# Furosemide In Patients With Respiratory Distress



## Sasha (Feb 6, 2009)

I found an interesting study on the use of furosemide.

*Evaluation of prehospital use of furosemide in patients with respiratory distress.*
Full study is here: http://www.ncbi.nlm.nih.gov/pubmed/16531376


> Of the 144 included patients, a primary or secondary diagnosis of CHF was reported in 42% and 17% patients, respectively. The initial BNP was > 400 in 44% of the 120 patients in which this lab test was obtained. Sixty patients (42%) did not receive a diagnosis of CHF, 30 (25%) patients had a BNP < 200, and 33 (23%) had an order for IV fluid hydration. A diagnosis of sepsis, dehydration or pneumonia without a diagnosis of CHF or a BNP > 400 occurred in 17% of patients. Seven of the 9 deaths did not receive a diagnosis of CHF. *Furosemide was considered appropriate in 58%, inappropriate in 42% and potentially harmful in 17% of patients.*



If furosemide is being used inappropriately nearly half the time, should it remain available on a truck, especially where there's a short transport time? Should the protocols be rewritten to require better assesments to determine if furosemide is appropriate? I've seen some medics give lasix simply because lung sounds were a little raley.


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## Epi-do (Feb 6, 2009)

While I was at an audit and review in January, our medical director told us that our new protocols for 2009 will have lasix completely removed from our protocols.  Anywhere within the county you are no more than 10-15 minutes from an ER, and he believes that with transport times that short, there is no reason for us to be using it.  I know it has been a battle he has been fighting for the last couple years, and he sounded pretty happy to have finally won it.

Personally, I haven't really had the chance to do much research regarding it's use.  I will definately be reading the entire study you posted a little later, when I don't have to worry about being interrupted by runs.


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## Veneficus (Feb 6, 2009)

Sasha,

I think it goes back to proper assessment. When I last worked on the truck I went out and got a thermometer with the disposable tips because we did not have one on the rig. One of the FTOs flipped out and several medics made fun of me when I actually used it.

Not to be outdone I asked them if pneumonia was a contraindication for lasix. To which they agreed it was. I then asked how you would tell the difference between a new onset CHF and pneumonia. Basically I was told by history, which is not reliable. But I took it a step farther. (I really didn’t like this FTO he got his position by seniority not by merit) What if a patient with CHF had pneumonia? (a very common occurrence) Now is their primary problem the CHF or the pneumonia? How do you tell? How do you treat it?

Since apparently he didn’t have the answer I reminded him that pneumonia is an infection, which sets off an immune response. A general immune response includes a fever. CHF does not produce a fever. His retort was he “never heard of any self respecting medic take a temperature...” 

Temperature is a vital sign. Without a temp you do not even have a complete set of vitals. Every hospital patient gets a temp taken. It is a primary symptom in sepsis as well. (which was listed in the study) incidentally people focus in on SPO2 reading which is not a vital sign.

If a medic would not give morphine or nitro w/o a BP what is the reason he would give lasix w/o a temp?

The fact that 42% had a BNP considered to indicate possible or mild heart failure further demonstrates that clinical assessment of the patient’s condition was not accurate. I would hazard a guess this is because many medics do not see critically ill people very often, they are overreacting to the s/s they do see or in their initial education they are too focused on “if, then” statements. “If I see a patient with x and Y s/s, then I give furosimide.”

I think this study clearly demonstrates the need for more in-depth pathophysiology in medic education. As always, physical exam and history is a dying art.


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## Wyoming Medic (Feb 6, 2009)

We carry lasix here.  I cannot remember the last time that anybody pushed it.  IMO it (like has been said) is being used too often w/o fully grasping the concept.

Wy medic


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## daedalus (Feb 6, 2009)

Veneficous, what a great post. Most EMTs and Paramedics out here do not care for a physical exam. In fact, the attitude you described is more prevalent than it should be, and people do get made fun of for trying to preform a full assessment.


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## vquintessence (Feb 6, 2009)

One employer has told us not to carry personal thermometers because they're not "company approved" and we won't be covered for any liability...  what a load of croc.  Anyways, for the OP, I personally will NOT push lasix UNLESS #1)  definitive _rales_, not solely rhonchi, #2) there is significant respiratory distress c relatively recent/"sudden" onset #3) consider orthopnea?  #4) like Veneficus said, no fever.

Out here, we have the luxury of a max of ~30 min transport on our most distant town contract, otherwise it's typically about 10-15 min.  I would rather wait for a BNP to be obtained than push lasix "on a hunch".  Sure, the hospital can be slammed and the pt may wait a hell of a long time for those labs... but if that's the case... was the need for lasix imminent?


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## mycrofft (Feb 6, 2009)

*vquint your employer is absolutely correct*

Home care instruments are not approved for clincial use and you could be sued individually and as a representative of your company (if they let you continue to use such items) should a patient bring suit with a decent lawyer.
That "load of crock" comment...you use that on your boss?? And how'd that work out for you?

PS: and what about your patients?


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## reaper (Feb 7, 2009)

What about your scope, is that provided by your employer?  You can buy any thermometer that your service can buy. I don't think he was talking about the Walgreen's special!


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## Ridryder911 (Feb 7, 2009)

I have fallen out of practice with using Lasix as a first line treatment. It is not because I cannot differentiate between CHF and Pneumonia rather there is much better first line treatments available now. Current research is showing as well, that there is potential harm of administering Lasix in the first 20 minutes after administration. (read this months _JEMS_)

Although I understand the confusion of determining the differential of pneumonia and CHF, majority of the time it is not that difficult. Obtaining an accurate history is the key. History of increasing SHoB primarily nocturnal and increasing heaviness will occur at the night time. Patients history may have a history of cough, but pneumonia is usually associated with flu like symptoms prior. General malaise, pleuritic type pain (sharp, burning) and history of being febrile. 

The presentation as well is different. Right sided failure may have the classic pulmonary HTN of distended EJ's, HTN, and extreme edema. When the shift occurs, one will start having increasing shortness of breath with rales (crackles) and increasing dyspnea. Basically the patient will appear that they are drowning, (since they are at a alveolar level). 

I read the discussion of thermometer. I am for assessing temp.'s but DON"T be fooled about being febrile for a diagnostic tool. A lot of patients will actually be non- to hypothermic due to sepsis. Remember pneumonia can be viral and the most common is bacterial (community acquired).  

Obtaining a detailed and accurate history is the key of being be able to determine what is wrong with the patient, (as in all medical related calls). Occurrence time, associated symptoms (weight gain, swelling), related symptoms of feeling achy and ill, productive cough (purulent vs pulmonary edema -pink tinged). Lung sounds usually will have consolidation of upper rhonchi versus fluid. 

The difficulty I see is the presentation of both. Patients that have active CHF and as well have acquired pneumonia.  Yes, patients that have a lower immune system that now has pneumonia. 

In treatment, the immediate use of CPAP and use of NTG to decrease the preload is most accurate and beneficial treatment. Diuretic therapy does have its place, but more and more doubt is seen as an immediate treatment. Remember, it takes about twenty minutes for Lasix to take effect. Now, with that saying there is definitely some patients that needs diuretics to be administered as soon as possible. The key is being able to make that clinical decision. Alike all other treatment regime it needs to be individualized and should not be a cookie cutter protocol. Also remember, if one is on p.o. Lasix, the dosage needs to be re-calculated. 

Again, treat the patient appropriately. Patients usually never fall into just one specific protocol. Hence the reason its a practice, good clinical skills have to be obtained by practice and learning good interviewing and history taking techniques.

R/r 911


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## vquintessence (Feb 8, 2009)

mycrofft said:


> Home care instruments are not approved for clincial use and you could be sued individually and as a representative of your company (if they let you continue to use such items) should a patient bring suit with a decent lawyer.
> That "load of crock" comment...you use that on your boss?? And how'd that work out for you?
> 
> PS: and what about your patients?



Haha, no I use more tact with managment/coworkers/pts/etc, it's the "internet-thug" of me coming out here.    I had bought a mediocre thermometer w disposable tips a ways back.  You're right, it was not allowed in the company protocol like you said regarding "personal instruments" but yet the personal stethoscopes are ok.  MA OEMS doesn't cite anything for or against prehospital thermometers as far as I know.

But yeah mycrofft, after the talk with boss, it wasn't worth it by any means to lose my house should a lawsuit arise from the possibility of me giving pt an infection or impaling their oropharynx.


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## emtfarva (Feb 8, 2009)

vquintessence said:


> Haha, no I use more tact with managment/coworkers/pts/etc, it's the "internet-thug" of me coming out here.    I had bought a mediocre thermometer w disposable tips a ways back.  You're right, it was not allowed in the company protocol like you said regarding "personal instruments" but yet the personal stethoscopes are ok.  MA OEMS doesn't cite anything for or against prehospital thermometers as far as I know.
> 
> But yeah mycrofft, after the talk with boss, it wasn't worth it by any means to lose my house should a lawsuit arise from the possibility of me giving pt an infection or impaling their oropharynx.



just to let you know MA requires all als level units have a thermometer on the truck.


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## vquintessence (Feb 8, 2009)

emtfarva said:


> just to let you know MA requires all als level units have a thermometer on the truck.



I really doubt it's a requirement, unless you're talking about a regional requirement?  I assume you're region V?  None of the services I work for (region III and IV) carry thermometers, and the one that was mentioned prohibits them (company policy).  If you could show me the OEMS link I'd appreciate it, it would be great to show to my MD's and supers.  It would be disturbing to see blatant OEMS violations, as well as an additional policy against regulations.


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## BLSBoy (Feb 8, 2009)

So what would y'alls treatment modality be for a pt with CHF AND pneumonia? 

Nitro if systolic BP >100, and C-PAP?

Its cases like this that make me happy I have a doc thats just a phone call away.


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## firecoins (Feb 8, 2009)

BLSBoy said:


> So what would y'alls treatment modality be for a pt with CHF AND pneumonia?



you could always just take them to the hospital.


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## BLSBoy (Feb 8, 2009)

Hahahaha!

A loooooooong ways away!


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## firecoins (Feb 8, 2009)

BLSBoy said:


> Hahahaha!
> 
> A loooooooong ways away!



You could call Northstar.  I don't think they would like it but you could.


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## BLSBoy (Feb 8, 2009)

firecoins said:


> You could call Northstar.  I don't think they would like it but you could.



If there is a cloud in the sky, they don't fly. 

We had on of them the other day. On the 14th floor. In the furthest point of AC from ACMC-City. 

I went the cautious route, and monitored and treated. In the ER he got 40mg Lasix, and CPAP. And put out >2 liters in less then 30 min. 


D'oh:blush:


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## emtfarva (Feb 8, 2009)

vquintessence said:


> I really doubt it's a requirement, unless you're talking about a regional requirement?  I assume you're region V?  None of the services I work for (region III and IV) carry thermometers, and the one that was mentioned prohibits them (company policy).  If you could show me the OEMS link I'd appreciate it, it would be great to show to my MD's and supers.  It would be disturbing to see blatant OEMS violations, as well as an additional policy against regulations.



I am in reg. V. That is what I was told. I don't have evedence. our Bosses wanted thermometers put on als trucks.


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## Veneficus (Feb 8, 2009)

BLSBoy said:


> So what would y'alls treatment modality be for a pt with CHF AND pneumonia?
> 
> Nitro if systolic BP >100, and C-PAP?.



sounds good to me, some people like low dose morphine for CHF too, but as always there are opposing schools of thought. 

Unless the person is in 3rd or 4th stage CHF and you need to treat dehydration from pneumonia, it is not outrageous to give ~500ml/ ns as that will probably be third spaced anyway. 250 if you are conservative.

If they are in 3rd or 4th stage and you have to deal with dehydration, they go to ICU and the game is on. 

Once they get to the hospital, we can play the lasix/bumex/fluid game.


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## emtfarva (Feb 8, 2009)

BLSBoy said:


> If there is a cloud in the sky, they don't fly.
> 
> We had on of them the other day. On the 14th floor. In the furthest point of AC from ACMC-City.
> 
> ...



Boston medflight doesn't fly when the butterfly flaps to close to the windspeed indicater. no offence to medflight people only making a joke.


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## ffemt8978 (Feb 8, 2009)

Get back on topic, please


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