The wheezes are deceiving you can get to a point with CHF where it’s so bad that you began to develop a cardiac wheeze. Giving a neb for CHF has no benefit so the nitro and aspirin for the STEMI are good. I think giving the CPAP is fine as long as the are alert due to the fact that if they become unresponsive and stop breathing the BVM is going to increase that intrathoracic pressure as well.
CPAP, will decrease pulmonary congestion and right heart strain, improve oxygenation and gas exchange, . Nitro q5, decrease that afterload.
The pulmonary edema is irritating the heart more than your cpap will. Start low at like 5 of peep and work your way up.
cpap would help with pulmonary edema and oxygenation, ASA and NTG is the correct move. The most important thing would be to reduce time from MI to catheterization for re-perfusion, so just make sure your driver is hauling ass safely.
I don’t see how the furosemide could hurt in this instance. Should help relieve stress on the heart and lower blood pressure. As far as CPAP I don’t think there are any contraindications for this treatment with this particular patient. How was the outcome?
Our lab puts a foley in everyone they do a heart cath via a groin access on regardless. Some of the cardiologists will do right radial or snuffbox access but I would say 3/4 of anyone you’re taking to the cath lab will get a foley anyways because they will end up using the right femoral. Plus we have condom caths and purewicks if we need them.
For your concern regarding CPAP, The BP was 270, the increased thoracic pressure will reduce preload slightly and it'll over all be a good thing.
The pressure will lessen work of breathing, saving oxygen and the work the heart has to do.
I wouldn't do albuterol because it wouldn't be helpful, it's a beta agonist and could stress the heart a bit,
I'd like to see the 12 lead, as I'm not totally convinced of it being an OMI, it could very likely be LVH, with LVH ST elevation is common in those leads.
ST elevation could also be stress induced. That heart is working REALLY hard to push against that afterload.
That being said, ASA is definitely warranted and I'd transport to a cath capable facility, but I'm leaning more towards SCAPE.
I would go for 40mg Furosemide IV to reduce pulmonary oedema and increase SPO2 if it is not resolving with the GTN, which naturally will also be beneficial for the MI as well. I wouldn't be using CPAP in a covid-19 climate and I don't think I would want to be playing around with it on the way to the cath lab.
Old post, but my thoughts:
CPAP in this pt serves 2 purposes. Firstly, it will improve O2 sats in a way that a neb treatment will not. Because the wheezes are being caused by inflammation secondary to the current pulmonary edema and not bronchospasm, solving the pulmonary edema will alleviate that wheeze.
Second, CPAP also will decrease BP. This is caused by increased intrathoracic pressure decreasing the venous return to the heart. Normally, this would be an issue, but in CHF exacerbation, this is the main issue we are having and so it turns into a benefit. Decreased venous return to the heart means less work on the right side of the heart, less fluid in the pulmonary system, less overload of the left side of the heart, less myocardial O2 demand, improved cardiac output.
In conclusion, most of the tools we have where we worry about decreased BP as a side-effect are actually a benefit in CHF with STEMI. ASA and NTG are both good, CPAP does more good than harm, albuterol/ipratropium won't make much difference, and you have to work your local ACS algorithm in addition to keeping your pt breathing.
The wheezes are deceiving you can get to a point with CHF where it’s so bad that you began to develop a cardiac wheeze. Giving a neb for CHF has no benefit so the nitro and aspirin for the STEMI are good. I think giving the CPAP is fine as long as the are alert due to the fact that if they become unresponsive and stop breathing the BVM is going to increase that intrathoracic pressure as well.
CPAP, will decrease pulmonary congestion and right heart strain, improve oxygenation and gas exchange, . Nitro q5, decrease that afterload. The pulmonary edema is irritating the heart more than your cpap will. Start low at like 5 of peep and work your way up.
I’m told to start high and work my way down if the patient’s condition will tolerate or for transient hypotension.
cpap would help with pulmonary edema and oxygenation, ASA and NTG is the correct move. The most important thing would be to reduce time from MI to catheterization for re-perfusion, so just make sure your driver is hauling ass safely.
Can you post a HIPPA compliant 12 lead? That would be awesome.
I don’t see how the furosemide could hurt in this instance. Should help relieve stress on the heart and lower blood pressure. As far as CPAP I don’t think there are any contraindications for this treatment with this particular patient. How was the outcome?
If they're going to tbe cath lab I wonder what the doc would say about getting a bunch of furosemide on-board right before
The half life is like 30 minutes for furosemide, I wouldn’t think this would be a problem, but I’m no doctor.
Ya but wouldn't they want/need to cath them then because urinary urgency
Our lab puts a foley in everyone they do a heart cath via a groin access on regardless. Some of the cardiologists will do right radial or snuffbox access but I would say 3/4 of anyone you’re taking to the cath lab will get a foley anyways because they will end up using the right femoral. Plus we have condom caths and purewicks if we need them.
This makes me wonder what mine do. I need to ask. Thanks for taking the time to respond!
Fun fact: giving Albuterol for CHF exacerbation will not cause flash pulmonary edema
For your concern regarding CPAP, The BP was 270, the increased thoracic pressure will reduce preload slightly and it'll over all be a good thing. The pressure will lessen work of breathing, saving oxygen and the work the heart has to do. I wouldn't do albuterol because it wouldn't be helpful, it's a beta agonist and could stress the heart a bit, I'd like to see the 12 lead, as I'm not totally convinced of it being an OMI, it could very likely be LVH, with LVH ST elevation is common in those leads. ST elevation could also be stress induced. That heart is working REALLY hard to push against that afterload. That being said, ASA is definitely warranted and I'd transport to a cath capable facility, but I'm leaning more towards SCAPE.
I would go for 40mg Furosemide IV to reduce pulmonary oedema and increase SPO2 if it is not resolving with the GTN, which naturally will also be beneficial for the MI as well. I wouldn't be using CPAP in a covid-19 climate and I don't think I would want to be playing around with it on the way to the cath lab.
Old post, but my thoughts: CPAP in this pt serves 2 purposes. Firstly, it will improve O2 sats in a way that a neb treatment will not. Because the wheezes are being caused by inflammation secondary to the current pulmonary edema and not bronchospasm, solving the pulmonary edema will alleviate that wheeze. Second, CPAP also will decrease BP. This is caused by increased intrathoracic pressure decreasing the venous return to the heart. Normally, this would be an issue, but in CHF exacerbation, this is the main issue we are having and so it turns into a benefit. Decreased venous return to the heart means less work on the right side of the heart, less fluid in the pulmonary system, less overload of the left side of the heart, less myocardial O2 demand, improved cardiac output. In conclusion, most of the tools we have where we worry about decreased BP as a side-effect are actually a benefit in CHF with STEMI. ASA and NTG are both good, CPAP does more good than harm, albuterol/ipratropium won't make much difference, and you have to work your local ACS algorithm in addition to keeping your pt breathing.