Proper diagnosis of volume overload requires laboratory testing beyond the capability of most EMS systems, and misdiagnosis of acute CHF can be disastrous with furosemide in the armamentarium. As always, a thorough history and assessment are the keys to choosing the proper treatment. Pulmonary crackles on auscultation and moist skin can just as easily be pneumonia as acute CHF, and vasodilation and diuresis in these patients can yield disastrous results.
More than anything else, the presence of profound hypertension and orthopnea in a patient with severe respiratory distress points to acute pulmonary edema. If your patient isn’t hypertensive and his history doesn’t point to volume overload, it’s best to leave the furosemide in the box and let the ED administer it when they have a better diagnosis. Or better yet, take furosemide out of the box entirely.
1. Mosesso, Jr. VN, Dunford J, Blackwell T, Griswell JK. Prehospital therapy for acute congestive heart failure: state of the art. Prehosp Emerg Care 7(1):13–23, 2003.
2. Bertini G, Giglioli C, Biggeri A, et al. Intravenous nitrates in the prehospital management of acute pulmonary edema Ann Emerg Med 30:493–9, 1997.
3. Sacchetti AD, Harris RH. Acute cardiogenic pulmonary edema. What’s the latest in emergency treatment? Postgrad Med 103:145–66, 1998.
4. Sacchetti A, Ramoska E, Moakes ME, McDermott P, Moyer V. Effect of ED management on ICU use in acute pulmonary edema. Am J Emerg Med 7:571–4, 1999.
5. Fuster V, Alexander RW, O’Rourke, et al. Diagnosis and management of heart failure. Hurst’s The Heart 11th ed. 723–62.
6. Tintinalli, Congestive heart failure and pulmonary edema. Emergency Medicine 7:405–13.
7. Hoffman JR, Reynolds S. Comparison of nitroglycerin, morphine and furosemide in treatment of presumed prehospital pulmonary edema. Chest 92:586–93, 1987.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ