# when do you give saline?



## paradoqs (Nov 11, 2011)

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?


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## Shishkabob (Nov 11, 2011)

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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## Handsome Robb (Nov 11, 2011)

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.


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## JPINFV (Nov 11, 2011)

paradoqs said:


> 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?


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## Handsome Robb (Nov 12, 2011)

paradoqs said:


> 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.


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## paradoqs (Nov 12, 2011)

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?


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## DV_EMT (Nov 12, 2011)

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. ok 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.


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## fast65 (Nov 12, 2011)

JPINFV said:


> ...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 

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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## Handsome Robb (Nov 12, 2011)

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.


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## STXmedic (Nov 12, 2011)

DV_EMT said:


> 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.


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## fast65 (Nov 12, 2011)

PoeticInjustice said:


> 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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## Handsome Robb (Nov 12, 2011)

fast65 said:


> zoom zoom zoom
> 
> 1 cookie to anyone that gets the reference
> 
> ...



MAZDA! Now where's my cookie? I like snickerdoodles or chocolate chip.


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## DV_EMT (Nov 12, 2011)

PoeticInjustice said:


> 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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## fast65 (Nov 12, 2011)

NVRob said:


> MAZDA! Now where's my cookie? I like snickerdoodles or chocolate chip.



No...


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## Handsome Robb (Nov 12, 2011)

lies! the mazda commercials always say zoom zoom.


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## STXmedic (Nov 12, 2011)

fast65 said:


> No...
> 
> 
> Sent from my iPhone using Tapatalk



Ok good! If the answer was Mazda, I was going to be confused as hell


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## 18G (Nov 12, 2011)

paradoqs said:


> 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?


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## fast65 (Nov 12, 2011)

NVRob said:


> lies! the mazda commercials always say zoom zoom.



Agreed, I however posted 3 "zooms"


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## paradoqs (Nov 12, 2011)

fast65 said:


> Always saying what I was thinking
> 
> So why was the nurse a moron? Exactly what did they leave out of their report that constitutes such a statement?
> 
> ...



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)


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## STXmedic (Nov 12, 2011)

Scrubs?


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## fast65 (Nov 12, 2011)

paradoqs said:


> 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)



So it's your job to prod for more info. I don't know why you wanted to "save her a stick", with a history of "failure to thrive" and some sort of a bag already hanging, those are indicators that she could possibly be dehydrated. Granted I'm not going to be dumping fluids into this lady, but I'm also not going to base my IV therapy off of just a set of numbers.

I will restate the answers of others, there's no clear line, you use your own clinical judgement to make that decision. Everyone is different and you must combine ALL of your tools to determine whether or not someone needs fluids.


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## fast65 (Nov 12, 2011)

PoeticInjustice said:


> Scrubs?



COOKIE! 


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## STXmedic (Nov 12, 2011)

paradoqs said:


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


Unfortunately, the answer remains the same. There is no magic number that says "She needs a bolus!!" It is still very driven by cumulative assessment findings, not a check list.


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## STXmedic (Nov 12, 2011)

fast65 said:


> COOKIE!
> 
> 
> Sent from my iPhone using Tapatalk



Woohoo!!! I'll have Rob's snickerdoodle, please


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## Akulahawk (Nov 12, 2011)

paradoqs said:


> 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?


You're starting to futz around with the right concepts... but you've not quite grasped it. 


JPINFV said:


> ...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*?


OOOOhh.... I'm liking that idea..  IABP FTW!! :rofl: Just kidding.


NVRob said:


> *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.


Uhm... That's _exactly_ like saying "treat the patient not the monitor". for the OP: What makes more sense to me is "treat the patient, not _just_ the monitor. Those devices can give you glimpses into what's going on, but it takes consideration of the whole patient, as best as you can ascertain, to come up with an appropriate treatment plan to address those problems that your patient has.

Out here, our protocols are basically somewhere between a guideline and a cookbook. If you're a cookbook type, you'll dismiss those other indications that trouble is brewing because they don't fit neatly into "the recipe." The clinician in me looks for what the problem is, as best as I can determine, and come up with a plan of care to suit that... and if that plan basically says: use _xyz_ _protocol_, I can verbalize _why_ I selected that protocol vs coming up with a whole new plan that I'd have to call in to get approval to do it.

But the point of all this is that I can't really make that decision without taking into consideration the patient's entire situation/condition _including_ what the monitors are telling me.


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## JPINFV (Nov 12, 2011)

Oh, you had labs? Was the patient hypernatremic?

F'ing electrolytes, how do they work.


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## Shishkabob (Nov 12, 2011)

DV_EMT said:


> 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.



Actually, you would be better off doing a fluid challenge of, say,  250cc and re-checking, and going from there.

Few CHF patients have pulmonary edema due to hypervolemia.  Infact, most CHF patients are actually HYPOvolemic.  Giving some fluid will hopefully bring up that BP a bit, 'priming the pump' to kick in Starling law, and keep more fluid from backing up due to inadequate contractile force.  That fails and we move on to inotropes such as Dopamine. 


And good luck laying a CHFer flat on their back / trendelenberg.


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## paradoqs (Nov 12, 2011)

Akulahawk;
But the point of all this is that I can't really make that decision without taking into consideration the patient's entire situation/condition [I said:
			
		

> including[/I] what the monitors are telling me.


. 

That is my point. The only abnormal finding I got was a stable but low bp and I decided the pt did not need fluids. If the pt had been tachy and dehydrated i would have given fluids. I understand there is no checklist but I was just wondering if the posters here had any advice. But it seems like the advice is just keep doing what I am doing i.e. using good judgment and not just treating numbers.


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> .  If the pt had been tachy and dehydrated i would have given fluids



How do you know they werent dehydrated?

Why rely on tachycardia as a sign?  For one, tachycardia can relate to MANY different conditions, even with 'hypotension'.

On top of that, did the patient have any cardiac meds, such as beta blockers, which would artificially lower the HR despite BP changes?


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## paradoqs (Nov 12, 2011)

JPINFV said:


> Oh, you had labs? Was the patient hypernatremic?
> 
> F'ing electrolytes, how do they work.



If i remember correctly it was low potassium and elevated wbc. No signs of any infection though.


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> If i remember correctly it was low potassium and elevated wbc. No signs of any infection though.



Elevated WBC can't indicate a possible infection?


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## paradoqs (Nov 12, 2011)

Linuss said:


> How do you know they werent dehydrated?
> 
> Why rely on tachycardia as a sign?  For one, tachycardia can relate to MANY different conditions, even with 'hypotension'.
> 
> On top of that, did the patient have any cardiac meds, such as beta blockers, which would artificially lower the HR despite BP changes?



Tach was an example of a finding that would be abnormal. Pt had no signs of dehydration, turgor, conjunctiva, mucous membranes etc were all fine.


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## JPINFV (Nov 12, 2011)

Linuss said:


> And good luck laying a CHFer flat on their back / trendelenberg.



Pfft, you can put the feet up and the head up at the same time. An RN told me that, so it must be true.


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## JPINFV (Nov 12, 2011)

Linuss said:


> Elevated WBC can't indicate a possible infection?




::twitch::

I'm happy I'm not the only one who caught that.


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## paradoqs (Nov 12, 2011)

Linuss said:


> Elevated WBC can't indicate a possible infection?



There were no other signs aside from the elevated wbc


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## JPINFV (Nov 12, 2011)

paradoqs said:


> There were no other signs aside from the elevated wbc




You mean besides the elevated WBC count, borderline hypotension, and what sounds like an altered patient (poor historian)? The elderly or immunocompromised aren't always going to spike a fever.


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> There were no other signs aside from the elevated wbc



The body tends to not spike it's WBC for no reason, be it an infection, what it perceives as an infection, or another disease process.  Elderly don't always have a fever when they're sick, as their immune system is, well, crappy.  100 systolic can be normal, or can be low, depending on the patients body type and normal BP.



If you took a look at the patients BGL, I'd be willing to bet it was slightly elevated as well.  Do you happen to remember the value?  What about the pts HR?  RR?


Could very possibly be SIRS.


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## paradoqs (Nov 12, 2011)

JPINFV said:


> You mean besides the elevated WBC count, borderline hypotension, and what sounds like an altered patient (poor historian)? The elderly or immunocompromised aren't always going to spike a fever.



Pt didnt seem to be altered, just apathetic about her tx. Sure, she could have had an infection starting and I considered that but as a basic I am going to leave that to the md, because those findings arent significant enough for me to initiate saline infusion.


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## paradoqs (Nov 12, 2011)

Linuss said:


> The body tends to not spike it's WBC for no reason, be it an infection, what it perceives as an infection, or another disease process.  Elderly don't always have a fever when they're sick, as their immune system is, well, crappy.  100 systolic can be normal, or can be low, depending on the patients body type and normal BP.
> 
> 
> 
> ...



Didnt get a bgl as it was not indicated. Pulse and rr normal. This wasnt a 911 call it was a BLS non emergent to the ed. The pt didnt have much going on except for the low bp and labs. Anyway, time for bed. I will come up with a different question for tomorow.


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## Aidey (Nov 12, 2011)

Not indicated? 

::twitch::

/inbeforeJP


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## Handsome Robb (Nov 12, 2011)

Akulahawk said:


> Uhm... That's _exactly_ like saying "treat the patient not the monitor". for the OP: What makes more sense to me is "treat the patient, not _just_ the monitor.



I feel like we agreed but with different verbage...



			
				PoeticInjustice said:
			
		

> Woohoo!!! I'll have Rob's snickerdoodle, please


This guy!!! I can haz halfs? 

As for the elevated WBC + HypoTN I'm thinking infection. Like someone said, geris are immunocompromized therefore lacking the compensatory mechanisms to combat infection such as fever. Pneumonia with the unilateral rhales in the lung maybe?


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## fast65 (Nov 12, 2011)

Geez, I take one little nap and end up missing an entire page of discussion...

Anyways, you two will have to split the cookie PJ and Rob 


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## DV_EMT (Nov 12, 2011)

Linuss said:


> Actually, you would be better off doing a fluid challenge of, say,  250cc and re-checking, and going from there.
> 
> Few CHF patients have pulmonary edema due to hypervolemia.  Infact, most CHF patients are actually HYPOvolemic.  Giving some fluid will hopefully bring up that BP a bit, 'priming the pump' to kick in Starling law, and keep more fluid from backing up due to inadequate contractile force.  That fails and we move on to inotropes such as Dopamine.
> 
> ...



I agree, 3 things to note though:

1. EMT-B... only can transport NS, D5W, & LR. Drugs out of the questions aside from pt's own.

2. Refrencing trandelenberg - I meant it as if they were on a stryker gurney... only lifting the legs up... not putting them on their back (i've seen that go wrong a few times)

3. I know that CHF is indicative of decreased cardiac output, not necessarilly low blood volume (and in turn blood pressure).


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## JPINFV (Nov 12, 2011)

DV_EMT said:


> 2. Refrencing trandelenberg - I meant it as if they were on a stryker gurney... only lifting the legs up... not putting them on their back (i've seen that go wrong a few times)



Think about how trendelenburg is supposed to work and basic fluid dynamics. If the heart is above the legs, how are you increasing venous return to increase end diastolic volume?


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## DV_EMT (Nov 12, 2011)

JPINFV said:


> Think about how trendelenburg is supposed to work and basic fluid dynamics. If the heart is above the legs, how are you increasing venous return to increase end diastolic volume?



If the legs are higher than the heart but the patient is still reclined and tolerating it alright, then the fluid dynamics should work (ie: legs are at a 30-45 degree angle with the gurney and the head is reclined at around 15-30%). It may not be a huge difference, but you should in theory get some blood return.


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## mycrofft (Nov 12, 2011)

*Parse.*

We are assuming you are not going to be determining whether they go to the hosp or not, you are there to transport a living person for admission.
So, what is the rationale for a NS IV, to save the ER some trouble? Or is the transport time long enough and the situation declining quickly enough that a TKO is necessary?
Are "challenges" and procedures exhibited necessary in the transport time, or ways of padding billing, or impressing the new ER nurse, or "just keeping my skills sharp" (no pun intended), or "just in case" (that's called a tort and a battery)?

1. What exact mechanism and benefit will the NS IV provide?
2. Is it rational in this setting?
3. Is it allowed?

Some people feel the need to have an IV swinging above every patient they bring in, useful or not. That might be called "Whackerism Level II".


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> This wasnt a 911 call it was a BLS non emergent to the ed. The pt didnt have much going on except for the low bp and labs. Anyway, time for bed. I will come up with a different question for tomorow.



I worked IFT for nearly a year before moving to 911.  I can't tell you how many simply mundane BLS calls turned in to a pseudo-911 ALS call.



Treat each nursing home call as a 911. One day you might actually catch something and save a life... or make it slightly more bearable.  Little piece of advise:  SNFs aren't known for their ability to care for acute patients and pass big things off as "electrolyte inbalance" ... especially since I can think of several potentially life threatening "electrolyte inbalances" that we can fix/change/reduce in the field.




Hell, this patient very well could have had hyponatremia (lower BP, confusion) and while we can't "fix" it, giving NS (hypertonic would be better) can go some length at diminishing the symptoms/ preventing death for a little bit.


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## Aidey (Nov 12, 2011)

Did anyone else catch the fact that this is a *50* year old female in a SNF? I'm guessing she has a significant medical history, which is being completely left out of the picture here.


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## paradoqs (Nov 12, 2011)

Linuss said:


> Hell, this patient very well could have had hyponatremia (lower BP, confusion) and while we can't "fix" it, giving NS (hypertonic would be better) can go some length at diminishing the symptoms/ preventing death for a little bit.



I recently worked a marathon and the MD said never to treat hyponatremic runners with ns. So the question is, why would you give ns for some hyponatremia and not other hyponatremia?


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> I recently worked a marathon and the MD said never to treat hyponatremic runners with ns. So the question is, why would you give ns for some hyponatremia and not other hyponatremia?



Normal sodium levels are 135-145.  If you get in to the 120s, that's getting pretty severe.  That shows how narrow of a range sodium is kept at in the body.

I don't know why the doctor told you that, that's your thing, but he was probably on the "I don't want an EMT-IV jacking with something they don't understand" spiel.    But if I have a runner, at a run, who admitted to only drinking water and is in severe cramps, maybe a PVC or two, guess what they're getting?  NS for sodium replenishment, as that's high on my differentials.



Confusion, 'hypotension', and low sodium levels... sounds like symptomatic hyponatremia should be on your list of differentials.  Like I said, hypertonic saline would be more ideal, but most places don't carry anything aside from NS and Ringers.  Though I don't advocate jacking with electrolyte balance if you don't understand what you're doing and the idea behind it, and can back up your decision.


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## JPINFV (Nov 12, 2011)

Linuss said:


> Hell, this patient very well could have had hyponatremia (lower BP, confusion) and while we can't "fix" it, giving NS (hypertonic would be better) can go some length at diminishing the symptoms/ preventing death for a little bit.



According to the OP, the patient was hypokalemic, not hyponatremic on the labs. 

I wouldn't go about fixing sodium issues without labs as sodium concentration disorders are normally do to changes in total body water than total body sodium. Hyponatremia patients often have either too much water or not enough circulating volume while hypernatremic patients normally have not enough water. With out a basic metabolic panel (chem 7), where you can calculate serum osmolality among other things, you're most likely shooting in the dark with some causes. The runner following a race is an exception due to the recent history.

Another thing is for chronic (>24 hours) hypo/hypernatremic patients, you don't want to fix the condition too quickly or else really bad things will happen (osmotic demylenation syndrome and cerebral edema respectively).


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## JPINFV (Nov 12, 2011)

Aidey said:


> Did anyone else catch the fact that this is a *50* year old female in a SNF? I'm guessing she has a significant medical history, which is being completely left out of the picture here.




Could be for rehab for something.


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## Aidey (Nov 12, 2011)

JPINFV said:


> Could be for rehab for something.



I know. But if she just had a hip replacement that would be pretty significant wouldn't it? 

*facepalm* Semantics issue. Significant = relevant, not significant = major.


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## Shishkabob (Nov 12, 2011)

JPINFV said:


> According to the OP, the patient was hypokalemic, not hyponatremic on the labs.


  All this talk about sodium and I got stuck on it 




> I wouldn't go about fixing sodium issues without labs as sodium concentration disorders are normally do to changes in total body water than total body sodium.



Agreed, I'm not advocating people just go out and bolus patients for the heck of it because a number is off or they're confused, but as stated, I'm not adverse to giving NS to things such as muscle cramps, which technically can be hyponatremia, as part of the differential.  


I'm not going to bolus a SNF patient with a serum sodium level of 130


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## usalsfyre (Nov 12, 2011)

Somehow the relevance of "elevated temp" and "altered labs" gets missed in EMS training programs. 

It gets tiresome explaining to green providers why this patient needs an IV and a liter of saline, only to have them respond "no other medic does it that way" :facepalm:

I give saline a lot. Outside of the ESRD crowd, there are very few patients who can't take 500-1000mls without any affect other than a transient increase in UO.


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## paradoqs (Nov 12, 2011)

Linuss said:


> Agreed, I'm not advocating people just go out and bolus patients for the heck of it because a number is off or they're confused, but as stated, I'm not adverse to giving NS to things such as muscle cramps, which technically can be hyponatremia, as part of the differential.



What about a runner with altered mental status that tells you they havent eaten today, and just finished a marathon and has s/s of hyponatremia. You would then give saline? If so, that is odd because the race MD told 50 medics/emts and captains that saline is an inappropriate tx for hyponatremia in this situation.


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## Aidey (Nov 12, 2011)

I also had a MD tell me that he will continue to give all of his AMI patient's O2 because he had seen it help and if we could squeeze a couple more O2 molecules past the blockage that was a good thing. 

Just becuase they have MD after their name doesn't make them infallible. As Linuss said the MD may have been dumbing it down for his audience.


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## Shishkabob (Nov 12, 2011)

paradoqs said:


> What about a runner with altered mental status that tells you they havent eaten today, and just finished a marathon and has s/s of hyponatremia. You would then give saline? If so, that is odd because the race MD told 50 medics/emts and captains that saline is an inappropriate tx for hyponatremia in this situation.



So many variables.  They haven't eaten, so what's the BGL?  Medical history?  Meds?  What other signs / symptoms?  Maybe the doctor just didn't trust you guys?


If someone just got done doing a physical activity, haven't been hydrating well, and are complaining of cramps / things of that nature, yes, I am doing some fluids.




At the risk of annoying JP... Just because someone has MD / DO at the end of their name doesn't mean they're the end-all / be-all of intelligence.  You'll meet plenty of, well... silly... doctors, medics and nurses in your career.  That's why you need to further YOUR education, so you can know when something is or is not called for.   There are EMS agencies that have medical directors that have no other experience in emergency medicine aside from the rotations they did during medical school decades ago and just do it to collect the easy check, not for proper patient care.  Granted, if that physician is your med control, that really constrains what you can do, but still.


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## usalsfyre (Nov 12, 2011)

To be fair, I'd have to think long and hard about treating hyponatremia with 0.9%. In dilutional hyponatremia you do actually stand a chance of increasing TBW and worsening the issue. If the patients actually dehydrated your safe treating with NS, if the patients been hydrating well but has not been taking electrolyte, tread carefully.

Given the situations above? I'd make the runner eat if able and I'd let the ED sort out the SNF patient. The only time I'd start adjusting sodium would be an extended CCT where I had 3% saline and an iSTAT available. There's much badness to be had from getting it wrong.


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## Shishkabob (Nov 12, 2011)

usalsfyre said:


> To be fair, I'd have to think long and hard about treating hyponatremia with 0.9%. In dilutional hyponatremia you do actually stand a chance of increasing TBW and worsening the issue.
> 
> Given the situations above? I'd make the runner eat if able and I'd let the ED sort out the SNF patient. The only time I'd start adjusting sodium would be an extended CCT where I had 3% saline and an iSTAT available. There's much badness to be had from getting it wrong.



Agreed fully.

But the Ops question wasn't about fixing, but more so when it a fluid challenge, or ever TKO warranted, and it comes back on a "case by case basis", determined by your knowledge and experience. You know me, usual, I don't go around bolusing every altered patient... well... not with NS anyway


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## usalsfyre (Nov 12, 2011)

Agreed.

As to the "what do I do until I have experince" question? Rely in others, and....get it wrong. The dirty little secret of medicine is that it requires it's providers screw up to learn.


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## DV_EMT (Nov 12, 2011)

Linuss said:


> I worked IFT for nearly a year before moving to 911.  I can't tell you how many simply mundane BLS calls turned in to a pseudo-911 ALS call. Treat each nursing home call as a 911. One day you might actually catch something and save a life... or make it slightly more bearable.  Little piece of advise:  SNFs aren't known for their ability to care for acute patients and pass big things off as "electrolyte inbalance"



That's the truth!!


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## Nervegas (Nov 12, 2011)

Linuss said:


> I worked IFT for nearly a year before moving to 911.  I can't tell you how many simply mundane BLS calls turned in to a pseudo-911 ALS call. Treat each nursing home call as a 911. One day you might actually catch something and save a life... or make it slightly more bearable.  Little piece of advise:  SNFs aren't known for their ability to care for acute patients and pass big things off as "electrolyte inbalance" ... especially since I can think of several potentially life threatening "electrolyte inbalances" that we can fix/change/reduce in the field. Hell, this patient very well could have had hyponatremia (lower BP, confusion) and while we can't "fix" it, giving NS (hypertonic would be better) can go some length at diminishing the symptoms/ preventing death for a little bit.



Or you could be dispatched to a "BLS" transfer out of a shall remain unnamed level 1 trauma center going to Childrens and when you get there the kid is breathing 50+, tachy at 150-180, using accessory muscles and wheezing like an 80 y/o smoker, the RT has given 35mg of albuterol and 3 of atrovent and there isnt any prednisone or solumedrol to be found, and during Tx the kid looks at you and tells you that they are tired and want to sleep now... yea, it isnt just nursing homes...


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## usalsfyre (Nov 12, 2011)

I'm discovering "specialty" hospitals (which we didn't have in the backwoods of East Texas) provide a whole 'nother level of "interesting" patients as well.


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## the_negro_puppy (Nov 13, 2011)

Giving IV normal saline is a simple task/concept but on a second glance is much more complex. The dynamics of fluid shifts, osmosis, electrolytes and different conditions and injuries need to be taken into account.

We don't give out much NS here. Its indicated for inadequate tissue perfusion/shock.

Just remember you can always titrate more fluids, err on the side of caution by giving less.


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## johnrsemt (Nov 16, 2011)

Be careful treating numbers:  I had an ED doc order 1L fluid bolus on me;  when I was in with Anaphalaxis due to my BP being at 92/50.   Didn't ask,  I had other things on my mind to ask why the high flow fluid.  Later when I was asleep (after 2nd attack, same stay in ED) same doctor ordered Dopamine, due to BP of 88/48.   
  I woke up when  the nurse bumped my arm, hanging the bag,  looked at it and pinched the line off myself and asked to see the Doctor.   The nurse got upset,   told me that she wouldn't get the doc until I let the IV go:  so I did, she left and I pulled the IV pole/pump closer and turned it off.
   When the doc came in I asked him if he takes patient hx before he orders extra meds;  when asked why I told him that my normal BP was 86-94/50.  He said that he wouldn't have thought of that because so few people are that low.  
    GET PATIENT HX before treating numbers.


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## BandageBrigade (Nov 16, 2011)

*Wait..stop.. What?*



paradoqs said:


> 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)



Im sorry, am I the only one who caught this? Is your partner a medic? If not, he has no business d/cing a med, told to by a nurse or not. Was this med supposed to be d/ced before transport? Was it finished infusing? If the answer to either of those is no then 2 emts had no business transporting this patient. Why did you not attempt to find out what med it was? You obviously had time and were able to figure out that it was a medication and not saline...


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## systemet (Nov 17, 2011)

DV_EMT said:


> 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.



So if they're hypotensive with pulmonary edema, it's not ok to raise their CVP / preload with fluid, but it's ok to do it by raising their legs?  

And at the same time, it's going to be just fine to compress the diaphragm, increase the intrathoracic pressure and reduce the FRC?


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## systemet (Nov 17, 2011)

paradoqs said:


> 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.



Ok.  You've got a little bit of a harsh reception, because some of the thing you did weren't that smart.  You can choose to be offended by that, or you can listen.  Judging by the fact that you recognised there was something to learn here, and posted a question, you're probably going to be a good EMT / medic.

You have some pretty major issues here:

* You didn't get an adequate history.  This is your job.  The LPN does not sound very professional or easy to deal with.  But you have to get the necessary information from her.  This may mean refusing to move the patient on to your stretcher before she gives you the details.  It may mean looking for an RN or a physician in the facility.  It may mean calling your supervisor and having them call the unit.  But you can't just take a patient like this (potentially an ALS patient, btw), without better information.  

* _Your partner d/c'd a medication, without orders, without finding out what the med was!?_  You're now responsible for finding out what the med was, whether it needs to be re-initiated, whether the patient should be going ALS, and exactly what's going on!  Would it mean something to you if that IV bag said "Dopamine 1600 ug/ul?", or "Cefuroxime 750mg"?

* You can't just throw your hands up in the air and say the LPN was unhelpful, or the sending facility were a bunch of retards.  This might be true, but it won't get you out of trouble if and when something goes wrong --- because, believe me, if you keep doing this, it will happen.  Someone will die, complaints will be made, the doctor's will circle the wagons, and unless there's demonstrable gross incompetence the attention will focus on the nurse's, the sending and receiving facilities and your company will all point fingers at each other, likely no one will get disciplined, but the one person left when the music stops without a get-out-of-jail-free card will be you!




> My original question restated is, where is that line between needs fluid resuscitation, and doesn't. (for hypovolemia)



This is a difficult question to answer, because it's not a set number:

*  Someone with a migraine headache may have a pressure of 150 systolic and benefit from a liter of fluid.  

*  Someone young with gastroenteritis who's been puking their guts out might benefit from a couple of liters but have a normal pressure.  

*  The hyponatremic marathon runner might just get pushed over the edge with a liter of saline.

*  Your decompensated CHFer may need dopamine more than fluid.

To try and answer, it depends on a couple of factors.

(1) Is there a current disease process that is likely to be improved by fluid administration?  -- here, we don't know what the disease process is, but it's sounding a lot like pneumonia.

(2) Is there a low risk that a current condition exists that would be worsened by fluid therapy?

(3) Does the potential benefit of fluid therapy outweigh the potential risk of fluid therapy in all situations, and if not, is the likelihood of a situation in which fluid therapy going to be detrimental small enough that you're willing to accept the risk for the patient?

With the situation described there's basically no history.  So it makes it really hard to answer any of these questions.  My suspicion is that this is a patient with pneumonia, that the med discontinued was likely an IV antibiotic, and that the "wet lungs" are probably rhonchi.  She's probably dehydrated, and probably not truly septic, although she might be.  If there's no history or indication of renal failure / CHF here, and other findings/history support dehydration, she'd get a 12-lead to do a quick due diligence check for STEMI, and I'd probably run through 500-1000ml fluid and reassess - depending on the 'lytes and how hypokalemic she is.  

[If the hypokalemia is truly that bad, I'd consider a call to the receiving facility regarding initiating potassium at the sending facility, while recognising that their response is probably going to be, just bring her here, she's been compensating for hours, 30 minutes will be ok, which it probably is.]


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## mikie (Nov 17, 2011)

*Thanks MIEMSS*

The only saline we give is in the flush (syringe), otherwise it's Lactated Ringers' for everyone!


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## DV_EMT (Nov 17, 2011)

systemet said:


> So if they're hypotensive with pulmonary edema, it's not ok to raise their CVP / preload with fluid, but it's ok to do it by raising their legs?
> 
> And at the same time, it's going to be just fine to compress the diaphragm, increase the intrathoracic pressure and reduce the FRC?




Hey, Im a basic... if their condition worsens...I can at least undo it by lowering their legs unlike you ALS guys... with your IV fluids an stuff


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