Flash Pulmonary Edema

[EMS Patient Care Advocate]

or based on the equations that would be counterproductive? I need to study up on MAP big time, useful stuff.

 

[ArcticKat]

Perhaps, but I'm thinking that the hypoxemia is a more likely cause of cardiac arrest in this patient. However, I wouldn't be surprised if it was a combination of the two.

What rhythm did he go into? Asytole?

Agreed, given the new information and quick Asystole, I'd say the Hypoxemia played a big part.

 

[EMS Patient Care Advocate]

Agreed, given the new information and quick Asystole, I'd say the Hypoxemia played a big part.

Yes when I say pink frothy I dont mean he could spit it up. I mean pink frothy was FLOWING from his mouth. Quite a site to be honest

 

[medicsb]

Reducing SVR is why we treat with Nitro in CHF I would think, I made a mistake earlier for some reason- i do know this lol. Unfortunatly I did not have a usable blood pressure, so why not try to increase SVR some while also increasing inotropy-more bang for my buck, my origional stated goal? Isnt that part of titrating to effect? I have limited experience actually using dopamine. Im going to sponge information off you if its ok

The equation can take a bit to wrap your head around, because most people equate MAP (BP) with SVR when they are actually different. (Also, I should mention that for simplicity, I've left out CVP - for completeness the full eqn is CO = (MAP-CVP)/SVR)

With the patient you had, it is possible that the patient is not vasodilated and is already vasoconstricted to some degree due to endogenous catecholamines. However, it is possible that should there be enough metabolic byproducts and/or inflammatory mediators floating around, that vasodilation has begun to occur or is occuring (particularly if this was slowly evolving). Anyhow it still comes down to the fact that the pump is the biggest problem and it is worth taking a step wise approach to improve cardiac function and tissue perfusion. You don't want to over tax the heart anymore than you need to, so if you can improve hemodynamics with inotropes alone, then good, if it doesn't work then move on to stimulating vasoconstriction.

Anyhow, with CHF where shock is not present, there are multiple mechanism producing the cardiovascular effects observed. Ultimately the goal of NTG is to reduce preload, though it does affect SVR, so it can allow CO to increase as long as preload is not decreased too much (CO does rely on preload).

 

[medicsb]

Yes when I say pink frothy I dont mean he could spit it up. I mean pink frothy was FLOWING from his mouth. Quite a site to be honest

It'll probably be a long time before you see a case like that again. I don't think I ever did.

Though, I once pronounced a man who had pink frothy sputum that had been flowing down his chest. It started and killed him at the wheel of his car. We would have coded him had bystanders not waited 20 minutes to call 911. (His car rolled to a stop in the middle of a parking lot.)

 

[EMS Patient Care Advocate]

It'll probably be a long time before you see a case like that again. I don't think I ever did.

Though, I once pronounced a man who had pink frothy sputum that had been flowing down his chest. It started and killed him at the wheel of his car. We would have coded him had bystanders not waited 20 minutes to call 911. (His car rolled to a stop in the middle of a parking lot.)

Yes I think I intentionally failed to mention this was one of my first paramedic intercepts withen a few months of receiving my card. You have been so helpful. Please keep feeding it to me. I dont know how this site works yet but Id love to link up. Your brain is power.

 

[EMS Patient Care Advocate]

The equation can take a bit to wrap your head around, because most people equate MAP (BP) with SVR when they are actually different. (Also, I should mention that for simplicity, I've left out CVP - for completeness the full eqn is CO = (MAP-CVP)/SVR)

With the patient you had, it is possible that the patient is not vasodilated and is already vasoconstricted to some degree due to endogenous catecholamines. However, it is possible that should there be enough metabolic byproducts and/or inflammatory mediators floating around, that vasodilation has begun to occur or is occuring (particularly if this was slowly evolving). Anyhow it still comes down to the fact that the pump is the biggest problem and it is worth taking a step wise approach to improve cardiac function and tissue perfusion. You don't want to over tax the heart anymore than you need to, so if you can improve hemodynamics with inotropes alone, then good, if it doesn't work then move on to stimulating vasoconstriction.

Anyhow, with CHF where shock is not present, there are multiple mechanism producing the cardiovascular effects observed. Ultimately the goal of NTG is to reduce preload, though it does affect SVR, so it can allow CO to increase as long as preload is not decreased too much (CO does rely on preload).

Ill be re-reading this a few times, back to the books! Thank You for your help and time

 

[usafmedic45]

Patients Vitals were a systolic of less than 80, RR and everything else is also in the dumps. So CPAP is out, Nitro is out.

Why is CPAP out? Define "in the dumps".

I also dont have a vent but tried PPV and would have used a peep valve if available. Yes no es bueno.

Do you see the irony of these two conflicting statements? I'm guessing no, so I bolded the parts in question to make it easier for you.

 

[EMS Patient Care Advocate]

Why is CPAP out? Define "in the dumps".



Do you see the irony of these two conflicting statements? I'm guessing no, so I bolded the parts in question to make it easier for you.

Well I am trying to learn so Id be thankful if you stopped being a punk. And Ill gladly address your questions. In my training someone who has little to no respiratory drive contraindicates CPAP- what else would you like to know was in the dumps to change your decision?

Just so you know, they do make a cute little device that goes on the end of a BVM called a peep valve. They are expensive, provide PEEP with pressure bagging- im sorry you dont know how to do this, Id be happy to show you the device and how to use it on the BVM to provide PEEP. Is it perfect, nope. Is it a product that might work, yup.

 

[Scott33]

The F word

Just going to throw this out there. Would anyone have considered a fluid challenge?

 

[Scott33]

Well I am trying to learn so Id be thankful if you stopped being a punk.

Just so you know, they do make a cute little device that goes on the end of a BVM called a peep valve. They are expensive, provide PEEP with pressure bagging- im sorry you dont know how to do this, Id be happy to show you the device and how to use it on the BVM to provide PEEP

...And so endeth the adult discussion.

 

[fast65]

Just going to throw this out there. Would anyone have considered a fluid challenge?

Wouldn't that make things worse? How large of a fluid challenge were you thinking?

 

[EMS Patient Care Advocate]

Wouldn't that make things worse? How large of a fluid challenge were you thinking?

Well how to you know if the patient has third spaced all his fluid and is empty in the vasculature warrenting fluid. I dont think the Pulmonary Edema patient is automatically assumed to have an overload of fluid in the veins?

 

[EMS Patient Care Advocate]

...And so endeth the adult discussion.

He is attacking me on another thread as well for some reason my lack of education and willingness to learn makes him mad.

 

[fast65]

Well how to you know if the patient has third spaced all his fluid and is empty in the vasculature warrenting fluid. I dont think the Pulmonary Edema patient is automatically assumed to have an overload of fluid in the veins?

This is true, I had not really considered that

 

[usafmedic45]

someone who has little to no respiratory drive contraindicates CPAP- what else would you like to know was in the dumps to change your decision?

Just wanted to know which end of "in the dumps" you were at because some will refer to someone who is struggling to but not achieving good volumes as "in the dumps". Pardon me for asking for clarification and trying to make a teaching point out of something that confuses a lot of EMS providers (PEEP vs. CPAP)

Just so you know, they do make a cute little device that goes on the end of a BVM called a peep valve. They are expensive, provide PEEP with pressure bagging- im sorry you dont know how to do this, Id be happy to show you the device and how to use it on the BVM to provide PEEP. Is it perfect, nope. Is it a product that might work, yup.

Actually it works quite well if you have a closed airway circuit (read as: a tubed patient). It doesn't do so great if you're just using a mask seal.

Well I am trying to learn so Id be thankful if you stopped being a punk.

I'm trying to teach, so I would appreciate that out of you.

 

[EMS Patient Care Advocate]

Just wanted to know which end of "in the dumps" you were at because some will refer to someone who is struggling to but not achieving good volumes as "in the dumps". Pardon me for asking for clarification and trying to make a teaching point out of something that confuses a lot of EMS providers (PEEP vs. CPAP)



Actually it works quite well if you have a closed airway circuit (read as: a tubed patient). It doesn't do so great if you're just using a mask seal.



I'm trying to teach, so I would appreciate that out of you.

I commend all my teachers and their time. You dont call your students a moron, EVER. No clarification needed. Thats where you lost me

 

[usafmedic45]

for some reason my lack of education and willingness to learn makes him mad

LOL Who's mad? I don't know anything about your level of education and I applaud your supposed willingness to learn but being hostile to those who are instructors of the things you are trying to learn doesn't really lend itself to the belief that one is really interested in anything but having himself or herself patted on the back and told that his way of thinking was the best one out there.

He is attacking me on another thread

No, I questioned your decision making. Ask anyone here....if I was attacking you personally, I'd already be wearing your spine as a necklace. Learn the difference between someone attacking you and someone being critical of your choices. There is a significant difference and being able to separate the two is very helpful if one wishes to last long in any career field.

 

[EMS Patient Care Advocate]

I commend all my teachers and their time. You dont call your students a moron, EVER. No clarification needed. Thats where you lost me

This patient was two minutes from hospital. Treatments rendered while moving patient to ambulance, at hospital by time I had a scope in my hand. Perhaps I would have intubated sooner but he had a gag reflex.

 

[usafmedic45]

You dont call your students a moron, EVER

I called your decision moronic, not you. We all have our moments where we make bad calls. See my post immediately proceeding this one for a lesson about this....