Re: New puzzler

[Guest guest]

Dang you're up early this morning Gene. And creative too. Did you run this?

My belief is that a beta-blocker would be contraindicated in a patient with

pulmonary edema but he obviously needs something ASAP. Nitroprusside may be the

much safer method. If Labetelol were to be used it would need to be by a slow

push (not an infusion - since this guy's not gonna last long) and until it's

known what the neuro look is let's stay away from vasodilators such as NTG. What

does a neuro exam tell us?

Lasix seems very appropriate to add to this. Does he have a history of asthma &

therefore a beta-blocker could be harmful from that standpoint? But while we're

considering what medications might be useful - if we have him draw on a demand

valve with a mouth piece for a little IPPB does that help the Sa02? Or with

CPAP? And if we spray some benzoin & get the electrodes to stick - what is our

rhythm?

Some early thoughts ( & more questions) on this. Thankya Gene - you're twisting

our brains early on a Friday.

Don

>>> wegandy1938@... 10/10/2003 12:52:07 AM >>>

Well, kiddies, it's time for another of Uncle Gene's mind boggling

puzzlers.

This one has to do with pulmonary edema.

Suppose you're dispatched to a Short of Breath and find a 62 year old male in

full-blown pulmonary edema breathing with great difficulty in short, wheezy,

crackly respirations at about a rate of 40/min. He's diaphoretic to the

extent that the electrodes won't stick. And he is using all his accessory

muscles

to breathe. Sat is 70% on room air. O2 by NRB doesn't help immediately. HR

is 138 with STach, RR 40, BP 236/128. He has a long cardiac PMHx.

Premise: His BP needs to be lowered.

Question: Which would be the better method to lower his BP? Administer

labetalol in 20 mg increments or by infusion until BP is lowered and edema goes

away? Or administer NTG, furosemide, and MS?

Justify your answer by explaining what physiological effect you expect to

happen from administration of whichever you choose and why you didn't choose the

alternative.

Good luck.

Gene

[Guest guest]

In a message dated 10/10/2003 9:13:47 AM Central Daylight Time,

delbert@... writes:

Dang you're up early this morning Gene. And creative too. Did you run this?

Yes.

My belief is that a beta-blocker would be contraindicated in a patient with

pulmonary edema but he obviously needs something ASAP. Nitroprusside may be the

much safer method. If Labetelol were to be used it would need to be by a slow

push (not an infusion - since this guy's not gonna last long) and until it's

known what the neuro look is let's stay away from vasodilators such as NTG.

What does a neuro exam tell us?

Patient is awake and alert and in great distress. Patient is oriented to

time, place, and his situation. Follows commands correctly. Denies chest pain

or other pain.

Lasix seems very appropriate to add to this. Does he have a history of asthma

& therefore a beta-blocker could be harmful from that standpoint?

No hx of asthma but is an ~100+ pack year smoker. Has hx of CHF and multiple

CABGs.

But while we're considering what medications might be useful - if we have him

draw on a demand valve with a mouth piece for a little IPPB does that help

the Sa02? Or with CPAP?

Do not have CPAP or demand valve but assisted vents with BVM. This helped.

And if we spray some benzoin & get the electrodes to stick - what is our

rhythm?

Got some antiperspirant from his bathroom and rubbed it on and was able to

get electrodes to adhere better. Initial rhythm=Sinus tach with random unifocal

PVCs, sometimes with compensatory pause, sometimes interpolated or even

possibly fusion beats. We do not have 12-leads, but there were no significant

ST

changes; however there were inverted T waves in I, II, III, MCL1 and MCL4.

Lead I was rSr' (negative) and Lead III was qRs (positive). MCL1 was positive.

Some early thoughts ( & more questions) on this. Thankya Gene - you're

twisting our brains early on a Friday.

Don

>>> wegandy1938@... 10/10/2003 12:52:07 AM >>>

Well, kiddies, it's time for another of Uncle Gene's mind boggling

puzzlers.

This one has to do with pulmonary edema.

Suppose you're dispatched to a Short of Breath and find a 62 year old male in

full-blown pulmonary edema breathing with great difficulty in short, wheezy,

crackly respirations at about a rate of 40/min. He's diaphoretic to the

extent that the electrodes won't stick. And he is using all his accessory

muscles

to breathe. Sat is 70% on room air. O2 by NRB doesn't help immediately. HR

is 138 with STach, RR 40, BP 236/128. He has a long cardiac PMHx.

Premise: His BP needs to be lowered.

Question: Which would be the better method to lower his BP? Administer

labetalol in 20 mg increments or by infusion until BP is lowered and edema

goes

away? Or administer NTG, furosemide, and MS?

Justify your answer by explaining what physiological effect you expect to

happen from administration of whichever you choose and why you didn't choose

the

alternative.

Good luck.

Gene

[Guest guest]

Gene,

I will take a shot at this one...spending a decade in an area of Florida

known as " God's waiting room " , this patient is all too familiar.

Assisting ventilations to increase PAO2 is the first step. I would then

begin immediate treatment with 0.8mg SL of NTG to this patient. NTG is a good

vasodilator and will work to shunt the excess fluid into the arms and legs where

it won't necessarily make anything better, but it will reduce the preload and

afterload.

I would repeat this dosage every 3 minutes as long as the patient has a

radial pulse. I am suspecting a severe episode of pulmonary edema with

hypertension secondary to CHF. The BP will usually maintain itself just fine

with all

the NTG. BP's should be repeated as time allows, but NTG should not be delayed

for a BP check if the patient has a radial pulse.

Furosemide is next....40 mg IV unless the patient is on Lasix at home at

which time I would double the daily dose.

Morphine is where I get a little antsy...when we were doing the high dose NTG

work in Florida, we steered away from the MSO4 unless we intended to intubate

the patient. Our medical director's thoughts were that the patients fight

against the edema worked in a way like PEEP and if we knocked down that fight

any at all, fluid filling would become worse.....however, I also know that MSO4

(even a small dose...say 2-4 mg) also helps decrease afterload and preload, so

I would consider it, with a good watch on my patient's condition.

After 15+ minutes of this, I would re-evaluate my lung sounds, BP, PAO2, and

EKG. If we were able to get ahead of the game, the skin will probably be

drying, breath sounds may be improving, but PAO2 should be much better.

Continued

NTG therapy and O2 therapy should be continued and if the patient is showing

no signs of improvement, I would consider intubating the patient while they

are sitting up (nasal or oral) and providing ventilation support on into the

hospital.

With the hx of smoking and possible COPD, we too often get caught up in the

" Difficulty breathing...they must need a breathing treatment " mentality of

cook-book medicine. Numerous COPD patients have CHF episodes due to the

heightened pressure in their pulmonary system and pre-hospital get treated with

albuterol because " They have COPD " . Unfortunately, these are the patients that

after

about 3/4 of the breathing treatment is done...they suddenly take a turn for

the worse.... " can't breathe " , decreasing PAO2, worsening lung sounds, and

increased anxiety and combativeness.....all because we were successful in

opening

up the air tubes so that more water could come in.....

Anyway, enough of my soapbox on CHF.

Dudley