Paramedic A-fib CHF SOB question

[medicmikee]

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?

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[leviathan]

Your CHF exacerbation patients are already far right on the Starling curve where higher filling pressures / increasing preloads do not improve stroke volume and may actually decrease it. The CHF patient who is in acute failure with a low pressure and high SVR (your wet + cold patient) is in a bad position that is difficult to deal with. The best treatment for these patients is to give inotropes such as milrinone or dobutamine. You may still be diuresing them while keeping a close eye on their pressure. They ideally should be admitted to CCU for tailored therapy, or at the very least to a step-down unit.

IV fluids may help increase intravascular volume and blood pressure but I don't think it would help to reduce pulmonary edema. With your patient not showing evidence of right sided congestion I wonder if this is something more acute like an infarct with flash pulmonary edema where the patient is not hypervolemic. Alternatively as you said it could have been rate-related, was he on too much dig or amiodarone? Or perhpas he had non compliance with his dig which temporarily worsened contractility? In that case more fluids may help, although I would defer to residents/attendings for their input on that.

 

[JLM]

I dont think this is a rate issue at all. If this guy has known a-fib he is likely used to living with no atrial kick.

And the failing heart is generally preload unresponsive, meaning that an bolus of IV fluids will do absolutely nothing to change the cardiac output. Check out the graph. The normal heart has a nice increase in stroke volume (and thus cardiac output because CO= SV x HR) when you increase the preload (fluid bolus).

But the failing heart has a much more flat curve. So, extra preload does not increase the stroke volume.

I would give this guy a NRB mask and a saline lock. What he really needs is an echo.

 

[joeDO2]

Although you did not see a negative effect in this case, I would not give fluid boluses to patients with pulmonary edema. The blood pressure in this case was not horrible (assuming there were no other signs of inadaquate tissue perfusion) and therefore my management of the patient would be the following:

-Place patient on NRB to improve dyspnea
-Consider MI and obtain serial 12-lead ECGs
-If available, monitor patient with continuous waveform capnography
-Obtain IV access x2 with saline lock only

If BP trends down, pt develops signs of decreased perfusion, or complains of increasing dyspnea....

-Administer pressor and titrate slowly up
-Place patient on CPAP/BiPAP at 10cm h2O and titrate up if tolerated
-Consider intubation if deemed necessary

As far as the other "standard" treatments you mentioned (nitrates, diuretics, morphine)...

-nitrates work quite well, but as you suggested would be contraindicated due to BP
-the use of diuretics is somewhat controversial prehospital. you should consider that they take a relatively long time to work and the effects may not be appreciated in the setting of rapidly developing pulmonary edema. also, it has been suggested that without knowing chemistry values, significant derangements in electrolytes can occur causing more harm than good. these are all points to consider even in patients with normal BPs.
-I would discourage the use of morphine in prehospital CHF management. this is another controversial point but as you know, morphine can cause significant respiratory depression as well as hypotension/histamine release. if you are looking for something to reduce anxiety in CHF, probably a low dose benzodiazepine would be a better choice if you absolutely had to give something.

As I have mentioned in other threads, I am a proponent of prehospital ultrasound. This would be a great case to incorporate that technology. If you had additional time in transport, you could measure IVC collapsible to get a rough idea of fluid status. It would also be extremely helpful to obtain cardiac images to determine ventricular wall motion abnormalities which may identify a problem not otherwise noted on the ECG.

 

[jwk]

Gee, let's just go ahead and drop a TEE.

 

[Socrates25]

Gee, let's just go ahead and drop a TEE.

yeah you can tell from JoeDO2's other posts that his next idea is that paramedics should be doing open chest cardiac massage in the field LOL

 

[joeDO2]

yeah you can tell from JoeDO2's other posts that his next idea is that paramedics should be doing open chest cardiac massage in the field LOL

haha, well not quite. really nothing besides the ultrasound was outside of a normal paramedic scope of practice. I just have a special interest in looking at uses for that in the prehospital environment. There are actually several studies that have looked at that in certain environments. Just something I thought I'd add in....obviously not a routine procedure for all systems. I do advocate for adjusting protocols to utilize treatments that show benefit and are time-sensitive. The problem is that right now I think we have a huge lack of evidence-based studies prehospitally. We need to change that- get rid of the treatments/procedures that have little benefit; add those that will make a difference.

EDIT:
Small Side rant on current state of EMS-

1. Why in EMS are we so closed-minded against change? For some reason, when we hear about adding a new procedure/treatment/whatever, we immediately have a reaction of "no way" (myself included until recently). Yet, we cling to traditional procedures that have no evidence and in some cases actually show harm! Now maybe some of these new ideas are not practical. That's ok! Let's be open-minded and explore them through research. If it turns out they are not helpful, let's try something else!

2. Why do we accept that a GED and 10 months of training is sufficient to practice as a paramedic. In the hospital, the person putting in the EJ, paralyzing the patient, and intubating is certainly not the person in the room with 10 months of training. If that is not acceptable in the hospital, why is it accepted in the field? Let's improve education, standardize it, and get more physician involvement.

 

[docB]

haha, well not quite. really nothing besides the ultrasound was outside of a normal paramedic scope of practice. I just have a special interest in looking at uses for that in the prehospital environment. There are actually several studies that have looked at that in certain environments. Just something I thought I'd add in....obviously not a routine procedure for all systems. I do advocate for adjusting protocols to utilize treatments that show benefit and are time-sensitive. The problem is that right now I think we have a huge lack of evidence-based studies prehospitally. We need to change that- get rid of the treatments/procedures that have little benefit; add those that will make a difference.

EDIT:
Small Side rant on current state of EMS-

1. Why in EMS are we so closed-minded against change? For some reason, when we hear about adding a new procedure/treatment/whatever, we immediately have a reaction of "no way" (myself included until recently). Yet, we cling to traditional procedures that have no evidence and in some cases actually show harm! Now maybe some of these new ideas are not practical. That's ok! Let's be open-minded and explore them through research. If it turns out they are not helpful, let's try something else!

2. Why do we accept that a GED and 10 months of training is sufficient to practice as a paramedic. In the hospital, the person putting in the EJ, paralyzing the patient, and intubating is certainly not the person in the room with 10 months of training. If that is not acceptable in the hospital, why is it accepted in the field? Let's improve education, standardize it, and get more physician involvement.

I agree with your #1 and especially #2. I'd add in that we need much more EMS based research to answer these best practice questions.

As for US I think that there is a niche for field US but I think it's in aero med. FAST and checking for pericardial effusion would be valuable and US for line placement and looking for pneumothorax while at altitude would be really helpful. I would take training but the machines are definitely small enough and cheap enough for that arena.

 

[Paseo Del Norte]

Caveat Lector: Anecdote and probably some bias to follow.

Agreed. I would love to see best practice research. Unfortunately, with certain professions that I will not name, a less is just as good approach is the newest drum to beat. Where I teach, I have little ammunition to use to present an evidence based argument for creating a more robust curriculum. My current argument is based on the additional material added to the NSC for EMS providers and the fact that the newer textbooks are much more detailed and technical than the ones of years past. With a little luck, we may mandate prerequisite courses such as microbiology and anatomy & physiology for our advanced EMT and paramedic courses. Currently, they are suggested but not mandatory requirements as we have a three credit anatomy and physiology course that is part of our paramedic curriculum versus an eight credit sequence with labs that are taught by professors with graduate and doctoral degrees in those subjects.

With that, if you compare our curriculum to the core nursing curricula in our area, the paramedics spend just as much time in school on a clock hour basis and currently we have comparable amounts if not more clinical time in some cases than some of the nursing programmes. Our programme is about 11 months long (not including the EMT and advanced EMT courses prior to applying to the paramedic programme) and the students are in class from about 08:00-17:00 Monday-Thursday except during clinical rotations because 12 hour shifts are common, so there is certainly a fair amount of time being spent in class, lab and in clinical rotations. Not to mention we have an active medical director who not only lectures a couple times a semester, but reviews all paramedic student charting. In addition, we have a good working relationship with the respiratory therapy programme and often share resources with them.

Unfortunately, they do lack many of the core pre-requisite courses that other health related professions must take and at the very least it potentially impacts credibility. With that, things have improved drastically in some areas and I am hopeful that the education of novice paramedics will become something that I am proud of in my lifetime. Already, I have seen improvement from 15 years ago when the first paramedic programme that I saw was a 750 clock hour course (250 didactic and clinical lab & 500 clinical hours).

Regarding advanced procedures in the field such as RSI, I am not convinced such things are particularly helpful and there is certainly evidence suggesting they are harmful.

 

[Socrates25]

Caveat Lector: Anecdote and probably some bias to follow.

Agreed. I would love to see best practice research. Unfortunately, with certain professions that I will not name, a less is just as good approach is the newest drum to beat. Where I teach, I have little ammunition to use to present an evidence based argument for creating a more robust curriculum. My current argument is based on the additional material added to the NSC for EMS providers and the fact that the newer textbooks are much more detailed and technical than the ones of years past. With a little luck, we may mandate prerequisite courses such as microbiology and anatomy & physiology for our advanced EMT and paramedic courses. Currently, they are suggested but not mandatory requirements as we have a three credit anatomy and physiology course that is part of our paramedic curriculum versus an eight credit sequence with labs that are taught by professors with graduate and doctoral degrees in those subjects.

With that, if you compare our curriculum to the core nursing curricula in our area, the paramedics spend just as much time in school on a clock hour basis and currently we have comparable amounts if not more clinical time in some cases than some of the nursing programmes. Our programme is about 11 months long (not including the EMT and advanced EMT courses prior to applying to the paramedic programme) and the students are in class from about 08:00-17:00 Monday-Thursday except during clinical rotations because 12 hour shifts are common, so there is certainly a fair amount of time being spent in class, lab and in clinical rotations. Not to mention we have an active medical director who not only lectures a couple times a semester, but reviews all paramedic student charting. In addition, we have a good working relationship with the respiratory therapy programme and often share resources with them.

Unfortunately, they do lack many of the core pre-requisite courses that other health related professions must take and at the very least it potentially impacts credibility. With that, things have improved drastically in some areas and I am hopeful that the education of novice paramedics will become something that I am proud of in my lifetime. Already, I have seen improvement from 15 years ago when the first paramedic programme that I saw was a 750 clock hour course (250 didactic and clinical lab & 500 clinical hours).

Regarding advanced procedures in the field such as RSI, I am not convinced such things are particularly helpful and there is certainly evidence suggesting they are harmful.

I've got a better idea. Lets expand the curriculum a little bit, and give paramedics a doctoral degree.

Then your slogan can be "why go to the ER for a doctor when we can send a doctor to you in the field?"

 

[Paseo Del Norte]

My feelings on such issues should be well known at this point; however, I believe continued dialogue and work toward defining evidence based standards(standardised minimal educational standards and scope of practice) in EMS is long overdue. The NSC sets a minimal guideline, but it's interpretation is still highly nebulous IMHO. Additionally, since EMS has traditionally been highly dependant upon physician direction in the United States, physician involvement and direction will be a critical component in whatever process occurs.

 

[proman]

All statements above are accurate for systolic heart failure. But there's a real chance that this may have been diastolic heart failure (aka heart failure with preserved ejection fraction). Diastolic heart failure does need higher filling pressures and may indeed respond to fluid.

 

[drmwvr]

Can't rule out the possibility of mitral regurge being the cause of all of this...heart sounds would've been helpful. Agree with access, O2 and get to the hospital for an echo. And certainly pressors in the absence of an echo are a bad idea.

 

[drmwvr]

as long as transport wasn't delayed...

 

[leviathan]

All statements above are accurate for systolic heart failure. But there's a real chance that this may have been diastolic heart failure (aka heart failure with preserved ejection fraction). Diastolic heart failure does need higher filling pressures and may indeed respond to fluid.

More fluids aren't going to help improve pulmonary edema in a patient with congestive heart failure regardless of whether it's pure diastolic or systolic failure. The one exception to that might be dynamic LVOT obstruction ie. HOCM, but even then I'm not sure.