# Giving patients fluid?



## GraysonK (Jul 25, 2006)

I've just finished the EMT-B course a few months ago, and I was curious about all the different variables on giving patients fluids for patients suffering from shock, heat exhaustion, and heat stroke.

Ive read the course texts, and numerous online sources on how to treat it.

As far as I understand, a patient suffering from heat exhaustion can be given water (Ive also heard anything with electrolytes.....in the form of gatorade, or even salt water....does this work, and what does it do?)

For heat stroke AND hypoperfusion, I have read everything from:
-no fluids
-wet the patients lips
-allow them to sip tiny amounts
-allow them to drink as they please
-have the patient drink as much water as possible

-Electrolytes mentioned once again
-Fluids in stomach arent good for surgery
-IV lines can help rehydrate instead

My question is: Which are correct, and why?

What about outside of an EMS enviornment, without being able to rely on ALS, or immediate transport to a hospital, how should I respond to these situations?

Thanks for the advice,
Grayson


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## DT4EMS (Jul 25, 2006)

GraysonK said:
			
		

> I've just finished the EMT-B course a few months ago, and I was curious about all the different variables on giving patients fluids for patients suffering from shock, heat exhaustion, and heat stroke.
> 
> Ive read the course texts, and numerous online sources on how to treat it.
> 
> ...



Welcome to the "practice" of medicine. No one has it perfect. Treatment for specific cases/causes will vary greatly. 

Simplify your life. If you KNOW the person is going to surgery, very little if anything is given by mouth.

When a person is having heat cramps or heat exhaustion the basics of removing from the heat source to a cooler environment and giving liquids by mouth is usually OK as long as the person is conscious and alert enough to drink it on their own. 

The reason for drinks like Gatorade is because when we sweat we lose more than just water. Anytime a person has an imbalance of electrolytes very bad things can happen at the cellular level.

When in doubt, contact medical control. I have worked under medical directors that only allowed us to start mini-drips on heat stroke and others that wanted two large-bore IV's. 

Hence.... the "practice" of medicine.

Rid may chime in with some helpful tips too.


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## Guardian (Jul 26, 2006)

Heat cramps and heat exhaustion result from lack of electrolytes (sodium) and dehydration.  Therefore, fluids are a GOOD thing.

Heat Cramps = either water with sodium (4 teaspoons of salt per gallon of water) or sports drink.  No soft drinks unless you're stranded and thats all you have.

Heat Exhaustion = same fluid treatment as heat cramps unless they can't swallow for some reason.

Heatstroke = You can also give these pts oral fluids if they can swallow but please call ALS as they probably need IV or Normal Saline infused wide open.


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## Ridryder911 (Jul 26, 2006)

The problem of giving fluids p.o. or oral is that most of these patients present with associated N & V as well. Most people when having heat exhaustion do not feel like drinking a liter or two. Therefore I.V.'s are recommended along with p.o. route later, after antiemtics is administered. The key is to take small sips (approx. teaspoon at a time) the stomach tends to increase acidity, also increasing nausea. Lab's should be performed to make sure potassium, magnesium and sodium is not to altered. There has been many reported muscle cramps, seizures, dysrhythmias, and even v-fib- death reported with such electrolyte imbalance. 

Heat stroke, (which has no co-relation with fluids) is a serious and life threatening illness. It is the hypothalamus in the brain that has been effected, and temperature regulation is not successful. Cooling the patient is essential,(cool packs to pulse points)  and establishing I.V. routes is one way of performing this.... be careful not administer too much fluid raising the blood pressure, causing an increase for potential re-current CVA.


R/r 911


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## Guardian (Jul 26, 2006)

You also have to be aware of hyponatremia which is caused by overhydration.  There was a great article on this in the June 04 EMS magazine (sorry, can't find a link right now).  They had a problem with this in the Boston marathon.  The runners were supplied with so much water that it decreased the level of sodium in the blood and caused "water intoxication."  Anotherwords, low amounts of salt in the blood just like dehydration, just a different way of getting there.  The actually killed someone at the Boston marathon if i'm not mistaken in 02'.

Typical s/s include- cramps
                           cup of water every mile while running
                           ST
                           H/A, N/V
                           lethargy
                           vomits water
                           seizure

The point is this can be very hard to diagnose without an electrolyte panel which can only be done at the hospital.

Other neat tidbits include- more common in females and less competitive athletes (toward the back of the race), NSAID increase risk of hyponatremia (very commonly used by runners and Tylenol is the only safe analgesic in this case, hence why they are sponsors i guess)


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## Guardian (Jul 26, 2006)

Ridryder911 said:
			
		

> The problem of giving fluids p.o. or oral is that most of these patients present with associated N & V as well. Most people when having heat exhaustion do not feel like drinking a liter or two. Therefore I.V.'s are recommended along with p.o. route later, after antiemtics is administered. The key is to take small sips (approx. teaspoon at a time) the stomach tends to increase acidity, also increasing nausea. Lab's should be performed to make sure potassium, magnesium and sodium is not to altered. There has been many reported muscle cramps, seizures, dysrhythmias, and even v-fib- death reported with such electrolyte imbalance.
> 
> Heat stroke, (which has no co-relation with fluids) is a serious and life threatening illness. It is the hypothalamus in the brain that has been effected, and temperature regulation is not successful. Cooling the patient is essential,(cool packs to pulse points)  and establishing I.V. routes is one way of performing this.... be careful not administer too much fluid raising the blood pressure, causing an increase for potential re-current CVA.
> 
> ...



Also depends on whether you're talking about classic heatstroke or the far more common exertional heatstroke.  In the latter, I saw a guy chug 1/2 gallon of water before I took it away from him.  Remember also that many, including myself, believe that a diagnosis of heatstroke instead of heat exhaustion can only be made after recovery when organ damage can be assessed because despite popular belief, more than half of heatstroke victims continue to sweat.

anhydrosis (no sweating) is a late finding of heat stoke and means you've got one sick puppy.

CNS dysfunction in hyperthermic pt is heatstroke until proven otherwise.


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## GraysonK (Jul 27, 2006)

How will having too many electrolytes in the bloodstream affect a patient?

Couldnt you just play it safe and give a patient as much SALT-water, or gatorade, as they asked for, until ALS arrived?

Im very curious about the subject because I'm also a member of a fire company...one of two members in the entire company who has his EMT-B cert, so I would be looked to for any kind of heat related/exhaustion emergency, and Id like to be able to provide a better level of care than "AHH! Ill call the medics!"


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## MMiz (Jul 27, 2006)

GraysonK said:
			
		

> How will having too many electrolytes in the bloodstream affect a patient?
> 
> Couldnt you just play it safe and give a patient as much SALT-water, or gatorade, as they asked for, until ALS arrived?
> 
> Im very curious about the subject because I'm also a member of a fire company...one of two members in the entire company who has his EMT-B cert, so I would be looked to for any kind of heat related/exhaustion emergency, and Id like to be able to provide a better level of care than "AHH! Ill call the medics!"


I once had a patient present with heat exhaustion.  We had 20 patients collapse at once, with only four ALS ambulances.  MCI was declated, mutual aid responded.  

As we were clearing out the mess and sending the last patients on their way, I got out of my empty rig and went next door to check on the last pt.  She presented with the classic signs of heat exhaustion.

I went to give her a bottle of gatorade without thinking, and she responded "Are you trying to kill me?"  It turns out she was diabetic and had adverse reactions to going from extreme hypoglycemia to hyperglycemia.  I'm not sure a bottle of gatorade really would have done much harm, but my ALS partner sent me off to get water.

There isn't much BLS-wise you can do for heat exhaustion / stroke.  An IV drip does absolute miracles for the dehydrated patient.  I have story after story after story about that, but it's really amazing what an IV drip can do.  BLS-wise you just have to monitor and treat with O2 and ice packs to cool the patient down.


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## Guardian (Jul 27, 2006)

GraysonK said:
			
		

> How will having too many electrolytes in the bloodstream affect a patient?
> 
> Couldnt you just play it safe and give a patient as much SALT-water, or gatorade, as they asked for, until ALS arrived?
> 
> Im very curious about the subject because I'm also a member of a fire company...one of two members in the entire company who has his EMT-B cert, so I would be looked to for any kind of heat related/exhaustion emergency, and Id like to be able to provide a better level of care than "AHH! Ill call the medics!"




This is getting out of hand...lol. Lets just make this simple.  If they're thirsty, give them water or better yet half gatorade/half water mix and let them drink.


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## ffemt8978 (Jul 27, 2006)

The simple solution to this is to ask yourself, "What do my protocols say?"

Our protocols specifically prohibit us giving the patients fluid PO unless certain criteria are met.


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## Wingnut (Jul 28, 2006)

Maybe this will help answer some basic questions...

http://epa.gov/heatisland/about/heatguidebook.html


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## MariaCatEMT (Jul 28, 2006)

*Excellent discussion, thank you all! I learned a lot!*


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## emtd29 (Aug 2, 2006)

This is what my ( New York State ) protocols say: 

But, *ALWAYS FOLLOW YOUR LOCAL PROTOCOLS*

*Heat Emergencies*



I. *Patients presenting with moist, pale, normal to cool skin temperature:*


A. Perform initial assessment.


B. Assure that the patient’s airway is open and that breathing and circulation are
adequate.


C. Remove the patient from the heat source and place in a cool environment.


D. Administer high concentration oxygen.


E. Loosen or remove outer clothing.


F. Place patient in the supine position with legs elevated.


G. Transport the patient immediately.


H. Cool the patient by removing excess clothing and fanning the patient.


*Do not delay transport to cool the patient!*


1. *If the patient is conscious, is not nauseated, and is able to drink without*
*assistance, *have the patient drink water (if available).


2. *If the patient is unconscious or is vomiting, *transport to the hospital with the
patient positioned on their left side.


I. Ongoing assessment. Obtain and record the patient’s vital signs, repeat enroute as often as the situation indicates.


J. Record all patient care information, including the patient’s medical history and all
treatment provided, on a Prehospital Care Report (PCR).



II. *Patients presenting with hot, dry or moist skin:*


A. Perform initial assessment.


B. Remove the patient from the heat source and place in a cool environment.


C. Remove outer clothing.


D. Apply cool packs to neck, groin, and armpits.


E. Keep patient’s skin wet by applying wet sponges or towels.


F. Fan the patient aggressively.


G. Transport immediately.


H. Ongoing assessment. Obtain and record the patient’s vital signs, repeat enroute as often as the situation indicates.


I. Record all patient care information, including the patient’s medical history and all
treatment provided, on a Prehospital Care Report (PCR).


Again, *ALWAYS FOLLOW YOUR LOCOL PROTOCOLS*


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## Guardian (Aug 3, 2006)

ffemt8978 said:
			
		

> The simple solution to this is to ask yourself, "What do my protocols say?"
> 
> Our protocols specifically prohibit us giving the patients fluid PO unless certain criteria are met.




But also remember that protocols are just amenable guidelines and really can't "prohibit" any specific treatment.  I deviate from my protocols regularly but never aimlessly.  The simple solution is to recall what your protocols say, but please remember that simple solutions are not always the best solutions.


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## Jon (Aug 3, 2006)

When I do Mass-Gathering Event EMS, we have copious amounts of H2O and Gatorade. For our largest event, in the middle of the summer, we have a local Mass Transit bus parked behind our tent to put patients in to sit, relax, cool off, and drink water.

Our on-site medical director likes to see us re-hydrate orally if possible, but he'll plug someone into a liter bag and watch them for a while if needed.

Our Gatorade is the "Gatorade All Stars" stuff - it is "childrens gatorade" and is watered down and less potent than regular gatorade, but everyone still drinks 1 gatorade and 1 water. All staff are required to drink 1 of each an hour.

In short - we have a golden rule: "Transport as few as possible" - we try to treat and turf as many as possible, and our docs and nurses write discharge orders. So we try to re-hydrate P.O. if possible.

In the field, at the Volly Squad - we have H2O for the FD for Rehab operations... we don't give patients water.


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