Severe Pulmonary Oedema.
Sit the patient up.
O2 by face mask 100% if there is no existing lung disease.
Insert IV cannula and take bloods for blood gases, U & E and cardiac enzymes.
Continuous ECG monitoring
Arrange for a CXR. Take a brief history if possible. Note drugs;
precipitating factors: MI and infection; pre existing lung disease, hypertension and previous heart disease. Examine for signs of pulmonary oedema: pink frothy sputum, pulsus alternans, fine crackles on auscultation of the chest and gallop rhythm.
Drugs: Frusemide 40-80mg iv
Diamorphine 5mg iv
GTN spray 2 puffs SL
In AF give: Digoxin 0.5mg iv
Baseline tests and markers of progress: BP, heart rate, cyanosis, Respiratory rate, JVP, peripheral oedema and enlarged liver.
Continuing management: Frequently check BP, pulse rate, heart sounds, restrict fluids, measure urine output, further IV frusemide and check U and E and ECG.
If improving oral frusemide, sequential CXR, daily weighing, 6 hourly BP and pulse.
If BP¯ the danger is cardiogenic shock. Consider venesection to remove 500ml blood quickly
In patients with severe pulmonary oedema following MI may develop VSD or Mitral regurgitation.
DD: Bronchospasm and Pneumonia. All 3 conditions may coexist in elderly. Treat with Salbutamol nebulizer, Frusemide IV, Diamorphine and ampicillin.