A elderly nursing-home F with a hx of COPD and diastolic failure comes in with dyspnea. She is in severe respiratory distress. Her vitals are HR 128 RR 24 BP 167/112 T 97.6. EMS placed her on a bipap and her sat is 95. On exam, she has bilateral crackles, jvd, an S3, and minimal LE edema. This is her cxr.
Do we send a bnp?
Do we do a pulmonary sono?
Do we give sl nitro, iv nitro, or lasix? If so, at what dose?
Do we give nebs, steroids, abx?
Do we use bipap, oxygen via non-rebreather, or nasal cannula?
Do we intubate?
I would include a bnp in my set of labs. I also think it’s reasonable to throw a probe on her chest to look at the heart, then check the lungs and IVC real quickly (to get a better bedside assessment of volume status). I would keep the patient on bipap, maybe hold lasix and nitro to see if she improves; but I would have a very low threshold to initiate either of those if I got the impression that it was ADHF. Abx…I’m generally for these in old patients who look crappy.