April 2011 CE Site code # 107200E-1211 The Patient With ......Region X SOP’s. Define CPAP as used...
Transcript of April 2011 CE Site code # 107200E-1211 The Patient With ......Region X SOP’s. Define CPAP as used...
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 Acute weight
gain,
dependent
edema
Fever, malaise Gradual weight
loss
Cough Frothy sputum Productive thick
green
Chronic;
productive
Onset Rapid Gradual Gradual
B/P High Normal Normal
Meds Dig, anti-
HTN, diuretic
Antibiotic, cold prep Bronchodilators,
steroids
Tx O2, NTG,
lasix, MS
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?
Prequiz April 2011
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? 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