85 year old female CC: Respiratory distress

EMS is called to a local nursing home for a 85 year old female with a chief complaint of respiratory distress.

On arrival the patient is found lying in bed in obvious distress.

Respirations are 40 and shallow with a prolonged expiratory phase and accessory muscle usage.

Auscultation of the chest reveals a poor tidal volume with tight expiratory wheezes.

There are signs of cyanosis around the mouth and nail beds.

The patient appears weak and listless.

Past medical history: CHF, COPD, NIDDM, Breast CA, Depression
Medications: Numerous

Vital signs are assessed.

RR: 40
Pulse: 130 and irregular
NIBP: 170/91
SpO2: 74

The patient’s external jugular veins appear prominent but the patient is lying flat.

A 12-lead ECG is captured.

What is your interpretation of this ECG?

What do you think is wrong with the patient?

What is your treatment plan?

See also:

85 year old female CC: Respiratory distress – Discussion


  • Ryan says:

    Got a case here with multiple issues. I’ll break it down the way I’d attack it.

    We’ve got A-Fib as an underlying rhythm, and it appears uncontrolled. Knowing she’s in a NH, what’s her baseline mental status, what’s her compliance with medications? Why is she in the NH? Rehab, or permanent placement. She is a COPD PT with CHF history, so some hypercapnea is to be expected, though, with the tight wheezes she may be holding on to more Co2 than necessary leading to her current mental state and affect. Beyond that, she’s got depression in the lateral leads, and hyper acute T waves in Septal and Anterior leads..may be an infarct, may be hyperkalemia. Along with the JVD, I’d say shes in failure, with hyperkalemia and uncontrolled afib, with cardiac ischemia. We have multiple treatments that should be done.

    I’m going to start with O2, probably via BVM going to attempt to do a duoneb of Albuterol and Atrovent through the BVM. Going to attempt to get an end tidal Co2 to figure out how acidotic she is. Bilateral Iv’s as she’s heading for the ICU, and I may need multiple lines. Sending my 12 lead to a PCI capable hospital. She has some significant metabolic issues, and few of which I can fix right now except for the suspected acidosis/hypercapnea and respiratory issues. I have the potential with my service to do cardizem, but, I’m not even considering it right now. Definitely getting a blood sugar as she may be hyperglycemic.

    I’m calling med control at this point, give them my findings, and figure out where we want to go next. She’s a mess with some massive metabolic issues.

  • Chris T says:

    12 lead rapid a-fib with LVH. No apparent STEMI. No noted concordance. No noted excessive discordance in ralation to QRS. There is QRS widening possibly borderline BBB or maybe just poor oxygenation.

    If I got a 12 lead on this patient prior treating breathing, FAIL. I hate treating lungs without being there but ill pick though it to make myself volunerable and learn.

    COPD exacerbation(unknown what the aggrivating factor is with this information)

    Nasty Hx. no mention if been ill, no mention of events prior, no mention of peripheral edema. No mention of how obese this patient may be. No mention of edema in LS. NO mention of home 02 or CPAP for sleeping. Place fowlers as strait as tolorated, DUO NEB to start. Reassess and consider CPAP starting with low PEEP 5 and titrate to effect. If broncospasm releived albuterol witheld. If not then if available I will put in IN LINE with CPAP. If signs of CHF nitro 0.4 SL up to 3, then Nitro paste one inch. Not a fan of Lasix, if presents of pulmonary edema not resolving and already on lasix I would consider a low dose 40mg IV.
    I really cant say for sure because I would only do these treatments based on my assessment of LS and Hx. If treatments are innaffective and unable to relieve broncospasm, BVM assist with inline neb and coaching. My overall goal, increase SP02 90% or better, decrease in RR im sure she is retaining massive amounts of c02 and will become acidotic, possibly the other explination for QRS widening. Help by increasing tidal volume and relieve broncospasm. Then repeat 12 lead and reevaluate.
    This is my most agressive approach since I dont know what results I got with my first treatment. CPAP has been added near the top of our reactive airway (COPD, ASTHMA) and of course still CHF. I do not have experience using CPAP for RAD I know how it works for splinting the aveoli but its not going to relieve broncospasm. id be intereste to hear opinions on how well it works. especially if you dont have an albuterol port. I think by now we have all seen what it can do for a correctly identified CHFer

  • Ryan says:

    Oops, missed the depression, could be possible she OD’d on andtidepressants. I’ll throw some narcan in too.

  • Ryan says:

    And I forgot sepsis as well. The more I think about it, the worse she seems.

  • Shalom says:

    Atrial Fibrillation, LVH. Other than V4 all the ST-T look normally discordant.(I would like to know what medications this patient is taking, specifically digitalis, and what the patient’s glucose levels are).
    Something about this seems like PE…

    Treat the monitor not the patient. Treat the respiratory distress first then worry about the ecg.

  • Chris T says:

    Ryan im curious for my learning
    Narcan for tricylate antidepres OD and RR 40 and concious? If your thinking tricyc and we are thinking pt is retaining c02 and getting acidotic, wouldnt you want to consider Sodium Bicarb instead?

  • Firemedic24 says:

    I know she is a little tachycardic, but I wouldn’t call it uncontrolled a-fib. I would say she is tacky because she is in so much distress and trying to compensate. My primary concern would pulmonary.

    No mention of edema in the narrative so it probably is exacerbation of copd.

    Treatment would concentrate on airway and breathing.
    Consider albutetol, atrovent, duonebs, or I might go straight to nebulized epi.

    If she has depressed loc go with bvm and concentrate on maintaining the airway.

  • Ryan says:

    Chris, I was thinking along the lines for narcotics, the fentanyl patches and such which tend to be common in NH patients. Nobody said they were TCA’s, though, that is a thought I had not considered. I didn’t write that correctly. I just sounded like an idiot in that post.

    There is also the possibility that a CNA is passing meds, I’ve seen it before. Could be that’s a CNA has just given the PT too much Tylenol 3. Lots of stuff here, not just a cut and dried case by any means.

  • Darryl says:

    I think this pt. would be an ideal candidate to sux and intubate and ventilate with 100% O2 if she has a gag reflex and she may not at this point. It’s apparent that she is in shock due to the visible cianosis and that’s the priority treatment at this point. Due to her pulse rate and BP, I would not use albuterol, atrovent or epi. Capnography and Sodium Bicarb may be prudent to check the probable acidosis as a second line of treatment. This appears to me to be a COPD episode and controlling it should help bring the rhythm back into normal range.

  • Ryan says:

    Firemedic, uncontrolled afib is a rate greater than 100BPM, so, yes, it’s uncontrolled.

  • DaveOC says:

    COPD exacerbation. Atrovent/albuterol x 2 and then CPAP with inline nebs if no improvement. Consider epi.
    The a-fib. is “relatively” uncontrolled. I’m sure if she wasn’t working so hard for air then it would be controlled. EKG looks like LVH with lateral ischemia (probably due to the fact she’s hypoxic).

  • Svyato says:

    I would try first Change her position in semi- fowler and right away O2 100%via NRB, check saturation and ask the patient if any changes- how she feels, still no change, get atrovent albuterol mixture monitor on ekg and v/s…probably change to bvm, nobody said but I think iv access already on( just for NYC protocols), listen lungs; no more nitro patch I see for NYC , but would help I guess for PE if railes show up.
    I am always against invasive management of the airway as placing ET tube, but consider it. Good chance of CPAP as mentioned already. Basically follow the flow as Pt possible condition.
    Nstemi is not Considered at all, either mi for sure. I am not sure mag sulfate will help with this patient at all

  • Terry says:

    A-Fib with LBB and LVH
    Put pt in an upright position.
    IV hep lock
    Pulse Ox is ??
    CPAP if pts mentation improves if not intubate
    NTG til the cows come home.
    I’m thinking this is more CHF than COPD due to the A-fib and HTN. Need more hx to confirm. Lasix and MS have lost favor in treatment of CHF. Also keep in mind giving Albuterol treaments can make the aveoli membranes more permeable and cause more problems. Just something to be aware of. Not saying not to do it just be cautious.

  • Mark says:

    I would be concerned that the so called “wheezing” might in reality be so called “cardiac asthma”. It’s been harped into me that “all that wheezes is not always asthma”. I recall a case I had in a SNF where we were convinced it was COPD related but the patient was hot, wet and very tachy – turned out to be CHF exacerbation.

    I would want to quickly sit the patient or elevate the head up 30 degrees to evaluate if the JVD remains or not, if this was tolerated. Bump the O2 up, although recognize the potential outcome for hypoxic drive in these patients (SNFs are typically a little too worried about this though). I would also further evaluate any sputum and any peripheral edema I might note in the legs to raise my suspicion for CHF vs. Asthma.

    Although it is reasonable to trial a course of albuterol for COPD exacerbation, I would also be considering the need for NTG, CPAP and Lasix if I felt that this was more CHF related after a little more assessment. Regardless, this will be a Code 3 return to the hospital.

  • Phil says:

    My vote is to treat the respiratory issues first. 02 with a nonreabreather and a Combivent neb. It says the pt is lying flat upon ems arrival. Do her symptoms improve when she is sat up? Unless changing her position changes her presentation I’m not going to be convinced of acute CHF. Based on the picture painted here, I’m going to go down the COPD path and treat accordingly. If possible I’d like to capture some capnography waveforms to see how acidotic she is and if there is a shark fin morphology, which would confirm my susupicions. IV access, repeat combivent if no improvement. If my CPAP has a nebulizer port then I would use that. Mag Sulfate IV 2-4 grams if the bronchodilators aren’t doing the trick. I’m a little hesitant to break out the Epi based on the patients age, presentation and the fact that we’re already dumping sympathomimetics and parasympatholytics on her but if online med control wants it then so be it. Based on transport time, patient presentation after all of the other interventions, and service specific protocols, I would consider medication assisted intubation or RSI.

    12 lead shows A-Fib with what looks like some LVH and a possible LBBB. I’m not convinced of a cardiac etiology here. I’d be interested to see a 12 lead captured after the respiratory issues have been dealt with. One big issue though would be that given that the patient is in a nursing home, her past medical history should be very well documented, yet it makes no mention of LVH which may suggest an acute cardiac issue. Or it could be the nursing home is not doing their job well, which of course never happens…. However, regardless of her documented history, it looks like she meets voltage criteria for LVH so I will stick with that as my final answer.

    Either way, wicked sick patient. Get to the hospital yesterday.

  • new medic says:

    12 lead- A-fib RVR, LBBB, and LVH

    Dx- CHF. We have a pt that has a damaged heart and the a-fib is making the heart work harder. Pt is also hypertensive.

    TX- Saline lock, monitor, vitals, Start with a NRB at 15 l/min while cpap is being set up,capnography, and NTG. Also I’m going to be ready to intubate if pt’s condition deteriorates

  • just another medic says:

    I keep seeing “LVH with LBBB.” I was under the impression that you could not accurately diagnose LVH in the setting of a LBBB.

    If I’m wrong, what are the criteria for doing so?

  • AMRmedic says:

    Well the first thing i would do before even hooking her up to the monitor is sit her all the way up (it said she was lying flat in the narritive) and throw her on oxygen, either with a BVM or CPAP.

    Now on to the EKG, the undelying rhythm is uncontrolled A-fib, A-fib is probably her normal rhythm because of the history of CHF. It also looks like she has some left axis deviation and a left anterior hemiblock. She also has LVH with early repolarizatiion, the early repole is what might fool some people into think she is having a STEMI, however the ST/S ratio in V2 is 4/35 which equals .11, it needs to be at least .20 to consider it a STEMI, there is more elevation in V3 but we can’t see the end of the QRS so thats why i used v2 to calculate the ratio.

    As far as differential diagnosis goes it sounds like COPD exacerbation based on the expiratory wheezes and prolonged expiratory phase, however it could be cardiac wheezes secondary to CHF. If the patient still has JVD after sitting her up as well as pedal edema then i’d probably treat with nitro and CPAP. This is a tough one to call without actually being there, but regardless my treatment of choice would be CPAP and either Nitro OR Albuterol (not both) depending on what i think it is.

  • Michael H says:

    This is a interesting and common case. It is difficult to say for certain from the information given, but with the pertinent info I would have to venture to say that this is a COPD case and the ECG findings are a secondary effect of the underlying respiratory complaint, (and normal for pt).

    First, a prolonged expiratory phase is indicative of broncho-spasm, hence COPD, also, if this was “cardiac asthma” from pulmonary edema I would expect to find a BP of at least 180 systolic and most likely 200 systolic+ with a 1:1 inspiratory-expiratory phase ratio.

    My treatment would be to aggressively treat the suspected underlying broncho-spasm with high flow O2, possible CPAP at 2-5cmH2O (if available, and not contraindicated by the LOC), and beta agonists. I would keep a vigilant look at the ECG to note extreme tachycardia from the beta agonists, since the ECG is already a bit concerning.

    If I would truly become concerned about the cardiac effects, I would consider calling med control to discuss administering magnesium for both smooth muscle relaxation to help the broncho-spasm and anti-arrhythmic properties.

    What are your opinions on Mag for an anti-arrhythmic for uncontrolled a-fib? I have usually only seen it used for MAT associated with broncho-spasm.

  • AMRmedic says:

    Just another medic is right, it is either a LBBB or LVH, not both, i just noticed the small Q waves in lead III so it is not a LAH like i said earlier, but i have a hard time believing it is a LBBB because the QRS complexes in leads V1 and V6 doesn’t really look like a typical LBBB QRS, they usually look more broad. It could just be LVH with a wide QRS because if someone has a large ventricle its going to to take a little longer for the impulse to get go through the ventricle.

  • Christopher says:

    Ignoring the ECG for now: I’d sit her up to ~30 degrees and check for JVD changes. After checking the JVD at 30 degrees I’d sit her all the way up, place her on nasal ETCO2, and slap on a NRB while I finish my initial assessment. Once I’ve got a capnogram and a look at JVD @ 30 degrees, this is where it gets tricky.

    My gut says it is either primary pulmonary or primary cardiovascular problems. Potential DDx: pulmonary embolism, acute pulmonary edema, or acute COPD exacerbation. APE and COPD can both have wheezes and “shark fin” capnograms. But APE and PE’s will have a lower ETCO2 (but so can hyperventilation).

    If I’m thinking pulmonary embolism, all I do is ventilate and drive. She needs anticoagulants or a surgical thrombectomy. The capnogram is going to show a lower ETCO2 due to the VQ mismatch, but she may also have a lower ETCO2 due to hyperventilation. JVD will probably still be present.

    If I’m thinking acute pulmonary edema, I’ve got to consider it almost always has a primary cause. Perhaps her AF is the cause, so a CCB or B-Blocker is indicated. But if her AF rate is purely compensatory for a primary respiratory cause I really don’t want to play with it, nor would I want a B-blocker on board! A quick history from family about orthopnea and PND would be very helpful.

    If I’m thinking acute COPD exacerbation, my course of Rx is simply albuterol, atrovent, and IV glucocorticosteroids. She’s not getting an Epi due to her rate. I’m also concerned that this is actually florid pulmonary edema causing cardiac asthma and adding albuterol is surely now going to lower her rate!

    Tough situation to be in and likely I’d request medical control to create a better treatment plan. Regardless I think this patient would benefit from CPAP @ 5 cmH2O and either NTG or albuterol based on the ETCO2.

    Oh and the ECG? Fib-flutter at 100-150 w/ LBBB and potentially ischemic changes.

  • Christopher says:

    And as another commenter pointed out the LBBB in V1 is kind of odd, potentially those r-waves in V1-V3 are indicative of right sided heart strain. Of this, however, I’m not certain.

  • Ben says:

    whats her blood glucose? Peaked T waves – could it be high? The long expiratory phase could be kussmaul respirations, meaning she was far down the line of Diabetic Ketoacidosis. Just a thought 🙂

  • Chris T says:

    You dont think this patient is retaining c02? I figured she is unable to breath off c02 so if I had nasal cap wouldnt I expect high c02 readings until I we get some air moving? I prolly have my values and the acid base balance thing opposite again but I think thats right. Also wont the likelyhood of her acidosis contribute to a widening of the QRS complex? Sorry if i have this all backwards.

  • Chris T says:

    Ben I would bite that. Good thought!

  • Great comments, everyone! To answer some questions: Temp: 99.1, BGL: 208, JVD still present at 45 degrees.


  • Chris T says:

    ugh, I cant treat cardiac tomponade, monitor for progression, drive faster.

  • Christopher says:

    Elevated-ish temp can be found with a PE and with a pericardial efflusion (this is like a race to find how many medical problems include the initials ‘P’ and ‘E’). It also doesn’t rule out APE or COPD. I’m hesitant to go with tamponade due to no electrical alternans and relatively high voltage ECG findings. If we carried US we could rule-out APE and tamponade with some degree of certainty.

    And Chris T, as for the ETCO2 if she had a Ventilation-Perfusion mismatch (VQ mismatch) as in a pulmonary embolism or florid pulmonary edema, she may not be exchanging O2 for CO2. In COPD exacerbation I’m almost 100% certain to find a high(er) ETCO2.

  • Chris T says:

    Thank you Christopher.

  • RN says:

    if albuterol fails, don’t hesitate to intubate. auscultation might show crackles or an enlarged heart (or a huge murmur). Magnesium often helps with ectopy and probably wouldn’t hurt anything (but I’d focus on other things–to answer Michael H’s question).
    This pt could have kidney problems elevating her K+ and also causing a CHF exsacerbation. The respiratory issues seem like COPD, but these pts often end up in the ICU as CHF/COPD exsacerbation. A hit of lasix and a foley seems like a good idea.
    Also, I see the HR close to 150 for a lot of this EKG. If it was only ~100 I wouldn’t worry, but @ 150 I think Cardizem is a good idea too.
    02, nebs x2, (intubate?), hospital, (lasix, foley, Cardizem if it’s gonna be a long drive). get a med list before leaving the scene.

  • Neil Holtz says:

    I am thinking A. Flutter with LBBB. Significant ST elevations in anterior precordial leads. I am personally suspicious of an anterior wall MI.

  • Kelly says:

    Interesting case…The first question for me is does she have advance directives? What is her code status? This is important information if intubation is being considered. I also want to know her baseline level of mental and respiratory function. How recent was the breast cancer?
    My first instinct is this is a respiratory problem (COPD) first confounded by heart failuare and diabetes (with some underlying renal dysfunction). Manage respiratory distress first to prevent further progression to complete failure/arrest.

  • VinceD says:

    Very difficult case, as everyone has stated. Keeping it simple, you won’t go wrong sitting her up, starting off on a NRB, and applying CPAP when you have the toys ready. I don’t think bagging is really a necessity just yet, but we need to keep an eye out for imminent respiratory failure if she doesn’t turn around. Any combination of COPD, acute pulmonary edema, and pneumonia could explain her respiratory status, but embolism isn’t high on my differential. Her mental status could be the effect of hypoxia, hypoperfusion, or infection; or this could be her baseline. I’m not too impressed by her ECG (at this point), but she’ll get a few more tracings en route. It’s a rapid a-fib, likely LVH with secondary QRS and T changes, and a not-too-leftward axis. It’s hard to say if the a-fib is the primary cause of her S/S, but I’m leaning towards it being secondary to the underlying pathology.

    Now the million dollar question of what treatments to administer… Someone else mentioned Mag in the comments, and that might actually have a very nice role in this case. I’m far from an expert regarding it’s pharmacology, but maybe I’d contact med control for an order. The bronchodilatory effects could help if it’s a COPD exacerbation, the vasodilatory effects would drop her vascular resistance and help with pulmonary edema, and the calcium channel effects could drop her heart rate a bit. Bam! Everything’s fixed…
    But really, depending on dose and route, I doubt it would do more than act as a useful adjunct in the situation, and I’d probably start off with a duoneb for assumed COPD exacerbation at this point. Besides JVD, I’m just not seeing a good enough picture for acute pulmonary edema to warrant using nitrates as my first line. While I have med control on the line, I’d definitely consult about just treating with both nitro and a duoneb; I doubt some preload reduction (beyond the CPAP) would kill the little lady at this point. Lasix gets tossed out the window as it doesn’t have a role here. Finally, locate the frickin DNR/DNI; I’m not going to tube this lady.

  • Robert F. says:

    Reasoning: Irregular rhythm, rapid, wide QRS, and no apparent P Waves.
    12 lead: AFibb w/ RVR, runs of A Flutter(look at v1), LBBB criteria (LAD, QRS 0.12, Broad Monophasic R Waves In the lateral leads), & Digitalis effect. The dig effect is what is making this LBBB look so different than the norm.

    Multiple problems.

    COPD Exacerbation, CHF Exacerbation, and possible Pnuemonia/SIRS(Systemic Inflammatory response) Respiratory as well as metabolic acidosis may very well be present.

    Treatment: Semi Fowlers, Immediate BVM,CPAP w/ Albuterol/Atrovent, Solumedrol 125mg, last resort Intubate.. NTG may very well be indicated if pt has edema,jvd,s3/s4 heart sound. If patient appears to be severely dehydrated, may even give a small 200 cc fluid challenge, but that’s just pushing it 🙂

  • Will says:

    What is her serum potassium?

  • NYCMedic says:

    Ok, this is killing me, this is my 3rd attempt, so I will be very brief. Hopefully my comment goes through this time…

    My DX is COPD exacerbation due to wheezing/prolonged expiratory phase.

    CPAP if severe distress
    Intubate if going into failure
    Withhold epi

    Rate: 70-140
    Rhythm: Rapid Afib/flutter (see V2)
    Axis: LAD
    Blocks: RBBB w/LAH or IVCD
    Infarct: None that I see, strain pattern
    Other: LVH

    I don’t think it’s a LBBB as some are saying. It has a clear RBBB pattern in I and V6 with an upright QRS and slurred S wave. V1/2 however don’t appear to have an RSR’ pattern or a R:S ratio > 1. Thus, this leads me to want to call this a generalized IVCD, especially with those tall T waves (hyperkalemia? QTc isn’t terrible I guess).

    LVH due to S in V2 + R in V5 > 35mm.

    Strain pattern due to LVH due to elevations in anterior leads progression nicely to depressions in lateral leads.

    Transport to nearest 911 receiving facility.

  • Robert F. says:

    I’m going to have to disagree w/ the RBBB 🙂 but who am i to say what is what, after all i am still just a student!

    Criteria for RBBB is QRS 0.12, RAD, Rsr’/qr pattern in v1/v2, Slurred S waves in the lateral leads,and positive amplitude in avr, but i must say it’s a funky looking 12 lead and very interesting case.


  • NYCMedic says:

    RAD is not a requirement for RBBB as far as I know. Again, I said in I and V6 it appears to have a RBBB pattern, not that in ALL leads it had that pattern. It doesn’t have a “stereotypical” LBBB pattern, and thus I want to call it an IVCD.

  • Robert F. says:

    My mistake! RAD is not part of the criteria for RBBB, but slurred s waves in lateral leads I, v6 are, which gives the impression of RAD. Here’s a great short video by the man, Dr. Amal Mattu about RBBB’s, sorry if it is off topic. Cheers!


  • Paramedic1052 says:

    Need more info on mental status.

    As far as the 12-lead goes, I see atrial fibrillation with rapid ventricular response, a pathological left axis, some ischemia in the lateral leads, left ventricular hypertrophy, and hyperkalemia. Nothing about the 12-suggests an acute infarction to me. Also, I’m not even close to being sold on a right bundle.

    With the tight wheezing, I’m leaning more towards COPD than CHF, but I would want to apply a nasal EtCO2 detector to see if the waveform’s got that “shark fin” pattern that will confirm bronchospasm. With that temp, the patient’s probably starting with sepsis.

    1) COPD exacerbation
    2) Hyperkalemia
    3) Sepsis

    IV access (preferably two lines, both 18g or larger)
    CPAP if no contraindications due to mental status, if not, I’d attempt endotracheal intubation
    In-line Duo-Neb and IV Solu-Medrol if the capnograph indicates bronchospasm
    Transmit the EKG to a PCI center
    Sodium Bicarbonate
    Repeat 12-lead after these treatments
    Get ready to code her if she does not have a DNR
    Get to the hospital as close to yesterday as possible

  • Paramedic1052 says:

    NYCMedic: A right axis deviation (which is what I assume “RAD” means)is always ventricular in origin. Right axis deviation is not part of RBBB criteria.

  • Paramedic1052 says:

    Also, is there an S3 upon auscultation of heart sounds?

  • justin farrens says:

    Iv tko, Nitro paste, cpap with duoneb, possibly solumedrol or terbutaline for farther down the line. Possible hyperkalemic from peaked t waves, if respiratory doesn’t respond to treatment dilt for a fib,I would intubate her as a last resort due to her hx I wouldn’t want her to spend her remaining life on a vent if I could help it.

  • NYCMedic says:

    Can those suggesting she needs two large bore IV’s? She is very hypertensive, we can’t give (nor does she need) blood products, and we won’t be giving mess that require separate lines.

  • Christopher says:


    My preference on critical patients is 2, but given my short transport and the ED’s desire to get labs often I will punt on the second line and let them do line #2 and get labs from that one.

    On this patient if I had access to IV NTG I would start a second line during transport.

  • Russ says:

    The wheezes u hear could be a cardiac wheeze and the pt has a known history of chf. I would give nitro paste, place a CPAP on starting at 15 L 5cm h20. I would also give captorpil 25 mg. the st segment depression u see in the lateral leads is from the chronic hypertension. More muscle in the left ventricle, the more oxygen it requires causing st depression. If the pt didn’t get better on CPAP, I would RSI.

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