Category Archives: Acute Cardiogenic Pulmonary Edema

Question: A CHF patient who has a BP of over 140mmHg systolic who is getting 0.8mg of NTG for SOB, patient's BP drops below 140mmHg so NTG dosage is changed to 0.4mg, patient's systolic BP rebounds above 140mmHg. Does patient go back to getting 0.8mg of NTG or is it like the "once you are out, you are out" mentality that they stay at 0.4mg NTG?

General answers to this question from other paramedics I have asked usually say that the patient will continue to get 0.4mg of NTG regardless of systoloic BP, if it has dropped below 140mmHg at any time during the call. Thank you in advance for your time and help.

Question: I have a question regarding nitro use with lung cancer patients. I recently had a patient who was obviously in the end stages of lung CA. Patient was complaining of mild SOB due excessive amounts of fluid buildup in his lungs. He stated that he needed to go to the hospital to have the fluid drained. Patent had 5-6 word dyspnea, O2 sats at 92 %, radial pulse 90, NSR, respiratory rate 22 regular, audible crackles when patient took a deep breath, and B/P 124/86. Patient stated that within the last couple of days he had noticed swelling to his ankles and abdomen which were abnormal for him. Patient had a previous history of nitro use due to angina. Would this patient benefit at all with nitro use? He wasn't in severe respiratory distress nor did he require assisted ventilations.

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

Question: I am a current PCP taking ACP. I was recently informed, during an ACP class, that on an unconscious CHF patient, nitro can still be administered if vitals are within normal range and the other conditions are met. When I checked the protocols, under conditions, it states that LOA: N/A (whereas for cardiac ischemia, the LOA must be unaltered). However, it seems to me that if the patient is unconscious, the patient is too unstable to receive nitro. I have never experienced a call like this, and it would seem that in most cases an unconscious patient would have vitals outside the perimeters of nitro administration. Can you please verify this? Thanks

Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient's spo2 31 and 42% with mottling noted. Patient's initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient's GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?

Question: Do all Phosphodiesterase Inhibitors generic names end in "fil"? Are all drugs that end "fil" Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

Question: I know there have been a lot of questions regarding the new cardiogenic pulmonary edema protocol. I am a student and just had a call regarding this. After the call there has been discussion about the directive and I have heard three different views and they are...

1. The first treatment column <140 you can ONLY give NTG if a IV is established (no hx.) 2. The second column stating that =>140 with no hx or Iv you can give 0.4mg is to be completely disregarded as it contraindicate the directives conditions 3. The third column stating that =>140 give 0.8mg ONLY if an IV is established (no hx.)

So the question I am asking is can you please clarify the treatment chart of the acute pulmonary edema directive?

Question: I had a question in regards to why do we need to establish an IV in a patient with suspected pulmonary edema? If they fit this protocol, they will most likely have crackles, and therefore if we happen to bottom out their pressure with nitro sprays, we will not be able to bolus due to the patient having crackles. Thanks in advance.

Question: In regard to the new Acute Pulmonary Edema protocol and the confusion surrounding it. Are we really giving 0.6 to 0.8 mg of Nitroglycerin SL to a patient with no IV and an Hx of use and a SBP of >140 mmHg?

Question: Why was Lasix removed from the pre-hospital CHF/Pulmonary Edema protocol, when the first thing an ER Physician orders on arrival at the ER is Lasix?

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