Friday, December 18, 2009

A difference of opinion?

We found her on the toilet. For some reason, when people become REALLY sick, they go sit on the pot. In this case, she was on the pot in a bathroom that was only accessible by passing through a hallway that was about 36 inches wide, and had stacks of junk and knick-knacks along both walls, reducing the shipping channel down to about 20 inches. This still would have only been an annoyance, except that she weighed about 310 pounds, and was 5 foot 2.

She is pale, her lips are blue, and her jugular veins are prominent. He legs are oozing fluid, and have large blisters on them. Cellulitis? Maybe. Her arms are swollen. Her complaint is shortness of breath, which she says she has had for about 4 days. She has a history of high blood pressure and hypothyroidism. She has been taking norvasc, lasix, lopressor, and synthroid for several years, and claims compliance. She has no known drug allergies.

Her vitals are as follows: HR78, SaO2 60% on room air, BP 81/50, EtCO2 is 80 with a normal appearance to the waveform. Lung sounds are clear, but diminished bilaterally. She is in a sinus rhythm, and her 12 lead is unremarkable.

My thoughts? The chief complaint in this case is supported by the cyanosis and the low O2 sats. The diminished lung sounds with the absence of wheezing, along with the JVD, the high CO2, and the hypotension lead me to believe that what we are dealing with is congestive heart failure. Since I have previously stated that CPAP is the flippity floppity floop, we went ahead and applied CPAP at 8cm and started an IV. While IV access was obtained, her O2 sats climbed to about 96%, and her EtCO2 fell to 60.

With the respiratory problem under our (temporary) control, it was time to turn our attention to the decompensating cardiogenic shock, so a Dopamine drip was hung. We hit our effect at about 800mcg/minute. I know that sounds like alot, but remember that the patient weighed in at 140kgs. Her BP climbed to 94/60, and I left it there.

When we got to the ER, the doctor on duty (same Doc from this post) wanted to know why we didn't give albuterol/atrovent by nebulizer. I pointed out that she was not wheezing, that albuterol is only to be used with caution in CHF patients, and that she was taking beta blockers. I told him that she seemed to improve with CPAP, so I saw no point in giving the albuterol. He proceeded to tell me how wrong I was, and said that diminished lung sounds were a form of wheezing. He took her off the CPAP, and ordered the nebulizer. I left.

There is an old saying that if everyone around you seems wrong, maybe it isn't them. I see so many cases of Doctors telling me things that contradict what I have been taught, and what I have been teaching to my own medic students, that I sometimes wonder if I am the one who is wrong. It has been known to happen. I had a junior medic with me on the call who now thinks I am an idiot, and a doctor who is trash talking me to the ER staff.

Maybe they are more current, maybe the people who taught me were wrong. What do you think?


RevMedic said...

I've seen Albuterol nebs used quite a bit for CHF, too, but that doesn't make it right.
Albuterol is a smooth muscle relaxer, and works in BRONCHOSPASM by dilating the bronchi.
Where does that fit into pulmonary edema treatment? I don't see where it does at all. The patient's problem is not bronchospasm. It's fluid in the alveoli. How do we fix that? With CPAP (first), nitrates (secondly, depending on local protocols), and possibly diuretics and/or opiates.
Thanks for bringing this up. I've been considering a post on it as well, but lets see where this one goes.

Ted said...

Patients with Congestive Heart Failure (CHF) AND Reactive Airway Disease (RAD) can be tricky to treat.

As RevMedic pointed out, the CHF component is treated with positive pressure ventilation and afterload reduction (traditionally by diuresis, although ACE inhibitors are being used with good effect). Pressors can be added if the problem is due to a too-weak pump rather than too-strong resistance. Opiates seem to be falling out of favor as recent studies link them to poor outcomes.

Where this gets really tricky is when the patient's RAD is triggered off by all the extra fluids in the lungs. That can lead to bronchospasm and related badness.

Based on the clinical exam related in the OP, this patient was clearly in CHF. The question is, did she ALSO have an RAD exacerbation?

Your doc pointed out that "diminished lung sounds were a form of wheezing". Fair enough. But remember that "all that wheezes is not asthma". CHF can certainly present with wheezes. Given the med list, the patient did not have an existing diagnosis of RAD. What are the odds that she suddenly developed severe enough RAD to cause an EtCO2 of 80?

All that said, albuterol/atrovent might have been a good idea in this patient IN ADDITION to the treatments you already gave. Maybe her lung exam had changed by the time you got to the ED. Maybe the NTG and CPAP had opened her up enough that she could tolerate a trial on facemask o2.

Sometimes it is appropriate to give bronchodilators in CHF. But that's a pretty tricky call, and I don't think it's appropriate to rake a medic over the coals for not doing it.

Divemedic said...

NTG, Morphine, and diuretics are all contraindicated in cases of decompensating cardiogenic shock. Noting her BP to be below 90 systolic, I would avoid anything that will reduce that any more than it already is.

Noting also that the patient had no Hx of airway problems. What would lead you to believe that the patient was experiencing anything other than CHF?

(Think pink puffer versus blue bloater.)

Ted said...

You have a point re: NTG, morphine, diuretics. I was writing about the general treatment of CHF in my second paragraph, and misspoke in the sixth.

Regarding your second question, not much. The JVD and severe pedal edema really point to CHF. That entire line of thinking is based on the possibility that the ED doc saw/heard something you didn't (not saying you missed anything--keep in mind that a critical patient's exam can change on a minute-to-minute basis). You seemed to be asking for other ways to think about the problem, and that's what I came up with.

Just to clarify, it sounds to me like your prehospital care was appropriate. You could have added some aspirin in case her decompensation was due to an MI, but that's just Monday-morning quarterbacking.

Divemedic said...

No offense. I was asking if there was something you saw that I may have missed. AS much as I would like to believe otherwise, I am not a god, and I have been wrong on occasion.


Ted said...

You and me both. I finally got around to reading your other post involving the same doc. It's a great case study in initial presentation of asthma as a predictor of bad outcome.

Next question: is this doc ED residency trained, or is he an off-service moonlighter?

Divemedic said...

I have no idea. I know that this hospital has a problem with EMS. Some of the staff there has a real attitude problem.

I their defense, though the ERs here are absolutely overwhelmed. Sometimes the ambulances are lined up, waiting for an ER bed. I myself have "held the wall" for up to 8 hours, waiting to get a bed.

It isn't quite as bad nowadays, but the burnout factor is still there.