CHF / Pulmonary Edema

 

History:

 

  • CHF
  • Past medical history
  • Medications (Digoxin, Lasix)
  • Erectile dysfunction medication
  • Cardiac history (MI)

 

Significant findings:

 

  • Severe SOB
  • Air hunger
  • Diaphoresis
  • Tachypnea
  • Tachycardia
  • Chest pain
  • Elevated blood pressure
  • Peripheral edema
  • Pink, frothy sputum
  • Bi-lateral rales

 

CHF vs Differential:

 

  • MI
  • CHF
  • COPD
  • Asthma
  • Anaphylaxis
  • PE
  • Aspiration
  • Pneumonia
  • Pleural effusion
  • Pericardial tamponade
  • Toxic exposure

 

Treatment:

 

 

 

  • Oxygen

 

 

 

  • 12-Lead EKG

 

 

 

  • Initiate IV/IO

 

Consider Acute Coronary Syndromes Protocol

 

  • Assess symptom severity
  • Allow patient to maintain a position of comfort (usually sitting)

 

MILD?

 

  • Normal HR
  • Elevated or normal BP

 

 

 

 

Improving?

 

    • Yes

 

  • Notify receiving facility or contact Medical Control

 

    • No

 

 

MODERATE/SEVERE?

 

  • Elevated HR
  • Elevated BP

 

 

 

 

 

 

 

 

 

 

 

 

 

Improving?

 

    • Yes

 

      • Notify receiving facility or contact Medical Control

 

    • No

 

CARDIOGENIC SHOCK?

 

  • Bradycardia?
  • Hypotension?

 

    • Yes

 

  • Remove CPAP, but only while hypotensive (SBP <90)

 

 

 

  • Consider Push dose Epi 10-20 mcg (1-2 ml) q 10-15 minutes if hemodynamically unstable.

 

PEARLS:

 

  • Withhold Nitroglycerin in any patient who has used an erectile dysfunction medication in the past 24 hours
  • For administration of Nitroglycerin, systolic blood pressure must be greater than 90. May be repeated at 5 minute intervals if dyspnea is not relieved and systolic blood pressure remains greater than 90.
  • Nitroglycerin may be administered without an IV as long as systolic blood pressure is greater than 100 and there is no evidence of an inferior wall MI
  • Once CPAP is in use, apply 1 inch Nitroglycerin Paste.
  • Nitroglycerin Paste is applied to upper chest and further doses of sublingual Nitroglycerin can be withheld. Remove paste and wipe chest clean if systolic blood pressure is less than 90.
  • Morphine is not indicated in the presence of CHF.
  • Be sure to monitor patient's breathing/ventilations, blood pressure and O2 sat.
  • Push Dose Epi:
  • Mix 1 ml of 1:10,000 Epi into 9 ml Normal Saline: gives Epi 1:100,000; Admin 1-2 ml (10-20 mcg) every 10-15 minutes

NREMR

NREMT

NRP

NREMT

NREMT

NRP