CHF/Pulmonary Edema & CPAP
McHenry Western Lake County EMS System Education
CHF
Common & potentially fatal condition Occurs when the left ventricle fails Pressure builds up in the ventricle This causes an overload of fluid in body When this fluid occurs in lungs it’s called pulmonary edema CHF is on the rise in the US CHF/Pulmonary Edema
CHF/Pulmonary Edema
When fluid saturates the interstitial spaces it will begin to accumulate in the alveoli CHF/Pulmonary Edema
Alveoli collapse with each exhalation Fluid washes out the surfactant Alveoli can not re-expand Pink frothy sputum Acute respiratory distress Rapid deterioration CHF/Pulmonary Edema
Signs & Symptoms – Dyspnea of varying degrees – Orthopnea – Anxiety / Restlessness – Tachypnea / tachycardia – Pink Frothy Sputum – SpO2 ≤ 94 % CHF/Pulmonary Edema
Signs & Symptoms – Pale/Cool/Diaphoretic – Labored respirations – Severe apprehension or confusion – BP usually elevated (Low would be ominous) – Pt not able speak normally – Lung Sounds-crackles & / or wheezes
CHF/Pulmonary Edema
Rapid Aggressive Treatment is required All that wheezes is not asthma and should not be treated with albuterol!
Treatment for CHF
Position the patient in a sitting upright at 90* and dangle legs if possible. If the patient is in severe distress you may have to consider DAI. Treatment for CHF
CPAP if immediately available – Do not use C-PAP in AMI
Treatment for CHF
Monitor-from the time of pt contact
IV-tko
Pulse Ox Treatment for CHF
ASA 324mg – (unless contraindicated) NTG – EVERY 3-5 MIN as long as SBP remains >90. No limit
Treatment for CHF
For severe anxiety in CHF, Versed in 2mg increments every 30-60 sec IVP (0.2 mg/kg IN) up to 10mg IVP/IN. May repeat to 20mg if SBP >90. Anxiety worsens the condition CPAP : What it is
Applies positive pressure to the airways throughout the respiratory cycle This keeps the alveoli open during expiration Allows for O2 & CO2 exchange Can rapidly improve pt’s condition Frequently prevents intubation CPAP
Why wouldn’t we want to intubate? – Mandatory ICU admission – Prolonged hospital stay & recovery – Higher potential for complications – Airway trauma possible – Infection can occur – More invasive & uncomfortable CPAP : What it isn’t
CPAP does not maintain the airway CPAP does not allow you to assist your pt with ventilation Pt MUST be able to maintain their own airway Pt MUST be able to clear their own airway CPAP
If your pt requires ventilatory assistance with a BVM he is not a candidate for CPAP Altered mental status – GCS ≤ 8 requires ventilatory assistance, therefore no CPAP CPAP – Indications/Inclusions
Pulmonary At least 18 yrs old Edema Alert with airway Dyspnea intact/maintainable Crackles SBP > 90 DBP >60 Wheezes Sp02 < 94%
CPAP - Contraindications
Age less than 18 AMS SBP < 90 Need for immediate airway control Unstable airway Acute MI CPAP – May exclude
Uncooperative patient Facial hair making it impossible to obtain seal Pregnancy Inability to properly fit mask CPAP - Procedure
Follow appropriate SOP Prepare equipment – Connect oxygen to 15 L – Peep will be 3.0-4.0 – Have intubation equipment available Position pt sitting up Explain procedure to pt & reassure CPAP - Procedure
Hold mask gently to face to allow patient to feel what the pressure will be like. After 3-5 min. lift mask & give next NTG Now gently place head straps on patient.
CPAP - Procedure
If needed, flow can be increased to 20 lpm which will provide 6.0 -7.0 of peep Sp02 of >95% is our goal.
CPAP - Procedure
If no improvement in 3 minutes: – Increase O2 to 25 LPM – PEEP will now be 8.5 – 10.0 – Maintain Sp02 >95% Continuously monitor pt for S/S requiring intubation Cardiogenic Shock
SBP < 90 MAP <60 Signs and Symptoms of hypoperfusion Dopamine 400mg/250ml – Start at 5mcg/kg/min and titrate up to 20 mcg/kg/min until SBP is >90. – NS 200 ml increments if lungs clear and respirations are not labored! CPAP – D/C in field
Inability to tolerate mask (Nobody likes CPAP at first) Need to intubate SBP falls below 90 ECG instability with evidence of acute ischemia CPAP
Be sure to document : – Time of initiation – Settings – Pt response-VS, color, work of breathing, SpO2, EtC02 Continually watch pt for improvement or deterioration CPAP
System is dependent on a good seal Pt MUST remain on O2 & cardiac monitor at ALL times, even when transferring pt care to hospital Continue to give NTG SL every 3-5 min, just lift mask briefly to administer medication Documentation
Time initiated O2 settings Patient response – V/S-resp. rate & depth – SpO2 & mental status – Respiratory distress-WOB, comfort level – Lung sounds – Complications- gastric distention, inability to tolerate Additional Indications for CPAP Include
Asthma/COPD patient in severe respiratory distress Near drowning patient who is congested has increased work of breathing who can maintain their own airwy. Case Study
You have a 68 y/o male with sudden onset of dyspnea, coughing pink sputum. He is restless and has tachycardia. His BP is 168/94 SpO2 is 94% and pulse is 140. What should your treatment be? Answer
Prepare equipment – Connect oxygen to 15 L – Have intubation equipment available Position pt sitting up Explain procedure to pt & reassure
Answer
Hold mask gently to face After 5 min. lift mask & give next NTG Now gently place head straps on and increase flow as needed.
Case Study
You have given your patient 4 ASA and 2 NTG during your treatment. His pressure remains stable at 154/78 and his pulse is still 140. SpO2 is 96%. Can you give him another NTG? Answer
Yes…there is no limit to the NTG every 3-5 minutes as long as the patient has a SBP >90 Questions??
Color Thanks Guys! I feel much better now!! good Alert Good Airway Sitting Upright