Here is the how and the why of the way I chose to treat each patient.
Patient #1: Placed initially on 6L o2 via cannula. Pt accepted cannula better at first. IV established, placed on monitor, pt given 1 SL NTG @0.4 mg. Pt admits to having had to be placed on C-PAP in the past. Pt's increased work of breathing, LS and vitals all placed them firmly in the C-PAP category for me. Pt placed on C-PAP, work of breathing eased, anxiety decreased. Repeat vitals post NTG and C-PAP: RR-24, HR-110, BP 230/p, LS conitued to have crackles in bases. Sats came up to 99%. Why only 1 NTG you ask? My protocols do not allow for large doses of NTG, the doc that was on in the ED doesn't grant orders for anything and because of proximity to ED I only got 1 in before we got there. I did not give the lasix because it works on the kidneys and the patient's have completely shut down. It wouldn't have worked like it should have. She also wasn't 3rd spacing in her perifery. What the pt needed was dialysis. I can't do that. Morphine causes respiratory depression and in a patient w/ severe respiratory compromise I wasn't going to push the limit. The MS was a proximity problem as well. In the time it would have taken me to get it out and draw it up I would have been parked in the bay of the ED.
Patient #2: Pt had improvement with position change right off. Then placed on 6L o2 via cannula. IV established, placed on monitor and transported to ED. Pt's repeat VS: RR-20, HR-80 BP- 190/p o2 sats 97% on o2, LS remained the same. Pt remained stable and able to speak full sentences. I did not go down the CHF route with this pt even though I suspected that was the problem because there were other mitigating factors. With the pneumonia diagnosis in the last week and being unable to determine what was causing those LS to be diminished I chose not to give a bunch of pharmacological agents that could potentially harm the pt. I am not sure why the patients doctor told them not to take their lasix. Maybe his sugar was low when he said it. With her other complications they needed more definitive testing to determine the cause of the difficulty.
Both patients were sleeping peacefully when I brought in my last patient of the night. Patient #1 x-ray looked horrible and was going for dialysis very soon. They had gotten the BP down with a NTG drip and they remained on the C-PAP. Pt #2 films were not back, they were suspecting it was a combo of the pneumonia and CHF and were treating accordingly. They remained on NC o2 without difficulty. Both of these patients were challenging medical cases. They had the myriad of problems that many patients have nowadays mucking up the waters regarding their condition. I based my treatment plan on my continued assessment of each. These cases show the importance of the assessment. If some of these things were not noticed or disregarded the treatment plans could have been very different or detrimental. Respiratory assessments are vital. They fall squarely into ABC and I don't have to remind anyone how important that is.