# Hypertonic saline



## E tank (Dec 23, 2016)

Hey all, 
Just throwing this out there purely for curiosity's sake...what are folk's experience with it? Under what conditions/circumstances is it used by HEMS or EMS? Is it initiated pre-hospital frequently or just continued IFT? 

Kind of a mundane question...


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## NomadicMedic (Dec 23, 2016)

Not at all in any EMS system I've worked in, nor have I heard of it being used in the field anywhere. Hard to justify without any labs, no?


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## Operations Guy (Dec 23, 2016)

E tank said:


> Hey all,
> Just throwing this out there purely for curiosity's sake...what are folk's experience with it? Under what conditions/circumstances is it used by HEMS or EMS? Is it initiated pre-hospital frequently or just continued IFT?
> 
> Kind of a mundane question...



I've only seen it be used in the IFT setting after labs. Reason is serum sodium levels cannot be measured in the field. Most of the time it was used on TBI patients with high ICP.


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## EpiEMS (Dec 23, 2016)

I've never seen it on any of the protocol or equipment lists I've read. I can't help but wonder if it is likely to be used without, say, an iStat? So maybe in a CCT setting, like @Operations Guy said.


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## WolfmanHarris (Dec 23, 2016)

Last I saw it prehospital was during a research trial a few years back. They halted it early due to complications and negative outcomes.


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## E tank (Dec 23, 2016)

EpiEMS said:


> I've never seen it on any of the protocol or equipment lists I've read. I can't help but wonder if it is likely to be used without, say, an iStat? So maybe in a CCT setting, like @Operations Guy said.



Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol  in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.


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## EpiEMS (Dec 23, 2016)

WolfmanHarris said:


> Last I saw it prehospital was during a research trial a few years back. They halted it early due to complications and negative outcomes.


Was it part of the ROC study?


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## WolfmanHarris (Dec 23, 2016)

EpiEMS said:


> Was it part of the ROC study?



Ya I think so.


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## Operations Guy (Dec 23, 2016)

I think 3% percent in the the ICU setting and 2% percent for IFT cause labs can be pushed out to 6 hours if Im not mistaken. Labs really need to be kept an eye on as overcorrection of serum sodium levels is common and have to be reversed with D5W or even oral water intake in extreme cases. Also last I heard it was given via central line and only peripheral IV while the patient is showing impending herniation.


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## EpiEMS (Dec 23, 2016)

E tank said:


> Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol  in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.



Very interesting! I think this is related to the aforementioned ROC study...but it seems like the evidence isn't particularly favorable?


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## VentMonkey (Dec 23, 2016)

The 3% our service carries is for predominantly IFT's, TMK. It isn't used a whole not, and in fact what we have now is on back order, but my partner managed to actually find some 3% to hold us over until the new year, which I don't see us using before then. The local hospitals seem to have a preference for Mannitol when we do pick up, and/ or transfer brain-injured patients. It's typically switched from their pumps to ours, and suffices for transport.

I was able to learn about how most of the more "cutting-edge" neuro ICU's seem to currently favor HTS over Mannitol through some of the CCP coursework I have done. @E tank if you have an article worth citing, I wouldn't mind taking a gander.


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## VFlutter (Dec 23, 2016)

We have considered replacing our Mannitol with 3% saline for TBIs.


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## Operations Guy (Dec 23, 2016)

VentMonkey said:


> The 3% our service carries is for predominantly IFT's, TMK. It isn't used a whole not, and in fact what we have now is on back order, but my partner managed to actually find some 3% to hold us over until the new year, which I don't see us using before then. The local hospitals seem to have a preference for Mannitol when we do pick up, and/ or transfer brain-injured patients. It's typically switched from their pumps to ours, and suffices for transport.
> 
> I was able to learn about how most of the more "cutting-edge" neuro ICU's seem to currently favor HTS over Mannitol through some of the CCP coursework I have done. @E tank if you have an article worth citing, I wouldn't mind taking a gander.[/QUOTE
> 
> Nevermind should of read the whole thing


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## Operations Guy (Dec 23, 2016)

E tank said:


> Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol  in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.



Are you talking about Hextend? If so it's a different beast then 3%. I have seen Hextend used in military applications but never civilian setting.


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## Operations Guy (Dec 23, 2016)

Here's an interesting read on Hextend from the army.

https://www.google.com/url?q=http:/...ggmMAs&usg=AFQjCNFm0HqbEDjemRTA7L5vbwgfQZnJZg


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## E tank (Dec 23, 2016)

Operations Guy said:


> Are you talking about Hextend? If so it's a different beast then 3%. I have seen Hextend used in military applications but never civilian setting.



The hetastarches (Hextend and Hespan) got a pretty good ride about 10 years ago because they were seen as a clean (non blood product) quick volume expander that stayed intravascular (about 40% of the infused volume over 24 hr). I used them a lot but they were implicated with AKI in critical patients and bleeding with doses over 20 or so ml/kg. But some of that data was from animal models and I think the Europeans made a statement  along those that more or less ended it's use. The FDA put out a warning and that was that. Too bad, to, because it was really useful.


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## E tank (Dec 23, 2016)

Operations Guy said:


> Here's an interesting read on Hextend from the army.
> 
> https://www.google.com/url?q=http:/...ggmMAs&usg=AFQjCNFm0HqbEDjemRTA7L5vbwgfQZnJZg



Well, leave it to the military to for a reasoned opinion based on good data. Would that private practice and academic medicine follow suit. Hate to sound pat and trite, but the defensive medicine bogey man strikes again, IMHO.


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## E tank (Dec 23, 2016)

Chase said:


> We have considered replacing our Mannitol with 3% saline for TBIs.


You'd be in good company.


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## VFlutter (Dec 23, 2016)

E tank said:


> You'd be in good company.



Unfortunately I believe the decision is based more on shelf life than actual efficacy of treatment.


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## E tank (Dec 23, 2016)

Chase said:


> Unfortunately I believe the decision is based more on shelf life than actual efficacy of treatment.



Well, if they get it right, who cares why


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## Operations Guy (Dec 23, 2016)

E tank said:


> The hetastarches (Hextend and Hespan) got a pretty good ride about 10 years ago because they were seen as a clean (non blood product) quick volume expander that stayed intravascular (about 40% of the infused volume over 24 hr). I used them a lot but they were implicated with AKI in critical patients and bleeding with doses over 20 or so ml/kg. But some of that data was from animal models and I think the Europeans made a statement  along those that more or less ended it's use. The FDA put out a warning and that was that. Too bad, to, because it was really useful.



Of course cause the European Medical and FDA opinions was based on civilian application and not it's designed application. It's application is proven and shown to be successful. Also European Medical and FDA groups where testing it on sepsis patients and patients already with one foot in the grave. I found its proper application outweighed all risk. The target of the application was healthy younger males with massive blood loss not little old ladies.


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## Brandon O (Dec 24, 2016)

Arguments against mannitol for elevated ICP include its rather potent osmotic diuresis (requiring vigorous fluid repletion to avoid hypovolemia, which is not desirable in these people).

Arguments for are mainly that it's perceived as being safe in peripheral lines. Hence, mannitol until you get a central line, then perhaps hypertonic, would be one approach.

(Hypertonic is contraindicated via IO in some places, but I don't think this position is well supported.)


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## E tank (Dec 24, 2016)

Brandon O said:


> Arguments against mannitol for elevated ICP include its rather potent osmotic diuresis (requiring vigorous fluid repletion to avoid hypovolemia, which is not desirable in these people).
> QUOTE]
> 
> Nah...there's more than giving volume to maintain CPP. Besides, neurosurgeons absolutely love dry patients. Gives the nephrologists something to do


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## Brandon O (Dec 24, 2016)

E tank said:


> Nah...there's more than giving volume to maintain CPP. Besides, neurosurgeons absolutely love dry patients. Gives the nephrologists something to do



Hmm... no neurosurgeons I've met. (Actually, I haven't found any that care very much -- they leave silly things like fluid balance to us ICU types.)

Neurocritical care folks do like their phenylephrine, but trying to respond to hypovolemia with anything but volume is really an uphill battle no matter your setting.


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## E tank (Dec 24, 2016)

Brandon O said:


> Hmm... no neurosurgeons I've met. (Actually, I haven't found any that care very much -- they leave silly things like fluid balance to us ICU types.)
> 
> QUOTE]
> 
> How do you manage volume replacement in crani patients (post aneurysm clipping or tumor excision?)


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## Brandon O (Dec 24, 2016)

E tank said:


> How do you manage volume replacement in crani patients (post aneurysm clipping or tumor excision?



Need a bit more detail there... are we talking about patients who are herniating and receiving mannitol or hypertonic (per the above discussion)? Patients with DI? Routine postop care?


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## E tank (Dec 24, 2016)

Brandon O said:


> Need a bit more detail there... are we talking about patients who are herniating and receiving mannitol or hypertonic (per the above discussion)? Patients with DI? Routine postop care?



Patients getting mannitol. How do you guide fluid management?


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## Alan L Serve (Dec 25, 2016)

Even in the ER hypertonic saline is only used under carefully controlled and monitored situations. Even then it's only done 15mL at a time. Even then it's only with close serial Na+ monitoring in PTs who are seizing due to hyponatremia. Even then there are often other options.


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## Brandon O (Dec 25, 2016)

E tank said:


> Patients getting mannitol. How do you guide fluid management?



Essentially like anybody else: fluid or pressors based upon your assessment of their fluid responsiveness and based upon your BP/CPP goals (surgeons do have an opinion about that!); but with the recognition that if their urine output is high they likely need volume to replace it. Would follow labs but likely start with NS.

That being said we tend to use more hypertonic used, at least after the initial phase (and after somebody gets a line in).

This is not really my strength BTW so I welcome input from anyone with a stronger background in neurocritical care.


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## E tank (Dec 25, 2016)

Brandon O said:


> Essentially like anybody else: fluid or pressors based upon your assessment of their fluid responsiveness and based upon your BP/CPP goals (surgeons do have an opinion about that!); but with the recognition that if their urine output is high they likely need volume to replace it. Would follow labs but likely start with NS.
> 
> That being said we tend to use more hypertonic used, at least after the initial phase (and after somebody gets a line in).
> 
> This is not really my strength BTW so I welcome input from anyone with a stronger background in neurocritical care.



I was just asking, because the point of hyperosmolar therapy is to shrink the brain not only for treatment of intracranial htn, but also to maximize exposure for the surgeons in the operating room, giving a "slack brain" to work with and minimizing post op cerebral edema. Volume management is only to avoid hypovolemia, and that is a pretty broad spectrum. Euvolemia with a rising CVP defeats the purpose. Surgeons can tell just by looking at the brain that too much fluid has been given, which can be a very reasonable and modest amount even with conventional replacement strategies are used. Pretty challenging to get just right. 

It's a pretty broad topic to be discussed in forum format, I just wanted to get a feel for what folks do.


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## E tank (Dec 25, 2016)

Alan L Serve said:


> Even in the ER hypertonic saline is only used under carefully controlled and monitored situations. Even then it's only done 15mL at a time. Even then it's only with close serial Na+ monitoring in PTs who are seizing due to hyponatremia. Even then there are often other options.



You probably use HTS for folks with subarachnoid bleeds as well. There's a difference correcting serum Na too quickly for hyponatremia and using it for a SA bleed/ herniation rescue. In that case, taking the sodium up to even the mid 150's hasn't been shown to be detrimental.

It can get confusing when the seizures are being caused by a bleed v. hyponatremia. Different deal.


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## Brandon O (Dec 25, 2016)

E tank said:


> I was just asking, because the point of hyperosmolar therapy is to shrink the brain not only for treatment of intracranial htn, but also to maximize exposure for the surgeons in the operating room, giving a "slack brain" to work with and minimizing post op cerebral edema. Volume management is only to avoid hypovolemia, and that is a pretty broad spectrum. Euvolemia with a rising CVP defeats the purpose. Surgeons can tell just by looking at the brain that too much fluid has been given, which can be a very reasonable and modest amount even with conventional replacement strategies are used. Pretty challenging to get just right.
> 
> It's a pretty broad topic to be discussed in forum format, I just wanted to get a feel for what folks do.



Sure. I haven't heard the neurosurgeons in our neck of the woods ask for us to keep these folks dry; practice may differ. Once they decompress, they tend to leave the skull open for a long time (months), so there's no real need to vigorously shrink the parenchyma.


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## LaAranda (Dec 25, 2016)

Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.


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## NomadicMedic (Dec 25, 2016)

LaAranda said:


> Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.



Wow. Istat in the truck? I'd be interested in seeing the whole set of protocols. I'd bet there's some other gems in there.


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## LaAranda (Dec 25, 2016)

DEmedic said:


> Wow. Istat in the truck? I'd be interested in seeing the whole set of protocols. I'd bet there's some other gems in there.



Yes, it's a neat service - met a few folks who have worked there. Not sure if they have other therapies available for other abnormal labs, although I believe they check trops.


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## Alan L Serve (Dec 26, 2016)

LaAranda said:


> Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.


100mL bolus of hypertonic saline=death


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## Operations Guy (Dec 26, 2016)

Per Emsworld Nov 1 2013

"As a current example, Grand Canyon National Park, which has a large number of heat-illness patients, is working on a treatment protocol for hyponatremia that involves infusion of a hypertonic saline solution based on some the latest treatment research. They have a local medical control physician who has researched this topic and developed the protocol with NPS staff at the Grand Canyon. It is currently being reviewed at Fresno for final approval, as are any park-specific protocols."


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## LaAranda (Dec 26, 2016)

Alan L Serve said:


> 100mL bolus of hypertonic saline=death



Not in a pt. with severe acute exercise-induced hyponatremia. This is a very specific clinical context; these are not geriatrics with severe kidney disease, they're healthy 30 year olds who went from baseline to serum sodiums in the 110s in only a few hours. Rapid correction is indicated.


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## Alan L Serve (Dec 26, 2016)

LaAranda said:


> Not in a pt. with severe acute exercise-induced hyponatremia. This is a very specific clinical context; these are not geriatrics with severe kidney disease, they're healthy 30 year olds who went from baseline to serum sodiums in the 110s in only a few hours. Rapid correction is indicated.



If you do 100mL slowly over 10 minutes or so you'd be ok. That's not a "bolus".


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## LaAranda (Dec 26, 2016)

Alan L Serve said:


> If you do 100mL slowly over 10 minutes or so you'd be ok. That's not a "bolus".



I will reach out for the exact protocol. I believe it's given quicker than 10 minutes. Running a burette wide-open for a few minutes isn't a bolus because it's not pushed? Do you think the term 'fluid bolus' is widely misused/misunderstood then?


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## Alan L Serve (Dec 26, 2016)

LaAranda said:


> I will reach out for the exact protocol. I believe it's given quicker than 10 minutes. Running a burette wide-open for a few minutes isn't a bolus because it's not pushed? Do you think the term 'fluid bolus' is widely misused/misunderstood then?


Let's leave the argument over "bolus" behind and focus on the actual volume over time. I feel rather confident that 100mL over 10 minutes is OK only for severe hyponatremia. Higher volume or faster infusion is likely to cause cerebral edema.


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## VentMonkey (Dec 26, 2016)

LaAranda said:


> Running a burette wide-open for a few minutes isn't a bolus because it's not pushed? Do you think the term 'fluid bolus' is widely misused/misunderstood then?


Perhaps "rapid infusion" is the more appropriate term? 

Either way, still an interestingly unique sounding set of protocols. Please feel free to share them when you do find them.


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## NomadicMedic (Dec 26, 2016)

It is interesting. Have you all seen the emcrit blog post about using sodium bicarb in place of 3% HTS? 

I'm also intrigued by the Parkmedic certification. Park rangers, trained up to the level of AEMT, with extra skills and expanded formulary. That sounds fascinating.


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## VentMonkey (Dec 26, 2016)

DEmedic said:


> It is interesting. Have you all seen the emcrit blog post about using sodium bicarb in place of 3% HTS?
> *I have not. Admittedly, I am behind on my podcasts, and due for a binge session.*
> I'm also intrigued by the Parkmedic certification. Park rangers, trained up to the level of AEMT, with extra skills and expanded formulary. That sounds fascinating.
> *This does sound kind of cool. Do you think this would be a worthwhile use of this providers skill set? I am pretty naive to the true ways the AEMT functions.*


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## DesertMedic66 (Dec 26, 2016)

DEmedic said:


> It is interesting. Have you all seen the emcrit blog post about using sodium bicarb in place of 3% HTS?
> 
> I'm also intrigued by the Parkmedic certification. Park rangers, trained up to the level of AEMT, with extra skills and expanded formulary. That sounds fascinating.


I was just reading up on that too. If I lived close to a huge national park I would almost be sold on applying.


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## TXmed (Dec 26, 2016)

DEmedic said:


> It is interesting. Have you all seen the emcrit blog post about using sodium bicarb in place of 3% HTS?.



Ive heard some promisimg things about sodium bicarb for head injury with seizures or one blown pupil as a quick rescue. But his has to be given as a fast bolus.


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## TXmed (Dec 26, 2016)

https://www.ncbi.nlm.nih.gov/pubmed/20422466


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## E tank (Dec 26, 2016)

DEmedic said:


> It is interesting. Have you all seen the emcrit blog post about using sodium bicarb in place of 3% HTS?
> 
> I'm also intrigued by the Parkmedic certification. Park rangers, trained up to the level of AEMT, with extra skills and expanded formulary. That sounds fascinating.



yeah, that's a good article. He points out that an amp of 8.4% bicarb has the osmolar equivalent of 6% NaCl which is a really quick way to set up the osmolar gradient from brain to blood.

What I found more interesting was his pointing out that there is a lot of hesitation to push 100 ml of  even 3% HTS when we give amp after amp of bicarb as fast as we can.


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## StCEMT (Dec 26, 2016)

Have y'all seen any places start implementing bicarb as a standard treatment for increased ICP? 

And what about Lidocaine? I remember being taught about it as a pre-intubation med for these cases, but I don't think I ever actually read if it made a appreciable difference. Time to google.


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## Operations Guy (Dec 26, 2016)

DesertMedic66 said:


> I was just reading up on that too. If I lived close to a huge national park I would almost be sold on applying.



I can think of a couple out in your neck of the woods. Also dont forget Bureau of Land Mismanagement and Forest Circus have their Law Enforcement trained to similar standards.


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## DesertMedic66 (Dec 26, 2016)

Operations Guy said:


> I can think of a couple out in your neck of the woods. Also dont forget Bureau of Land Mismanagement and Forest Circus have their Law Enforcement trained to similar standards.


The only parks around here are at the EMR or EMT level. Didn't pay $4,000+ for a paramedic education to work as an EMT.


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## E tank (Dec 26, 2016)

LaAranda said:


> Not in a pt. with severe acute exercise-induced hyponatremia. This is a very specific clinical context; these are not geriatrics with severe kidney disease, they're healthy 30 year olds who went from baseline to serum sodiums in the 110s in only a few hours. Rapid correction is indicated.



How rapid we talking here? Osmotic demyelination is the consequence of doing that, and there is a definitive way of avoiding it,  but 3% NaCl can go in a lot quicker without difficulty. 

It isn't the amount of sodium per se that is the issue, it is the wide swing in serum osmolality that is theorized to do the damage. Patients tolerate sodiums of mid 150's without demonstrable difficulty and if my math figures (someone will check it, I'm sure), 100 mls of 3% NaCl will bump serum sodium by about 6, and in a patient with a normal sodium, that isn't enough for a dangerous osmotic swing.

 FWIW, an amp of bicarb wil bump serum sodium by 2-3.


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## E tank (Dec 26, 2016)

StCEMT said:


> Have y'all seen any places start implementing bicarb as a standard treatment for increased ICP?
> 
> And what about Lidocaine? I remember being taught about it as a pre-intubation med for these cases, but I don't think I ever actually read if it made a appreciable difference. Time to google.



the oral board answer is that the lidocaine is for attenuation of sympathetic response to direct laryngoscopy and therefore the increase in ICP from being intubated. Timing is important and it doesn't hurt and it might help. Really important when intubating someone with an intracranial bleed to do that one way or another, while at the same time not bottoming out the MAP.


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## Operations Guy (Dec 26, 2016)

DesertMedic66 said:


> The only parks around here are at the EMR or EMT level. Didn't pay $4,000+ for a paramedic education to work as an EMT.



I can think of a couple off the top of my head. Lake Mead recreational area, Joshuah Tree, and all those wilderness areas that BLM runs. Most of them will post as a Law Enforcement position but it's dual role. Might have to put in some years as a seasonal Law Enforcement but once you hit gs-6 or have preference points Or LE trained  your offered full time. Also plenty of colleges offer a Park Service Law Enforcement course which gives you the certification to go out and get a job as a certified LE. Also Federal Law Enforcement Training Center will get you the needed certification to get the job. They make a point of making it hard to get a joB


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## Operations Guy (Dec 26, 2016)

@DesertMedic66
This is mostly geared towards seasonal but
https://www.fleta.gov/accreditation/program/seasonal-law-enforcement-training-program

agencies that hire full time send people to FLETC. For 18 week federal law enforcement academy.


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## LaAranda (Dec 26, 2016)

Alan L Serve said:


> Let's leave the argument over "bolus" behind and focus on the actual volume over time. I feel rather confident that 100mL over 10 minutes is OK only for severe hyponatremia. Higher volume or faster infusion is likely to cause cerebral edema.



Agreed re: bolus. Also agree that the specific rate is very important; i'll report back when I have more.



VentMonkey said:


> Perhaps "rapid infusion" is the more appropriate term?
> 
> Either way, still an interestingly unique sounding set of protocols. Please feel free to share them when you do find them.



That might make more sense. It seems people (myself included) play fast and loose in talking about fluid "boluses" whenever crystalloids are administered wide open w/o a specified drip rate. I think I see this referred to most commonly as a bolus, but I'd be interested in a more technical understanding.


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## E tank (Dec 26, 2016)

Alan L Serve said:


> Let's leave the argument over "bolus" behind and focus on the actual volume over time. I feel rather confident that 100mL over 10 minutes is OK only for severe hyponatremia. Higher volume or faster infusion is likely to cause cerebral edema.


 
Not to nit pick, and with all due respect,  but cerebral edema is not a risk here. The osmotic gradient that is produced with HTS will draw water from the brain.


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## VFlutter (Dec 26, 2016)

E tank said:


> Not to nit pick, and with all due respect,  but cerebral edema is not a risk here. The osmotic gradient that is produced with HTS will draw water from the brain.



I am guessing he was referring to over correction of hyponatremia however as you pointed out cerebral edema is not the issue, but rather ODM/CPM.


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## E tank (Dec 26, 2016)

Chase said:


> I am guessing he was referring to over correction of hyponatremia however as you pointed out cerebral edema is not the issue, but rather ODM/CPM.



Right, but even then, 100 ml of 3% is unlikely to do that.


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## VFlutter (Dec 26, 2016)

E tank said:


> Right, but even then, 100 ml of 3% is unlikely to do that.



Based off MDCalc 3% NS @ 103 ml/hr will increased serum sodium by 1 mmol/hr in an elderly 80kg Male with a sodium of 115. 1 mmol/hr is aggressive but may be appropriate if severely symptomatic. But I agree that 100ml is unlikely to cause issues, it would take more than that.


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## DesertMedic66 (Dec 26, 2016)

Operations Guy said:


> I can think of a couple off the top of my head. Lake Mead recreational area, Joshuah Tree, and all those wilderness areas that BLM runs. Most of them will post as a Law Enforcement position but it's dual role. Might have to put in some years as a seasonal Law Enforcement but once you hit gs-6 or have preference points Or LE trained  your offered full time. Also plenty of colleges offer a Park Service Law Enforcement course which gives you the certification to go out and get a job as a certified LE. Also Federal Law Enforcement Training Center will get you the needed certification to get the job. They make a point of making it hard to get a joB


Lake Mead is 6 hours away for me which is not something I would be able to afford. Joshua tree rangers are not ALS. 

The rangers in the Ocotillo Wells area are not ALS. The "medical responders" out there are called "desert lifeguards". In the summer months they are assigned to lifeguard duties and in the winter they are put at the off-road areas. 

The rangers in the San Jacinto mountains are EMR/EMT and not ALS (we meet up with them very often)


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## E tank (Dec 26, 2016)

Chase said:


> Based off MDCalc 3% NS @ 103 ml/hr will increased serum sodium by 1 mmol/hr in an elderly 80kg Male with a sodium of 115. 1 mmol/hr is aggressive but may be appropriate if severely symptomatic. But I agree that 100ml is unlikely to cause issues, it would take more than that.



Yah...I never know what to make of those calculators. Maybe its the extreme example of 115. But in clinical practice where there are many multiples of dynamics occurring in the critically ill, sometimes experience and theory don't match up...as an example, in the rare circumstance of giving several amps of bicarb, say three to five, what you give there is essentially 2 % NaCl and the sodium bumps several points in a very short period of time, such that you need to be careful of creating a hypernatremia.


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## Alan L Serve (Dec 26, 2016)

Alan L Serve said:


> Let's leave the argument over "bolus" behind and focus on the actual volume over time. I feel rather confident that 100mL over 10 minutes is OK only for severe hyponatremia. Higher volume or faster infusion is likely to cause *OSMOTIC DEMYELINATION*.


I deleted cerebral edema as it was clearly incorrect. In its rightful place now sits ODS.



> Previous observational studies reported from our institution have shown that ODS can usually be avoided in severely hyponatremic patients by limiting correction rates to no more than 12 mEq/L in 24 h and 18 mEq/L in 48
> *Hypertonic Saline for Hyponatremia: Risk of Inadvertent Overcorrection *
> 
> http://cjasn.asnjournals.org/content/2/6/1110.full


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## LaAranda (Dec 27, 2016)

Great discussion all around. Here's the 3% protocol -- thanks for your patience.



> *Indications*: Serum sodium <135 mmol/L with ALOC or seizure activity; Serum sodium ≤128 Note: Hyponatremia needs to be acute onset (excessive fluid intake within the past 24 hours)
> *Contraindications*: Suspected chronic hyponatremia (CHF, liver cirrhosis)
> *Dosage*: 100ml 3% saline bolus x3 q 10 minutes using burette set. Administer each bolus with drip chamber wide open. Administer all 3 boluses. Check 2nd iStat after full dose administered.
> *Note*: Rapid correction of hyponatremia that is not acute can cause permanent damage of the nervous system. Conditions that can cause chronic hyponatremia include heart failure, cirrhosis, renal failure, cancer, adrenal insufficiency, and certain medications. A thorough history is the best means of determining the cause of the patient’s hyponatremia. Generally, a history of ingesting large amounts of unmixed water throughout the day in conjunction with physical exertion suggests acute hyponatremia. Be sure to obtain follow-up iStat values after administration of hypertonic saline. Every 100mL of hypertonic saline will correct a patient’s serum sodium by 1-2 mEq/L.
> ...



So the the actual infusion rate is 100ml/~3min, q 10 min.


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