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I have been a paramedic in a busy system for about 12 years but I am always still learning and wanted some advice on a call I had the other day.
80 year old male with a history of CHF and A-fib calls for increasing mild shortness of breath x1day. No other associated symptoms Pt is found seated at home. Presents conscious alert and oriented x4 GCS15, normal skin signs, mildly increased breathing rate but no significant work of breathing. Rales are appreciated in the very lowest bases from the back fields but not in lateral or anterior fields. Tidal volume is good and there is no wheezing. Room air sat is 90%. No significant pedal/sacral edema is found and there is no JVD. Pt is mildly hypotensive at 92/56 HR 69 and pt is in A-fib without ventricular ectopy.
My question comes regarding my treatment. I know this patient has CHF and he is currently exhibiting some pulmonary edema. But he isn't the typical hypertensive CHF patient that would seem to benefit from nitrates, diuretics, morphine. (Plus it's obviously contraindicated due to pressure.) To me it seems that his rate is just not fast enough to support his A-fib and it's reduced atrial kick and it is making him hypotensive and compromising cardiac output, resulting in pulmonary edema. I can't really play with his rate but it seemed that if I could increase preload a little with judicious fluids, the whole starling's law thing could help me increase cardiac output and blood pressure enough to overcome his vascular resistance and thus make the rales reduce or go away. So I oxygenated the patient and gave him a 250cc bolus of NS, and after checking his lungs in 5 minutes I gave him another 100cc. My ending pressure was 106/70. The patient did report feeling better and I wasn't able to hear any rales 15 minutes later upon arrival at the hospital.
Was my thinking correct? It seemed to work well but was that just coincidence? The ER MD seemed satisfied with my decision but some of my colleagues questioned how I could reduce pulmonary edema by giving more fluid. What do you think?
80 year old male with a history of CHF and A-fib calls for increasing mild shortness of breath x1day. No other associated symptoms Pt is found seated at home. Presents conscious alert and oriented x4 GCS15, normal skin signs, mildly increased breathing rate but no significant work of breathing. Rales are appreciated in the very lowest bases from the back fields but not in lateral or anterior fields. Tidal volume is good and there is no wheezing. Room air sat is 90%. No significant pedal/sacral edema is found and there is no JVD. Pt is mildly hypotensive at 92/56 HR 69 and pt is in A-fib without ventricular ectopy.
My question comes regarding my treatment. I know this patient has CHF and he is currently exhibiting some pulmonary edema. But he isn't the typical hypertensive CHF patient that would seem to benefit from nitrates, diuretics, morphine. (Plus it's obviously contraindicated due to pressure.) To me it seems that his rate is just not fast enough to support his A-fib and it's reduced atrial kick and it is making him hypotensive and compromising cardiac output, resulting in pulmonary edema. I can't really play with his rate but it seemed that if I could increase preload a little with judicious fluids, the whole starling's law thing could help me increase cardiac output and blood pressure enough to overcome his vascular resistance and thus make the rales reduce or go away. So I oxygenated the patient and gave him a 250cc bolus of NS, and after checking his lungs in 5 minutes I gave him another 100cc. My ending pressure was 106/70. The patient did report feeling better and I wasn't able to hear any rales 15 minutes later upon arrival at the hospital.
Was my thinking correct? It seemed to work well but was that just coincidence? The ER MD seemed satisfied with my decision but some of my colleagues questioned how I could reduce pulmonary edema by giving more fluid. What do you think?
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