April 2011 CE Site code # 107200E-1211 The Patient With Heart Failure; CPAP as an Intervention Prepared by: Lt. Bill Hoover, Medical Officer Wauconda Fire District Reviewed/revised by Sharon Hopkins, RN, BSN, EMT-P To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=352
Date of CE presentation: April 2011 Topic: Patient with CHF; Using CPAP Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to: Define heart failure and congestive heart failure. Identify causes of heart failure. Identify symptoms of heart failure. Identify patterns of medical history related to the patient with heart failure. Identify current home medications typically taken by the patient with congestive heat failure. Identify the difference between the patient with congestive heart failure and pneumonia. Identify the assessment of the patient with congestive heart failure. Identify the proper procedure for assessing breath sounds. Identify treatment goals and options for congestive heart failure following Region X SOP s. Define CPAP as used by EMS for the patient with pulmonary edema. Describe how CPAP will benefit the patient with pulmonary edema. State indications, contraindications and medications used with CPAP. Describe the process of setting up the CPAP device. Describe the process of adding in-line Albuterol with CPAP. Describe patient assessment while delivery CPAP. State components to document when using CPAP. Demonstrate the set up of CPAP. Demonstrate the set-up of regular and in-line Albuterol. Demonstrate adding in-line Albuterol with CPAP. Actively participate in case scenario discussion. Successfully complete the post quiz with a score of 80% or better. References: 2007 Condell Medical Center EMS System SOP s 2008 Northwest Community EMSS SOP www.webmd.com www.mayoclinic.com www.emedicinehealth.com Advanced Medical Life Support, 3rd Ed., Brady Flight for Life Pocketbook Guide, 2009 Ed.
Fluid build-up in CHF may be pulmonary, peripheral, sacral, or ascites Right heart failure
Evaluation CHF/PE Pneumonia COPD History HTN, heart problems n/a Lung problems Dyspnea Orthopnea, PND Orthopnea possible Chronic; pursed lips Recent hx Cough Acute weight Fever, malaise gain, dependent edema Frothy sputum Productive thick green Gradual weight loss Chronic; productive Onset Rapid Gradual Gradual B/P High Normal Normal Meds Tx Dig, anti- HTN, diuretic O2, NTG, lasix, MS Antibiotic, cold prep Bronchodilators, steroids O2, neb, fluids O2, neb Separating Signs and Symptoms Symptom CHF/PE Pneumonia COPD SOB Yes Yes Yes Cough Maybe Yes Early a.m. Sputum Frothy pink Yellow/green Thick brown Fever No Yes No Skin Cold/clammy Hot/dry Normal or dusky Chest pain Possible Maybe No Smoking hx Possible Possible Usually Wheezing Maybe; bilateral Maybe; same side as disease Usually, bilateral Crackles Yes; bilateral Maybe; same side as disease No
CPAP Set-up Adding Albuterol In-line to CPAP Cut the CPAP corrugated tubing as close to patient as possible in smooth area of tubing Splice Albuterol kit T piece in-line Remove the mouthpiece and place the adaptor (used for in-line Albuterol) Connect adaptor to distal cut end of corrugated CPAP tubing Remove Albuterol corrugated tubing and connect proximal end of CPAP tubing to T piece of Albuterol Keep Albuterol cup upright Albuterol kit still needs to be hooked to O2
Case Scenarios Small Group and Large Group Discussions Read the presentation Form a general impression Discuss treatment options Discuss what/how/when to reassess the patient Decide what treatment to continue or what adjustments need to be made Note: Additional questions are asked on power point that can be discussed during group presentations. Case Scenario #1 Dispatch: You are called to a 70 y/o man c/o breathing problems HPI: Increasing shortness of breath for 1 day despite the use of inhalers PmHx: COPD, Hypertension, and Diabetes Medications: Albuterol Inhaler, Lasix, and Aspirin Allergies: Penicillin Physical Exam: Thin white man on home oxygen breathing through pursed lips sitting in a tripod position Vital Signs: B/P 180/90; HR 120 sinus tachycardia; RR 30; SaO2 88%; LOC alert; airway patent Head & neck: Perioral cyanosis, no JVD Pulmonary: Lung auscultation reveals inspiratory and expiratory wheezes Extremities: Cyanotic, no pedal edema Case Scenario #2 Dispatch: 65 y/o woman c/o of shortness of breath HPI: 1 week history of progressive dyspnea with exertion. Unable to lay down flat without shortness of breath, no chest pain or cough PmHx: Hypertension, Diabetes Medications: Lasix, Atenolol, and Glucaphage Physical Exam: 260 lb woman sitting in recliner. Vital Signs: B/P 160/80; HR 140 sinus tachycardia; RR 30; SaO2 78%, LOC follows commands; airway patent Head & neck: Cyanosis, JVD present Pulmonary: Crackles in all lung fields Extremities: Cyanotic, 3+ pedal edema
Case Scenario #3 Documentation Review Initial impression was acute pulmonary edema Based on physical assessment; history; recent hospitalization for CHF Treatment was routine medical care IV O2 non-rebreather- monitor CPAP started after ordered by Medical Control 2 sets of vital signs and 2 cardiac rhythm interpretations documented Initial vital signs (B/P 170/98 92 32); cardiac rhythm sinus Second reading at the hospital; cardiac rhythm remained sinus Upon arrival patient found sitting upright, agitated, complaining of chest pain and difficulty breathing. Audible congested breathing standing next to patient. Unable to complete a full sentence. Bilateral pedal edema noted. Began oxygen via nonrebreather. IV started. Moved patient to ambulance. Medical Control contacted and ordered CPAP to be started. Patient becoming more agitated. After 5 minutes, SaO2 increasing. Patient stated breathing was becoming easier. Patient transported sitting upright. Continued CPAP during entire call. Transported patient into ED on portable O2 with CPAP continued. Documentation noted: Pt contact: 0954 Depart scene: 1025 Drugs 0959 - Oxygen - 15 l non-rebreather 1001 0.9 NS 1000ml TKO IV 1005 CPAP /oxygen 15l CPAP mask Case Scenario #4 - Discussion Dispatch: You are called to a 84 year-old female c/o breathing problems HPI: Running low grade fevers, not feeling well for 4 days PmHx: MI, Hypertension, TIA s Medications: Plavix, Lasix, Lisinopril Allergies: Iodine, shellfish Physical Exam: Vital Signs: B/P 142/80; HR 96 sinus rhythm; RR 28; SaO2 92%, LOC follows commands; airway patent Head & neck: Pale, no JVD Pulmonary: Crackles in right lower lung field Extremities: Pale, pedal pulses palpable Case Scenario #5 Documentation Dispatch: You are called to a home for a 78 year-old male with severe SOB HPI: Has been getting progressively SOB past 2 days; slept in recliner last night PmHx: MI x3; hypertension, diverticulitis, seizures Medications: Aspirin, Hydrodiuril, Verapamil, NTG PRN, Coumadin, Phenobarbital Allergies: none Physical Exam: Vital Signs: B/P 172/96; HR 110 sinus tachycardia; RR 36; SaO2 88%, LOC follows commands; extremely anxious; airway patent Head & neck: JVD Pulmonary: Crackles mid way up lung fields bilaterally Extremities: Cyanotic, pedal edema palpable
Documentation Practice
Pre-Quiz Paramedic And Basic Level From April 2011 CE Material The Patient with Heart Failure; CPAP Name Date 1. List 3 contributing factors to heart failure. 2. What is the influence of Starling s Law on myocardial function (think of a stretched rubber band)? 3. List at least 5 signs or symptoms of right heart failure. 4. List at least 5 signs or symptoms of left heart failure. 5. How can you tell the difference between CHF and pneumonia? 6. Describe the technique for listening to breath sounds? -Which side of the stethoscope is best bell or diaphragm? - Where do you place the stethoscope? - Why would you ask the patient to cough before listening?
7. If you are first on the scene with only BLS emergency equipment available, how would you start caring for the patient in acute pulmonary edema? Prequiz April 2011 8. What is the purpose of nitroglycerin given for the patient in acute pulmonary edema? 9. What is the purpose of CPAP and when should it be started in acute pulmonary edema? 10. How can you tell when CPAP and or medications are becoming effective in the setting of acute pulmonary edema? File: CE, EMS; CE Packets April 2011 Prequiz Heart Failure and CPAP