CHF and nitrates

[spidermedic]

Rales = fluid. Get rid of the fluid. Wheeze = constriction. Open them up. Keep it simple. Don't over think it.

It's really not a matter of over thinking...a beta-2 is simply not going to reverse airway constriction secondary to edema, and may increase preload.

Personally, I think medics need to do a bit more thinking on how they address respiratory issues. All the wheezes is not asthma and all that crackles is not HF.

 

[byun01]

Reasons behind treatment

Actually, both of you were wrong.

The current recommended treatment and research has shown those with CHF and complications of such should recieve CPAP ASAP! This has shown to provide better relief and reversal than Nitrates and Lasix.

I do agree with administration of NTG. However; there is no recommendation of a determine amount of dosages. Personally, 0.4mg (1/150 grain) is okay, but needs to be cautiously administered. Personally, I prefer NTG IV, or 1" topical to allow a slower administration, but bucossa spray is acceptable as long as there is not a right sided or inferior wall involvement. Causing an increase in preload will only cause problems... Remember, in CHF we are not treating so much the HTN, rather we should be focusing on the "pump failure" monitoring preload and afterload affects. The HTN is a side effect of preload inability to increase ejection fraction.

CPAP has been shown and demonstrated to reduce intubations by half and ICU admissions almost by that number.. it is the best thing in a few years in EMS.

Administration of Lasix in the prehospital setting is very controversial. I personally like it because of the shifting, if one is > 20 minutes from a hospital setting, and they are in Frank CHF (presence of pulmonary edema) however; it is now beginning not to be recommended unless you are certain it is CHF and have a delayed transport. It is estimated up to 80% of administration of Lasix is inappropriate in the field, either by tx CHF when it is not, or wrong dosages (already previously on home Lasix).

Good luck on your studies.. I suggest to perform a search on current treatment in the literature..

R/r 911

I am going to have to agree with ridryder that CPAP is a treatment of choice. However, I understand many services do not carry CPAP. On another note, I think we should discuss the reasons behind treating CHF. And as always, if anyone has a concern or disagreement, we can use this opportunity to learn from each other. Anway, back to CHF. CHF can be caused by a MI that ultimately reduced the ejection fraction of the left ventricle. Ultimately this causes a backup into pulmonary vein and into the lungs. When a patient, caused by a number of reasons (osmotic pressure), complains of difficulty breathing they are literally drowning in his or her own fluid. Lasix is a diuretic and MOST IMPORTANTLY TO REMEMBER is that it takes about 20min to achieve a therapeutic level. As a result, if lasix is the only drug you provide, they will still complain of difficulty breathing. Ultimately, it is Nitro that will provide fast relief (let's not forget oxygen). Nitro is a smooth muscle vasodilator. Veins have no/very little smooth muscles. Rather arteries depending on how close you are to the heart, have tons of smooth muscle. By providing the patient nitro, you expand the arteries making it easier for the patient's heart to eject blood. In short, assuming there was no contraindication, the paramedic should have given both nitro and lasix along with BLS.