pulmonary edema vs pneumonia oregon emt-intermediate
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Pulmonary Edema vs
Pneumonia
Oregon EMT-IntermediateOregon EMT-Intermediate
Acute Pulmonary Edema
Clinical signs: shock, hypotension, congestive heart failure, acute pulmonary edema
Most likely problem?
Volume problem Pump problem Rate problem
First-line ActionsOxygenNitroglycerine SLFurosemide 0.5 to 1mg/kgMorphine IV 2 to10 mg
AdministerFluid
Bradycardia?See algorithm
Tachycardia?See algorithm
Blood pressure
EMT-IntermediateAcute Pulmonary Edema, Hypotension, Shock
Let’s Review:
Cardiac OutputCardiac Output 5000-6000 ml/min.5000-6000 ml/min.
HR or SV = COHR or SV = CO Sympathetic effects:Sympathetic effects:
HR and SVHR and SV Parasympathetic:Parasympathetic:
Slows HRSlows HR Little effect on SVLittle effect on SV
Review:
SV = pressure in ventricle SV = pressure in ventricle Frank Starling effectFrank Starling effect
Peripheral vascular constriction Peripheral vascular constriction increases venous return increases venous return = Increased RV output.= Increased RV output.
Vasodilation of arteries decreases PVR Vasodilation of arteries decreases PVR and diastolic pressureand diastolic pressure = Decreased CO.= Decreased CO.
Vital Signs
Normal B/P is 120/70 mmHgNormal B/P is 120/70 mmHg Increases with ageIncreases with age General:General:
Systolic – 100 + age up to 140Systolic – 100 + age up to 140 At age 50: usually 140 mmHgAt age 50: usually 140 mmHg Increases 1 mmHg/yr after 50.Increases 1 mmHg/yr after 50.
CHF Causes
Normal heart muscle
AMI
Left ventricular enlargement
Abnormal Cardiac Function
Dispatched as:Dispatched as: Man downMan down Chest painChest pain Heart attackHeart attack SOBSOB FaintedFainted DizzyDizzy
Passed outPassed outChokingChokingStroke Stroke DFODFODRTDRT
Initial Assessment:
Brief HistoryBrief History OOnsetnset PProvoking factorsrovoking factors QQualityuality RRadiationadiation SSeverityeverity TTimeime BP changesBP changes
Initial Assessment
MedsMedsCardiac rhythmCardiac rhythmAbnormal breathingAbnormal breathingEdemaEdemaRalesRalesChanges in skin color and Changes in skin color and
moisturemoisture
Right and Left Heart Failure
Right Heart FailureRight Heart Failure CausesCauses
COPD COPD Left heart failureLeft heart failure
ProgressionProgression Right ventricle cannot Right ventricle cannot
eject all of the bloodeject all of the blood Fluid/pressure backs upFluid/pressure backs up
Right atriumRight atrium Venous systemVenous system Pedal edema, JVDPedal edema, JVD
Left Heart FailureLeft Heart Failure CausesCauses
High afterloadHigh afterload ProgressionProgression
Left ventricle cannot Left ventricle cannot eject all of the bloodeject all of the blood
Fluid/pressure backs upFluid/pressure backs up Left atriumLeft atrium Lung tissueLung tissue AlveoliAlveoli Pulmonary edemaPulmonary edema
Acute Left Ventricular Failure
Acute LVF from heart disease:Acute LVF from heart disease: #1 cause of heart failure.#1 cause of heart failure. Assume the worst, hope for bestAssume the worst, hope for best
Pt. with CAD w/ hx of MI(new or old) Pt. with CAD w/ hx of MI(new or old) May develop LVF.May develop LVF.
Frequently LVF is only manifestation of Frequently LVF is only manifestation of AMI.AMI.
LVF
Common causesCommon causes Systemic HTNSystemic HTN
AfterloadAfterload Coronary artery diseaseCoronary artery disease
Arteriosclerosis/atherosclerosisArteriosclerosis/atherosclerosis IschemiaIschemia
Local/temporary occlusionLocal/temporary occlusion
LVF
Common CausesCommon Causes InfarctionInfarction
Permanent, necrosisPermanent, necrosisSignificant Sized InfarctSignificant Sized Infarct
• Decrease effective wall motionDecrease effective wall motion
• Decreased stroke volumeDecreased stroke volume CardiomyopathyCardiomyopathy
• Alcoholism one of main causesAlcoholism one of main causes
LVF
Other CausesOther Causes Volume overloadVolume overload
Bag of Potato ChipsBag of Potato Chips Severe anemiaSevere anemia
HypoxemiaHypoxemia
LVF and Pulmonary Edema
Incidence of CHF doubles per decade Incidence of CHF doubles per decade of lifeof life
> 3 million in US; > 400,000 new > 3 million in US; > 400,000 new diagnoses/yrdiagnoses/yr
5 yr mortality rate /p dx;5 yr mortality rate /p dx; 60% in men60% in men 43% in women43% in women
Basically this happens
Forward or backward ventricular flow.Forward or backward ventricular flow. Forward – (LVF) – reduced flow into Forward – (LVF) – reduced flow into
aorta and systemic circulationaorta and systemic circulation Backward – elevated systemic Backward – elevated systemic
venous pressurevenous pressure
NY Heart Association’s classification of CHF Class IClass I
Not limited by symptomsNot limited by symptoms Class IIClass II
Fatigue, dyspnea, other sx with ordinary Fatigue, dyspnea, other sx with ordinary physical activityphysical activity
Class IIIClass III Marked limitation with normal activityMarked limitation with normal activity
Class IVClass IV Symptoms at rest or with any activitySymptoms at rest or with any activity
CHF
Acute CHFAcute CHF RapidRapid
Chronic CHFChronic CHF SlowSlow Midnight shoppersMidnight shoppers
Pulmonary edema also results from:
CVACVA Pulmonary embolismPulmonary embolism Infection - SepsisInfection - Sepsis AllergyAllergy Inhalation of fumesInhalation of fumes Narcotic abuse Narcotic abuse
Especially Inhaled (Heroin)Especially Inhaled (Heroin) Altitude sickness.Altitude sickness.
Acute Findings HistoryHistory
Recent change in sleep patternsRecent change in sleep patternsMore frequent trips to the bathroomMore frequent trips to the bathroomNeed to sleep on more pillows at nightNeed to sleep on more pillows at nightRecent move to the recliner at nightsRecent move to the recliner at nightsNew episodes of PNDNew episodes of PND
• Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea• Sudden awakening with acute shortness of Sudden awakening with acute shortness of
breathbreath• Relieved after standing or sitting upright for a Relieved after standing or sitting upright for a
period of time (Midnight Walmart shoppers)period of time (Midnight Walmart shoppers)
Acute Findings
HistoryHistory Is more nitroglycerin needed to stop the Is more nitroglycerin needed to stop the
episodes of chest pain?episodes of chest pain? Have nitroglycerin or oxygen doses Have nitroglycerin or oxygen doses
increased incrementally in the last few increased incrementally in the last few days? days?
Acute Findings – Critical Patient
General impression/initial assessmentGeneral impression/initial assessment Labored respirationsLabored respirations Audible soundsAudible sounds Tripod positionTripod position Frothy sputumFrothy sputum Retraction of chest musclesRetraction of chest muscles
Acute Findings – Critical Patient
General impression/initial assessmentGeneral impression/initial assessment Lung soundsLung sounds
Wheezing, cracklesWheezing, cracklesMiddle-to-upper lung fieldsMiddle-to-upper lung fields
Diaphoresis, change in skin colorDiaphoresis, change in skin color Severe anxiety or restlessnessSevere anxiety or restlessness Tachycardia or bradycardiaTachycardia or bradycardia Severe hypertension may be presentSevere hypertension may be present
TachypneaTachypnea OrthopneaOrthopnea Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea
Elevation of pulmonary venous & cap Elevation of pulmonary venous & cap pressurespressures
Wakening from sleepWakening from sleep
Pulmonary Edema – S/S
Pulmonary Edema – more S/S
Noisy Labored Noisy Labored BreathingBreathing
Fine crackles/RalesFine crackles/Rales WheezesWheezes
Reflex airway spasmReflex airway spasm ““Cardiac asthma”Cardiac asthma”
Coarse Coarse crackles/Rhonchi (larger crackles/Rhonchi (larger airways)airways)
CoughingCoughing Blood Tinged Blood Tinged
SputumSputum Pink FrothyPink Frothy
Normal chest xray
So, What to do?
Decide – Sick/NotSick?Decide – Sick/NotSick? VitalsVitals LookLook
Skin – wet/dry, color, tempSkin – wet/dry, color, temp JVDJVD Peripheral edemaPeripheral edema Subtle signsSubtle signs
Look
ListenListen Breath soundsBreath sounds Pulse x 6Pulse x 6 SkinSkin
Treatment of RVF & LVF CHF a circumstance not CHF a circumstance not
a Dxa Dx Treatment objectivesTreatment objectives
Decrease myocardial:Decrease myocardial:WorkloadWorkloadOxygen demandOxygen demand
Reduce fluid retentionReduce fluid retention
Treatment Decrease WorkloadDecrease Workload
No Physical activityNo Physical activity Sitting uprightSitting upright OxygenOxygen
Pt may tolerate BVMPt may tolerate BVM CPAP – studies are promisingCPAP – studies are promising
Decreases preload and afterload in CHFDecreases preload and afterload in CHF Improves lung complianceImproves lung compliance
BiPAPBiPAPCPAP but also delivers higher pressure CPAP but also delivers higher pressure
during inspirationduring inspiration
Treatment
OMIOMI Oxygen, Monitor, IVOxygen, Monitor, IV
MONA - MONA - if appropriateif appropriate Morphine, Oxygen, Nitro, ASA (Not in that Morphine, Oxygen, Nitro, ASA (Not in that
order)order) Don’t let patient walk!Don’t let patient walk! Position of comfortPosition of comfort ReassureReassure Positive Pressure Ventilations if necessaryPositive Pressure Ventilations if necessary
Treatment
Vasodilatory Therapy (Nitrates)Vasodilatory Therapy (Nitrates)AMI reperfusionAMI reperfusionContainer expansion reduces preloadContainer expansion reduces preload
Morphine Morphine Reduce Fluid RetentionReduce Fluid Retention
DiureticsDiureticsLasixLasixBumexBumex
Differential Diagnosis PneumoniaPneumonia Herpes ZosterHerpes Zoster Pleurisy Pleurisy COPDCOPD Rib fractureRib fracture AsthmaAsthma AnginaAngina MIMI PneumothoraxPneumothorax Pancreatitis Pancreatitis HepatitisHepatitis Salicylate ODSalicylate OD
BronchitisBronchitis HyperventilationHyperventilation Lung carcinomaLung carcinoma SepsisSepsis TBTB Muscle painMuscle pain CostochondritisCostochondritis PericarditisPericarditis CHFCHF Percardial tamponadePercardial tamponade
PneumoniaThe statistics Community acquired pneumoniaCommunity acquired pneumonia 4.5 million cases annually in US4.5 million cases annually in US
Winter months/Colder climatesWinter months/Colder climates More men than womenMore men than women 20% require hospitalization20% require hospitalization
66thth leading cause of death leading cause of death Most common infectious cause of deathMost common infectious cause of death
ViralViral Upper and lower respiratory infectionsUpper and lower respiratory infections
Untreated, mortality > 30 %Untreated, mortality > 30 % 37.7% in elder > 80 y/o37.7% in elder > 80 y/o
Sudden onset of S/S & rapid progression Sudden onset of S/S & rapid progression suggest bacterial pneumoniasuggest bacterial pneumonia
S/S
Productive coughProductive cough Sputum may beSputum may be
GreenGreenRust-coloredRust-coloredCurrent jellyCurrent jellyFoul smellingFoul smelling
Rigor or shaking chillsRigor or shaking chills
HeadacheHeadache MalaiseMalaise N/V/DN/V/D Exertional dypsneaExertional dypsnea Pleuritic chest pain, Pleuritic chest pain,
friction rubfriction rub Abdominal painAbdominal pain
S/S, cont.
FeverFever TachypneaTachypnea TachycardiaTachycardia CyanosisCyanosis Wheezes, coarse & Wheezes, coarse &
fine cracklesfine crackles Anorexia & weight Anorexia & weight
lossloss
Dullness to percussionDullness to percussion Altered mentationAltered mentation
typical pneumonia
generally resides in the nasopharynx
carried asymptomatically
in approximately 50% of healthy individuals
nosocomial pneumonia
aspiration or inhalation; ~ 45% of healthy people aspirate during sleep; even higher in severely ill patients; often bilateral
Pneumocystis carinii pneumonia
Bacterial pneumonia
Bacterial pneumonia
Viral pneumonia
Host Factors
DKADKA AlcoholismAlcoholism Sickle CellSickle Cell HIVHIV
So – how do we tell the difference????? CHF/Pulmonary EdemaCHF/Pulmonary Edema
Wheezes, fine & course Wheezes, fine & course cracklescrackles
Cardiac historyCardiac history Productive coughProductive cough ↑ ↑ dyspnea suddenlydyspnea suddenly JVDJVD CyanosisCyanosis Finger clubbingFinger clubbing Prolonged expiratory phaseProlonged expiratory phase Tachypnea, tachycardiaTachypnea, tachycardia Accessory muscle useAccessory muscle use Paroxysmal nocturnal Paroxysmal nocturnal
dyspneadyspnea
PneumoniaPneumonia Wheezes, Course & fine Wheezes, Course & fine
cracklescrackles Febrile, chillsFebrile, chills Productive coughProductive cough Hx URI, OM, Hx URI, OM,
ConjunctivitisConjunctivitis Tachypnea, tachycardia Tachypnea, tachycardia Cyanosis Cyanosis H/AH/A MalaiseMalaise Abdominal distentionAbdominal distention N/V/DN/V/D
PneumoniaPneumonia Pulm. EdemaPulm. Edema COPD/AsthmaCOPD/Asthma
HistoryHistory N/AN/A HTN, Heart HTN, Heart problemsproblems
Lung problemsLung problems
DyspneaDyspnea Orthopnea Orthopnea potentialpotential
OrthopneaOrthopnea Chronic dyspneaChronic dyspnea
Recent HxRecent Hx Fever, malaise, Fever, malaise, etc.etc.
Acute Wt. gainAcute Wt. gain
Edema in legsEdema in legs
Gradual Wt. lossGradual Wt. loss
CoughCough Productive, Productive, thick, greenthick, green
Foamy sputumFoamy sputum Productive Productive (bronchitis)(bronchitis)
OnsetOnset GradualGradual RapidRapid GradualGradual
BPBP NormalNormal HighHigh NormalNormal
MedsMeds Antibiotics, cold Antibiotics, cold medicinesmedicines
Digoxin, Digoxin, antiHTN, antiHTN, diureticsdiuretics
BronchodilatorsBronchodilators
SteroidsSteroids
TreatmentTreatment Oxygen, Med-Oxygen, Med-neb, IV fluidsneb, IV fluids
High flow O2High flow O2
NTG, Lasix, MSNTG, Lasix, MS
Oxygen, Med-neb Oxygen, Med-neb RxRx
Treatment summary
Pulmonary EdemaPulmonary Edema OMIOMI MONA if approp.MONA if approp. Position of comfortPosition of comfort Nitroglycerin 0.4 mg Nitroglycerin 0.4 mg
SL per protocolSL per protocol Morphine 2-10 mg Morphine 2-10 mg
Lasix per protocol Lasix per protocol (commonly 40 mg)(commonly 40 mg)
CPAP if availableCPAP if available
PneumoniaPneumonia OMIOMI
Limit IV fluids if Limit IV fluids if hx of cardiac hx of cardiac diseasedisease
CPAP if availableCPAP if available
Medications for Pulmonary edema NitroglycerineNitroglycerine MorphineMorphine LasixLasix
Nitroglycerin
Drug Class: Nitrate vasodilatorDrug Class: Nitrate vasodilatorRelieves myocardial workloadRelieves myocardial workload Dilates the arterial and venous systemsDilates the arterial and venous systems
Reduces preload to the already overworked Reduces preload to the already overworked ventriclesventricles
Reduces blood pressure to reduce afterloadReduces blood pressure to reduce afterload Allows pressure and fluid to move into the venous Allows pressure and fluid to move into the venous
systemsystem Sublingual doses start at 0.4mgSublingual doses start at 0.4mg
Morphine Sulfate
Drug Class: Narcotic AnalgesicDrug Class: Narcotic Analgesic
Relieves myocardial workload as wellRelieves myocardial workload as well Dilates the venous and arterial systemsDilates the venous and arterial systems
Reduces preload and afterloadReduces preload and afterload May cause hypotensionMay cause hypotension
Morphine Sulfate: Other Actions
Mechanism of actionMechanism of action Binds to opiate receptors throughout the Binds to opiate receptors throughout the
CNSCNS Slows respiratory rate at the medullaSlows respiratory rate at the medulla Stimulates the nausea center in the brainStimulates the nausea center in the brain
Morphine Sulfate
AdministrationAdministration 2-4mg over 1-2 minutes, every 5 2-4mg over 1-2 minutes, every 5
minutes (usual max dose 10 mg)minutes (usual max dose 10 mg)
Furosemide
Class: Loop DiureticClass: Loop Diuretic Moves sodium out of the blood vessels Moves sodium out of the blood vessels
early in the kidneyearly in the kidney Water follows sodium into the kidney Water follows sodium into the kidney
tubulestubules The site pulls out potassium as wellThe site pulls out potassium as well
Provides some vasodilation within 5 min.Provides some vasodilation within 5 min. Diuresis within 20-30 min.Diuresis within 20-30 min.
Furosemide
Reduces preload Reduces preload vasodilationvasodilation Pulls the extra fluid out of the circulationPulls the extra fluid out of the circulation Keeps fluid moving out of the kidneyKeeps fluid moving out of the kidney
Medication effects Medication effects Effects seen within 5-15 minutes of Effects seen within 5-15 minutes of
administrationadministration Peaks in 30 minutes after administrationPeaks in 30 minutes after administration
Furosemide Administration
20-40mg IVP over 1-2 minutes20-40mg IVP over 1-2 minutes Double the dose if the patient is currently Double the dose if the patient is currently
taking a diuretictaking a diuretic Relief of symptoms should begin within 5 Relief of symptoms should begin within 5
minutesminutesIf no relief, consider BVMIf no relief, consider BVM
SHOPS drugs – CHF patients
Street drugsStreet drugs Herbal drugsHerbal drugs OTC drugsOTC drugs Prescription drugsPrescription drugs Sexual enhancementSexual enhancement
Street drugs may contribute to CHF CocaineCocaine MethMeth Inhaled solventsInhaled solvents PCPPCP
Herbal remedies
Possibly helpsPossibly helps High-riteHigh-rite Aqua-riteAqua-rite L-arginineL-arginine Magnesium Magnesium Berberine Berberine
Possibly hurtsPossibly hurts St. Johns WortSt. Johns Wort EphedraEphedra Ginko BilobaGinko Biloba Kava KavaKava Kava Licorice Licorice Ginseng Ginseng Aconite Aconite Alisma plantago Alisma plantago Bearberry BuchuBearberry Buchu Couch grass Couch grass Dandelion Dandelion Horsetail rush Horsetail rush Juniper Juniper
Over-the-counter drugs (OTC)
Cold MedicationsCold Medications
Common Prescription medication for CHF/Pulmonary Edema (Calcium channel (Calcium channel
blocker)blocker) AmiodaroneAmiodarone NorvascNorvasc
Ace InhibitorsAce Inhibitors VasotecVasotec CapotenCapoten LotensinLotensin AccuprilAccupril AltaceAltace
Angiotension II Angiotension II receptor blockersreceptor blockers CozaarCozaar AvaproAvapro
Beta BlockersBeta Blockers CoregCoreg
Sexual enhancement drugs
ViagraViagra 24 hours24 hours
CialisCialis 36 hours36 hours
LevitraLevitra unknown unknown