when do you give saline?

paradoqs

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So my partner is always telling me to give saline when my pt is hypotensive, say 100 systolic. Im like, Im going to treat my pt, not the bp cuff. If my patient is running alittle low but has no other indications of hypoperfusion, such as tach or pallor or agitation or dehydration then I am not going to give saline. My question is, what are the key indicators for saline administration that you more experienced folks look for? In a sense, how bad off does a pt need to be to warrant a fluid challenge or even a tko'd bag?
 
There's so many variables to consider that saying when / when not to is near impossible.




Is the hypotension due to hypovolemia, or the heart, or something else? Is it a kid or adult? Are they on beta blockers, calcium channel blockers, or other medications that will 'mask' shock signs?

A kid can have a blood pressure of 86/52, but be minutes from crashing and still need fluid due to hemorrhage. A patient may have a heart rate of 52 and BP of 60/30, but is that due to fluid loss, vasodilation, or the heart not working right? Are you wanting to do a fluid challenge in a CHF patient? Fluid for an asthmatic?
 
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What's their baseline? Do they take anti hypertensive meds? Do they know their usual bp? Whats their HR? Are they dehydrated? Vomiting? Diarrhea? Peripheral edema? There are a ton of variables that go into this. If the have a hx of HTN then 100 systolic is more than likely hypotensive for them and might warrant a fluid challenge. At 100 sbp in most patients I'd consider hanging a bag at tko depending on transport time. They are at least getting a line with a lock on it so I have access established if I need it.
 
Im like, Im going to treat my pt, not the bp cuff.


...and I stopped reading. How are you going to determine the patient is hypotensive in the first place? Drop an arterial line for a little IAB?
 
Im like, Im going to treat my pt, not the bp cuff.

That's like saying treat the patient not the monitor. We don't use these tools for fun. We use them in conjunction with each other and a good physical exam to form a differential diagnosis and treatment plan. Look at the whole picture, not just the patient, and not just the BP/ECG yadda yadda. Now if something doesn't make sense at all for the presentation go back and look for why it doesn't make sense.
 
I dont have a medlist, I dont have a baseline before my own. Pt is 50 yo f with failure to thrive hx. Pt is completly asymptomatic of any illness but has a low bp. Pt doesnt give me any hx and the snf nurse is a moron and cant even give a report

It sounds like the answer to my original question of when do you give saline is "you have to rely on your asessment and your experience. But what about those of us that lack experience?
 
Well.... There's a lot to take into account. First off... would you rather fluid overload your patient, or let them run low. Secondly, whats their chief complaint (CHF/COPD, Pneumonia?) If they have fluid in their lungs but they're a little hypotensive, you may consider holding off on giving fluids and may opt for placing them trandelenberg.

prime example: Had a home to ER call the other day. Call for SOB x1 day & fluid in lungs (pt was home health). Patient Hx of COPD, Resp Failure. We arrived the Pt was on 1.0 Liter D5 1/2NS and a Nasal Cannula at 6Lpm. Family was instructed by RN to D/C IV (some nurse right) so we could transport BLS. En route the V/S were 92/62 and then 88/54 with pulse @ 94 both times and Resp at 22. Pt slightly diapohretic and cool. Pt ascultated w/ ronchi in Right Lung.

what'd I'd do as an EMT.... elevated legs and made sure that O2 was still running (at 4LPM due to COPD). Transport time after 2nd set of vitals was <5 mins and once we got to ER, the her BP was 124/62.

Just because a patient is hypotensive, doesn't mean they "need" and IV of saline. :ook at all of the signs and make a judgement call on what you're going to do. If the next set of vitals has still been in the gutter, we woulda upgraded to Code 3.... and that'd be that.
 
...and I stopped reading. How are you going to determine the patient is hypotensive in the first place? Drop an arterial line for a little IAB?

Always saying what I was thinking :P

So why was the nurse a moron? Exactly what did they leave out of their report that constitutes such a statement?

If they have a history of "failure to thrive" wouldn't consider that they could possibly be dehydrated? Use ALL your tools to decide when to use saline, that includes the BP cuff.


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Use your clinical judgement. I lived in CO for a bit, Boulder actually and also got my EMT-B there. Are you an EMT-B with the IV and EKG class or are you an EMT-I? If the pt is asymptomatic and at baseline mental status with no complaint's personally I'd start a line with a lock and monitor closely. How do you not get a medlist from an SNF? Sounds like you need to dig deeper. They are responsible for the care of that person and therefore responsible for their meds. I dealt with a few SNFs in the Boulder area during my EMT-B class and they seemed to be pretty good about providing us with the patient's chart if they verbally couldn't do it.
 
If they have fluid in their lungs but they're a little hypotensive, you may consider holding off on giving fluids and may opt for placing them trandelenberg.
Or instead of playing with their legs, give them a treatment that will actually do something... An inotrope maybe...

Edit: Just saw OP was an EMT-IV... I stand by what I said, just call an ALS to do it for you. :p
 
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Or instead of playing with their legs, give them a treatment that will actually do something... An inotrope maybe...

Zoom zoom zoom

1 cookie to anyone that gets the reference


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zoom zoom zoom

1 cookie to anyone that gets the reference


sent from my iphone using tapatalk

MAZDA! Now where's my cookie? I like snickerdoodles or chocolate chip.
 
Or instead of playing with their legs, give them a treatment that will actually do something... An inotrope maybe...


EMT-I here, can't do that... yet. Had the family not D/C'd the IV we woulda just made it an ALS call.
 
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MAZDA! Now where's my cookie? I like snickerdoodles or chocolate chip.

No...


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lies! the mazda commercials always say zoom zoom.
 
I dont have a medlist, I dont have a baseline before my own. Pt is 50 yo f with failure to thrive hx. Pt is completly asymptomatic of any illness but has a low bp. Pt doesnt give me any hx and the snf nurse is a moron and cant even give a report

It sounds like the answer to my original question of when do you give saline is "you have to rely on your asessment and your experience. But what about those of us that lack experience?

If she has a history of failure to thrive I would inquire about the patient's oral intake. Sounds like a good chance exists for the patient to be volume depleted from dehydration maybe? Did you ask about pt's. urine output and consistency? Skin quality? Turgor? Check membranes to see if moist or dry as a desert? What was the heart rate? Any indication of a compensatory response? What was the diastolic pressure like?

If it's a skilled nursing facility then they have to have medication records along with medical history and vital signs records. Did you ask for the information from the chart and told they absolutely did not have that information?

As other's have said, no absolute exists for giving IV fluid based on a blood pressure reading. Maybe the pressure you got was completely normal and baseline for her. What did the B/P trend look like?
 
lies! the mazda commercials always say zoom zoom.

Agreed, I however posted 3 "zooms"


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Always saying what I was thinking :P

So why was the nurse a moron? Exactly what did they leave out of their report that constitutes such a statement?

If they have a history of "failure to thrive" wouldn't consider that they could possibly be dehydrated? Use ALL your tools to decide when to use saline, that includes the BP cuff.


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I dont even think this lpn was the pt's nurse. She gave me a packet with the pt's labs and walked off. No report. I had to follow and ask what was going on. she said "abnormal labs." She didnt even tell me the pt had a bag hanging which my partner dc'ed and told me it was saline. Turns out it was a med and he forgot the name. Pt had a picc line which i cant use so i could either start an iv and give fluids or wait until the ed so they can use the picc and not need to stick her again. Pt was at around 102 sbp the whole trip. Bp was stable but low. ll other vitals stable and wnl so i chose not to stick her again.

My original question restated is, where is that line between needs fluid rescusitation, and doesnt. (for hypovolemia)
 
Scrubs?
 
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