Sit it up for a pulse

     Attack One responds to a report of a woman short of breath, and crew members find the patient in an office complex, with her coworkers hooking her up to an AED and preparing to initiate CPR. They report that the lady has a history of heart problems and reported increased shortness of breath over the last 2-3 days. As the boss in their office, she continued to come to work, but today was noted to be even more short of breath.

     She was seen going to the bathroom about lunch time, then her assistant entered her office and found her in respiratory distress. Her coworkers offered to help and called 9-1-1. One colleague, noticing her distress, thought the patient would be better off lying down, and the group moved her to the couch and insisted she remain there until help arrived. As she initially resisted this, her level of alertness decreased, and they laid her flat on her back. At that point she became unresponsive, and one coworker went to find the office defibrillator. The group thought the "shock position" might assist her, so they elevated her feet on the couch pillows and prepared to start chest compressions.

     The Attack One crew performs a rapid assessment. The patient is unresponsive, breathing about eight times a minute. She has no palpable pulse and, when placed on the cardiac monitor, shows a slow, wide-complex rhythm. Her neck veins are greatly distended, and her ankles very edematous. She has no signs of injury and no fever.

     Careful to be respectful to the coworkers who had done their best to provide first aid, the crew feels the best treatment for the patient will be to elevate her head and assist her breathing. They attach their defibrillator pads and raise her to a sitting position on the couch, swinging her legs down to the floor. Her pulse returns, and her heart rate increases to about 60 beats a minute. She's still breathing slowly, so they assist her respirations with a bag-valve mask.

     The coworkers are stunned-sit the patient up to restore the pulse!

     The cardiac complex narrows on the monitor, and the blood pressure palpates at 90 mmHg. The patient's lungs can now be auscultated, and rales are noted in both bases. Her neck veins are still distended, but much less so than when she was in the reclining position. The medic crew believes her original complaint of shortness of breath was caused by a worsening of her congestive heart failure (CHF). They find signs of volume overload in her lungs, neck veins and feet.

     They feel appropriate therapy should include positive-pressure ventilation assistance, supplemental oxygen and medication to assist her in removing the extra fluid (a diuretic). The crew has a continuous positive airway pressure circuit available, and they feel it would be appropriate for use, and perhaps allow the patient to resolve her problem without the need for intubation.

     After a conversation with medical control, the crew applies the treatment plan. The patient is bagged with 100% oxygen, a saline lock is initiated, and 80 mg of furosemide (Lasix) is administered. She is rapidly moved, in an upright position, to the ambulance, where the CPAP circuit is set up.

     Once the circuit is started, the patient begins to wake up. She insists on sitting upright on the stretcher in the medic unit. Her pulse rate increases to about 120 beats a minute, her blood pressure rises to 170/100, and her peripheral skin is pink and warm and appears to be perfusing well.

Transportation
     The patient reports that her shortness of breath is less severe, and her pulse oximeter reading continues to increase to 90%, so she is maintained on the CPAP circuit. Just prior to movement into the ED, her vital signs improve further, and she is able to speak through the mask to the crew. She denies any chest pain, palpitations, fever or cough, but says she's been short of breath at night. She was asked by her doctor to follow her weight, and she states it had increased about 20 pounds in the last week.

Hospital Course
     On arrival at the emergency department, Attack One's crew assists the ED staff in moving the patient onto the cart, where she again insists on sitting upright. She requests a bedside commode so she can urinate. Her ED workup indicates an abrupt worsening of her CHF but no myocardial infarction. After she urinates about 2 liters of fluid, the CPAP circuit is removed, and she is maintained on oxygen by nasal cannula. She is admitted and has an uncomplicated hospital course.

Case Discussion
     The patient here had an underlying history of congestive heart failure due to hypertension and a problem with one of her heart valves. Her primary doctor had placed her on a diuretic and asked that she record a daily weight to guide the dose of the medication. Patients with CHF are susceptible to having rapid fluid retention occur due to worsening of heart function, changes in medications or increases in sodium in their diets. The best way to follow fluid status is with a very simple monitoring tool: an accurate bathroom scale.

     The patient had noticed her weight increase and the increasing shortness of breath, but she'd run out of her diuretic medication and was feeling pressure to finish an important work project, so she hadn't contacted her physician. Her respiratory status deteriorated, and her well-meaning coworkers acutely exacerbated the problem by laying her down and raising her feet. She deteriorated rapidly to frank respiratory and heart rhythm failure. Her heart rate deteriorated to a bradycardic rhythm, and her blood pressure fell. Her heart function could rapidly recover when she was placed upright and her breathing assisted before therapy with the critical medication to remove the extra fluid.

     Patients with congestive heart failure have pump dysfunction that results in fluid overload. The fluid often presents as edema in the lower extremities. As the patient lies down, that fluid gets mobilized and returned to the vascular system, and in a full reclining position will fill the vascular system in the lungs. At the extremes, a change in position can cause the patient to deteriorate almost immediately.

     There is now a chance to use the CPAP breathing circuit to assist these critical CHF patients. The continuous positive airway pressure circuit is utilized with pressurized oxygen to reduce the fluid load in the lungs, increase oxygenation and ultimately improve cardiac function. In some cases, the patient with severe CHF or pulmonary edema may be managed without intubation. The pulse oximeter is an excellent monitoring tool for this group of patients, because oxygenation is the function compromised by CHF and fluid overload. The patient should have ongoing monitoring with this tool.

     CPAP has been compared to "breathing out the window, facing forward, with the car going 40 miles an hour." The continuous pressure into the airway and lungs translates into the alveoli and forces some fluid back into the capillaries. Supplemental oxygen will be more effective as the pressure allows the oxygen to reach the walls of the alveoli and be transmitted onto hemoglobin.

James J. Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Atlanta Hartfield Jackson International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugust@emory.edu.