment?

 Nitroglycerin?

NO    CPAP?

Lasix?

Morphine?

NO NO NO 76

Case Scenario #2



After CPAP started:

 5 min Vital Signs: B/P 100/60; HR 100; RR 24; SaO 2 stimuli 84%; LOC: responds to verbal  10 min Vital Signs: B/P 60/40; HR 30; RR 6; SaO 2 60%; LOC unresponsive 77

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 78

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 – O 2 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 79

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, SaO becoming easier.

2 increasing. Patient stated breathing was 80

Case Scenario #3 Documentation cont’d

 Patient transported sitting upright. Continued CPAP during entire call. Transported patient into ED on portable O 2 with CPAP continued.

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 82

Case Scenario #3 Documentation Discussion

What went well?

  Recognized pulmonary edema CPAP used with positive patient response 83

Case Scenario #3 Documentation Discussion

 What could be improved upon?

   Long on-scene time (0954 – 1025 -31 mins) Delay in initiating O 2 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 84

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 85

Case Scenario #4



Physical Exam:



Vital Signs:

B/P 142/80; HR 96 sinus rhythm; RR 28; SaO 2 92%, LOC follows commands; airway patent 

Head & neck:

Pale, no JVD 

Pulmonary:

Crackles in right lower lung field 

Extremities:

Pale, pedal pulses palpable 86

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?

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 88

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 89

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 90

Case Scenario #5



Physical Exam:



Vital Signs:

B/P 172/96; HR 110 sinus tachycardia; RR 36; SaO 2 88%, LOC follows commands; extremely anxious; airway patent 

Head & neck:

JVD 

Pulmonary:

Crackles mid way up lung fields bilaterally 

Extremities:

Cyanotic, pedal edema palpable 91

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 92

Bibliography

   Bledsoe, B., Porter, R., Cherry, R. Paramedic Care: Principles and Practices. Brady. 2009.

Limmer, D., O’Keefe, M. Emergency Care, 10 th 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 95