Ellen Diane Windham 11/8/15
Case Study: CHF

Helen Montgomery * An 83-year-old female presents to ambulance crew after an episode of sudden weakness. A GP is on scene and has assessed the patient, deciding on hospital admission by ambulance as a matter of urgency.
History
Patient became very weak and was put to bed by NOK. Her breathing became very laboured and the NOK called for the local GP out-of-hours service to attend. The doctor was on scene within 15 minutes, and upon assessing the patient requested an ambulance transfer to the ED.
Initial Clinical Findings * Airway – clear & patent * C Spine – not indicated (MOI/NOI: episode of weakness) * Breathing – tachypnoeic * Circulation – Pulse present, irregular, tachycardic; skin colour normal, cap refill normal * Disability – No LOC before ambulance arrival, patient responding to verbal stimuli
Clinical Impression * ? Exacerbation of CHF * ? CVA * ? Post-seizure
AMPLE History * A – Allergic to penicillin * M – Currently taking Warfarin, Furosemide * P – History of CVA x 1 year, CHF * L – Last oral intake 7pm the evening previous * E – Son stated patient became very weak before going to bed
Observations
* Pulse rate 110bpm * Pulse rhythm Irregular * ECG rate 116 * ECG rhythm A Fib * Resp rate 24 per minute, regular, shallow * Resp quality Bibasal consolidation & rales on auscultation * SpO2% 89% @ room air * Cap Refill <2secs * BP 178/112 * Pupils PEARRL, size 4 * GCS 11/15 (E4, V2, M5) * BGL 14.4.0mmol/l
Pre-hospital care & management
GTN 800mcg given SL & Furosemide 40mg administered IV as patient was dyspnoeic with audible crackles bi-basally. O2 @15lpm commenced via non-rebreather mask. 12 Lead ECG showed AFib, no obvious acute pathological changes. En-route to hospital patient’s SpO2% decreased to 85% on 15lpm via non-rebreather mask. Ventilations assisted as RR>30 per minute. Resuscitation equipment prepared as patient’s GCS remained at 11/15. SpO2% increased to 99% with assisted ventilations.
In-hospital care & management
Patient triaged as Category 1 (Life-Threatening Condition) with CHF Exacerbation. CPAP therapy initiated. Blood tests taken. Urinary catheter inserted.
Clinical Findings
Exacerbation of CHF, hypoxia secondary to same. Unresponsive to medication therapy.
Outcome
Patient’s condition deteriorated, intubated. Patient on ventilator in ICU department. Poor prognosis, same discussed with family by medical team.