San Mateo County Emergency Medical Services Respiratory Distress/CHF/Pulmonary Edema For congestive heart failure exacerbation History Signs and Symptoms Differential • Congestive heart failure • Hypotension/shock • Myocardial infarction • Past medical history • Bilateral rales/crackles • Congestive heart failure • Medications (e.g., Digoxin, Lasix, erectile • Anxiety • Asthma dysfunction medications) • Orthopnea • Anaphylaxis • Cardiac history including past MI • Jugular vein distension • Aspiration • Pink, frothy sputum • COPD • Peripheral edema • Pleural effusion • Diaphoresis • Pneumonia • Chest pain • Pulmonary embolus • Hypertensive • Pericardial tamponade • Wheezing • Toxic exposure Airway patent? Respiratory Arrest/Failure Ventilation adequate? No if indicated Oxygenation adequate? Yes Cardiac monitor Chest Pain: Suspected 12‐Lead ECG STEMI if indicated P Establish IV/IO Consider, EtCO2 monitoring Assess symptom severity SEVERE MILD Cyanosis, accessory muscle use, < 2 CARDIOGENIC SHOCK word sentences, decreased LOC, or Hypotension/Poor no response to Albuterol perfusion Nitroglycerin X 1 If systolic BP > 110 P if systolic BP > 110 Nitroglycerin P or P Dopamine Nitroglycerin X 2 Remove CPAP, but only if systolic BP > 150 O while systolic BP < 100 No O Apply CPAP If systolic BP < 90, Improving? P Dopamine Remove CPAP, but only O while systolic BP < 100 Yes Respiratory Arrest/ Respiratory Failure Notify receiving facility. Consider Base Hospital for medical direction Treatment Protocol R04 Page 1 of 2 Effective November 2018Effective October 2019 San Mateo County Emergency Medical Services Respiratory Distress/CHF/Pulmonary Edema For congestive heart failure exacerbation Pearls • Opioids have NOT been shown to improve the outcomes of EMS patients with pulmonary edema. Even though this has historically been a mainstay of EMS treatment, it is no longer recommended. • Avoid Nitroglycerin in any patient who has used Erectile Dysfunction Medications Viagra/Revatio (Sildenafil) or Levitra (Vardenafil) in the past 24 hours or Cialis (Tadalafil) in the past 36 hours due to potential for severe hypotension. • Carefully monitor the patient’s level of consciousness, chest pain, and respiratory status with the above interventions. • Consider MI in all of these patients. • A trial of Albuterol can be considered in the undifferentiated patient. Treatment Protocol R04 Page 2 of 2 Effective November 2018Effective October 2019.