PCTH - ACPE/CPAP Flashcards
What is acute cardiogenic pulmonary edema?
Fluid in the lungs (pulmonary edema) caused by increased pulmonary venous pressure leading to increased capillary hydrostatic pressure (which then pushes the fluid into the interstitium and alveolar spaces). This is due to pressures in your heart not being being adequate enough to pump blood out to the rest of the body, thus causing fluid to backup.
Acute Cardiogenic Pulmonary Edema Medical Directive
Indications
Conditions
Contraindications
Indications: moderate to severe respiratory distress AND suspected acute cardiogenic pulmonary edema (ACPE)
Conditions: for nitroglycerin
- Age: ≥18 y.o.
- LOA: n/a (because often these patients are hypoxic therefore may be altered) + you’re more relying on ax findings than hx
- HR: 60-159 bpm
- RR: N/A
- SBP: normotension
- Other: n/a
Contraindications:
- allergy or sensitivity to nitrates
- phosphodiesterase inhibitor use within the previous 48 hrs
- SBP drops by 1/3 or more of its initial value after nitroglycerin is administered
Acute Cardiogenic Pulmonary Edema Medical Directive
Treatment
Clinical Considerations
Treatment: see attached screenshot
- 1) Consider nitroglyerin
- 2) Consider 12-lead acquisition and interpretation
Clinical Considerations: IV condition applies only to PCPs authorized for PCP Autonomous IV
True or False. For a patient with ACPE, a maximum of 6 doses of nitro can be administered regardless of any previous administrations.
True
On arrival, how would you determine if a patient was having ACPE?
1) medical history
2) incident history
3) medications
4) Signs and symptoms
What sort of medical history are you looking for in a patient with suspected ACPE?
- CHF (right and left sided heart failure)
- some form of MI/CAD
- HTN
- High cholesterol
- A-fib
What sort of incident history would cause you to suspect ACPE?
- SOB that has worsened; may be getting worse with minimal exertion
- If on home O2, the O2 is not relieving the SOB
- coughing up print frothy sputum (later stages) - tell tale signs
- scene awareness - lived in area (food, garbage around) where they’re not moving from one location/can’t lay flat because it gets worse & they’re not moving around
What sort of medications would a patient be on that would cause you to suspect ACPE?
- HTN meds (ACE inhibitors)
- Beta blockers (-olol)
- CCB (-dipine) - amlodipine, diltiazem
- Lasix (diuretic)
- Nitro
Signs and symptoms of ACPE
- RHF: peripheral pitting edema, JVD (Due to backing up of blood; area that is accepting the blood is dysfunctional)
-
LHF: coarse crackles, pink frothy sputum (because blood not getting circulated from pulmonary circuit)
- crackles are bilateral and tend to start at the bottom, work their way up (if unilateral, may be pneumonia instead)
For a patient with suspected ACPE, do you have to do a 12 lead before giving nitro?
No. It’s not a requirement because RVIs typically do not present with ACPE however do get a 12 lead/15 lead when possible/practical to do so.
Also advised that if they’re also experiencing chest pain and pulmonary edema, do a 12 lead before giving nitro use.
If BP was initially ≥140mmHg and was receiving 0.8mg of nitro but then drops outside of parameters (now 120mmHg), are you still allowed to give nitro?
Yes. If BP is still within range, then you can switch from 0.8mg to 0.4mg doses.
Should a patient present with crackles receive Salbutamol? Why or why not?
NO. Salbutamol is a bronchodilator which means that it will drop the pressure in the lungs and make it easier for fluids to flow into the lungs causing worsened pulmonary edema. Additionally, since it works on beta receptors, it will also increase the patient’s HR but patient already has a shit pump to start with so salbutamol would just make things worse
There are times when wheezes could be an early sign of crackles. How do you then distinguish between a patient who is have an asthma exacerbations vs ACPE?
medical history (pt with CHF may likely be on home O2 and meds that point to heart-related while a pt who has asthma will likely have prescribed puffers)
Describe what physiologically occurs during inspiration
- diaphragm contracts (pushes downwards to increase thoracic space)
- Intercostal muscles contract (ribs go up and out to increase thoracic space)
- Creates negative pressure in the lungs (alveoli) compared to the atmosphere
- So atm air rushes in to fill the space
- Gas exchange then occurs by diffusion at the alveolocapillary membrane
The lungs exchange respiratory gases across a very large SA at the alveolo-capillary membrane, around ______ m2.
70