# Gave a pt an entire bag of IV fluid the other day



## Dennhop (Feb 17, 2017)

So I gave a patient an entire bag of fluid the other day.




Pts distal circulation was crap, hands and fingers were cold, screwing with our pulse ox readings.  Figured giving her a bag of saline out of our warming drawer to hold would warm her fingers up to potentially allow pulse ox to read correctly.  It worked.  So then I gave my district Lt a heart attack later when I saw him and told him I went ahead and gave my BLS pt and bag of fluid.


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## STXmedic (Feb 17, 2017)

A bag really isn't all that much fluid, assuming they aren't a renal or CHF patient...

And did you not just have heat packs? Or, maybe, a bag of warmed saline for them to hold on to?...

And were you that concerned about hypoxia that you needed to start a line and give a fluid bolus just to get a number that, had it have actually been low, you should've been able to distinguish with a good assessment?


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## hometownmedic5 (Feb 17, 2017)

I don't get it. Why is administering salt water a big deal?


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## Dennhop (Feb 17, 2017)

STXmedic said:


> Or, maybe, a bag of warmed saline for them to hold on to?...



I went back through my post thinking maybe I had typed it wrong...But no, I typed it in right....This was exactly what I did...


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## STXmedic (Feb 17, 2017)

So you didn't infuse anything? So what's the point of this thread?


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## Dennhop (Feb 17, 2017)

Part humor.  Part reminder of using what you have available to work for you.  I do forget that Im not automatically identified on this forum as an EMT-B, so the humor gets lost a bit


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## hometownmedic5 (Feb 17, 2017)

Ok. I'm on to it now. I think I've sherlocked my way through this.

The OP, a BLS provider, gave their patient a bag of warmed saline to hold on to to warm their hands. Then, in an attempt to be pithy and clever, they told their supervisor that they "used"(having the subtextual connotation of "administered") a bag of saline on their patient, which would have been a no no as a basic. Then, I'm assuming based on the rousing, knee slapping response to this whiz banger of a joke they got at the station, it was taken on tour and presented here.

And boy am I glad I was here for the first performance...


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## Dennhop (Feb 17, 2017)

My fault...Didn't realize any attempt at humor on this board had to be pretty approved by the board of directors here.

Tough crowd.  Was planning on asking a few legitimate questions here, but seeing as how it appears that the attitude here is the same as in the services, where the old crowd and the new crowd don't seem to mingle well, I'll just hold my tongue and find my answers elsewhere.  Sorry to waste your precious time.


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## STXmedic (Feb 17, 2017)

I'm all for humor. Please, bring some. There just wasn't any in your post- only an intentional effort to be deceptive with your wording, making it sound like you did something you didn't. You also put it in the BLS sub-forum. Put your humor in the humor section and it may be better received.

And your questions are certainly welcome. There's a wealth of knowledge here from some very educated and experienced people. Just ask your questions directly and save the word play.


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## Gurby (Feb 17, 2017)

hometownmedic5 said:


> Ok. I'm on to it now. I think I've sherlocked my way through this.
> 
> The OP, a BLS provider, gave their patient a bag of warmed saline to hold on to to warm their hands. Then, in an attempt to be pithy and clever, they told their supervisor that they "used"(having the subtextual connotation of "administered") a bag of saline on their patient, which would have been a no no as a basic. Then, I'm assuming based on the rousing, knee slapping response to this whiz banger of a joke they got at the station, it was taken on tour and presented here.
> 
> And boy am I glad I was here for the first performance...



Ohhhhhhhhhh!  I missed the "to hold" part of the OP.

That's actually pretty hilarious.


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## VentMonkey (Feb 17, 2017)

Dennhop said:


> *Tough crowd*.  Was planning on asking a few legitimate questions here, but seeing as how it appears that the attitude here is the same as in the services, *where the old crowd and the new crowd don't seem to mingle well*, I'll just hold my tongue and find my answers elsewhere.  Sorry to waste your precious time.


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## VentMonkey (Feb 17, 2017)

@Dennhop, seriously man we're about the same age, lol don't take it too hard. It's still a good forum with a lot of relevance to questions you may have.

Don't take the razzing as anything but either good fun, flattery, or both. You're in for a painstakingly long career otherwise.


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## StCEMT (Feb 17, 2017)

Dennhop said:


> Was planning on asking a few legitimate questions here, but seeing as how it appears that the attitude here is the same as in the services, where the old crowd and the new crowd don't seem to mingle well, I'll just hold my tongue and find my answers elsewhere.



Not true. There are people on here who have been doing this for a long time, quite possibly since I was in diapers. They are more than willing to help me sort out this new medic business I'm in when I ask for advice and call me out when I say/do something stupid, both to help me learn. The people here aren't interested in wasting time on petty things for the sake of being ****s.


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## Tigger (Feb 18, 2017)

Wouldn't a hot pack have worked much better?


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## CALEMT (Feb 18, 2017)

So I'm new to the whole medic thing and I'm still in school learning how to medic. Isn't the trend nowadays to not give patients a whole bag of fluid?


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## hometownmedic5 (Feb 18, 2017)

CALEMT said:


> So I'm new to the whole medic thing and I'm still in school learning how to medic. Isn't the trend nowadays to not give patients a whole bag of fluid?



It depends. What are we treating? Some complaints will get small amounts of fluid. Some get lots of fluid.


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## CALEMT (Feb 18, 2017)

hometownmedic5 said:


> It depends. What are we treating? Some complaints will get small amounts of fluid. Some get lots of fluid.



Yeah that I get. Some patients you can't give them enough fluids (i.e. sepsis) and others you want to withhold giving an excess amount of fluid (i.e. a CHF'er). My question is what is this guy giving a whole liter a fluid for. Reading the posts I'm kinda fuzzy on whats going on here. Is he administering IV fluid or is he providing a warm object for the patient to hold.


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## StCEMT (Feb 18, 2017)

CALEMT said:


> Yeah that I get. Some patients you can't give them enough fluids (i.e. sepsis) and others you want to withhold giving an excess amount of fluid (i.e. a CHF'er). My question is what is this guy giving a whole liter a fluid for. Reading the posts I'm kinda fuzzy on whats going on here. Is he administering IV fluid or is he providing a warm object for the patient to hold.


Sounds like warm object to hold. Between me and city EMS, I ran about 900cc into a guy the other night by the time he got to an ED bed. No cardiac history and pressures 70-90 the entire ride.


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## medichopeful (Feb 18, 2017)

CALEMT said:


> Some patients you can't give them enough fluids (i.e. sepsis) and others you want to withhold giving an excess amount of fluid (i.e. a CHF'er). My question is what is this guy giving a whole liter a fluid for. Reading the posts I'm kinda fuzzy on whats going on here. Is he administering IV fluid or is he providing a warm object for the patient to hold.



Sepsis is a fine balance.  Overly aggressive fluid resuscitation in septic patients can actually be detrimental.  

In this scenario, nothing was infused.  He used a warm bag of fluids as a warm object.  Smart idea, but misleading post.


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## medichopeful (Feb 18, 2017)

Tigger said:


> Wouldn't a hot pack have worked much better?



Personally if they're not perfusing their peripheries well, I just like to go straight to pressors.  Jump the gun a little, you know, mix things up.  Keep it interesting.


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## E tank (Feb 18, 2017)

medichopeful said:


> Personally if they're not perfusing their peripheries well, I just like to go straight to pressors.  Jump the gun a little, you know, mix things up.  Keep it interesting.



A warm bag of dobutamine to hold...best of both worlds...


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## VentMonkey (Feb 18, 2017)

Agreed with @medichopeful regarding "liberal" fluid boluses in the septic patient. Oftentimes the sequence of events leads to interstitial fluid shifts in these patients bed confined in an ICU TMK. Ask any ICU nurse and I am sure they can attest to the nightmare that these patients can become. 

Where we fail with paramedic students is all too often we only teach a "treat what we see" method, and some people can't think beyond that; that's a huge problem for another thread if anyone wants to start an actual discussion on it. 

I think a good safe 1-2 liters of fluids before moving on to pressors is practical in the (extended transport) prehospital environment, but perhaps I'm just more conservative.

When I think aggressiveness of fluid delivery I often think of the DKA, or HHNK patient.


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## CALEMT (Feb 18, 2017)

VentMonkey said:


> When I think aggressiveness of fluid delivery I often think of the DKA



We just had this discussion in class, forgot to add it to my other post.


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## StCEMT (Feb 18, 2017)

VentMonkey said:


> When I think aggressiveness of fluid delivery I often think of the DKA, or HHNK patient.


Isn't the idea behind this increasing volume to dilute concentration?


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## CALEMT (Feb 18, 2017)

StCEMT said:


> Isn't the idea behind this increasing volume to dilute concentration?



Thats how it was explained to me in the case of DKA. Aggressive fluids to dilute blood glucose.


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## VentMonkey (Feb 18, 2017)

StCEMT said:


> Isn't the idea behind this increasing volume to dilute concentration?





CALEMT said:


> Thats how it was explained to me in the case of DKA. Aggressive fluids to dilute blood glucose.


There's also something to be said about renal perfusion. In the prehospital setting, sure dilute away, but remember these patients are often _severely_ dehydrated and dry as a bone (think "3 P's") as they often have symptoms such as increased N/V, and are metabolically acidotic.

In the hospital they're usually placed on maintenance fluids as well as insulin with a D5W gtt as sudden drops in their glucose is bad, especially in pediatrics (our Central Valley peds ED has a whole protocol for it); it leaves  them susceptible to cerebral edema. 

Listen to Bauer's podcast I posted in another thread, he talks about this exact patient population in the critical care transport environment.


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## StCEMT (Feb 18, 2017)

CALEMT said:


> Thats how it was explained to me in the case of DKA. Aggressive fluids to dilute blood glucose.


Yea, didn't know if there is ever a time we fill the tank and just let the body help remove stuff through urine or if dilution was the main idea.


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## CALEMT (Feb 18, 2017)

Well mimicking vents post the body is in overdrive trying to get the excess glucose out via the renal and respiratory system. The body compensates with increased breathing and increased renal output due to the acidosis. The kidneys care cranked up to level 10 and can't sustain that for X amount of time, so renal failure is a option. Which is why you dump fluids in so you can try to dilute the glucose and you can replace volume/ hydrate to try to take the workload off the kidneys. I can go further in depth, but this summarization is how it was explained during the endocrine lecture and makes the most sense for me. So I guess its a little of both St.


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## DesertMedic66 (Feb 18, 2017)

VentMonkey said:


> There's also something to be said about renal perfusion. In the prehospital setting, sure dilute away, but remember these patients are often _severely_ dehydrated and dry as a bone (think "3 P's") as they often have symptoms such as increased N/V, and are metabolically acidotic.
> 
> In the hospital they're usually placed on maintenance fluids as well as insulin with a D5W gtt as sudden drops in their glucose is bad, especially in pediatrics (our Central Valley peds ED has a whole protocol for it); it leaves  them susceptible to cerebral edema.
> 
> Listen to Bauer's podcast I posted in another thread, he talks about this exact patient population in the critical care transport environment.


What? You mean we should actually pay attention to signs and symptoms like polyphagia, polydipsia, and polyuria? What is this witchcraft. I just drive


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## medichopeful (Feb 18, 2017)

CALEMT said:


> Thats how it was explained to me in the case of DKA. Aggressive fluids to dilute blood glucose.



Kind of.  DKA patients are also absurdly dehydrated, leading to the need to rehydrate them.  But it has to be done carefully, because of all the fluid/electrolyte shifts.


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## Handsome Robb (Feb 18, 2017)

medichopeful said:


> Sepsis is a fine balance.  Overly aggressive fluid resuscitation in septic patients can actually be detrimental.
> 
> In this scenario, nothing was infused.  He used a warm bag of fluids as a warm object.  Smart idea, but misleading post.



I read something interesting recently regarding fluid resuscitation in septic patients, it made even have been on here. It was a number of "myths" that the Surviving Sepsis campaign has in their guidelines and one of them was aggressive fluid resus for everyone. We do 20mL/kg instead of 30 and start pressers really early. Like the same time we start the fluids early. 


Sent from my iPhone using Tapatalk


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## StCEMT (Feb 18, 2017)

Handsome Robb said:


> I read something interesting recently regarding fluid resuscitation in septic patients, it made even have been on here. It was a number of "myths" that the Surviving Sepsis campaign has in their guidelines and one of them was aggressive fluid resus for everyone. We do 20mL/kg instead of 30 and start pressers really early. Like the same time we start the fluids early.
> 
> 
> Sent from my iPhone using Tapatalk


Wasn't this part of an emcrit podcast on sepsis?


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## Handsome Robb (Feb 18, 2017)

StCEMT said:


> Wasn't this part of an emcrit podcast on sepsis?



I think you're right. 


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## Summit (Feb 18, 2017)

I chuckled


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## medichopeful (Feb 18, 2017)

CALEMT said:


> Well mimicking vents post the body is in overdrive trying to get the excess glucose out via the renal and respiratory system. The body compensates with increased breathing and increased renal output due to the acidosis. The kidneys care cranked up to level 10 and can't sustain that for X amount of time, so renal failure is a option. Which is why you dump fluids in so you can try to dilute the glucose and you can replace volume/ hydrate to try to take the workload off the kidneys. I can go further in depth, but this summarization is how it was explained during the endocrine lecture and makes the most sense for me. So I guess its a little of both St.



Pretty much correct.  The respiratory system doesn't blow off any glucose, however.

The issue with DKA is that the body can't use sugar for energy (due to the fact that insulin isn't there).  The patient will continue to eat sugar, however.  The body, in place of sugar, will break down fats for energy, which leads to the presence of ketones in the blood.  These ketones lead to a metabolic acidosis (hence the name, "diabetic ketoacidosis").  The body, sensing this imbalance in pH, attempts to compensate by blowing off excess CO2 (here is where you get Kussmaul's respirations).  That's why you should avoid RSIing a patient in profound DKA.  If they can't hyperventilate, they'll become even more acidotic and you'll be working an acidotic arrest.  Bad news bears.

When it comes down to the renal side, you're correct that renal failure is an option.  My understanding is that the mechanism behind the excessive urination is that in the renal system, the body will try to eliminate ketones and glucose through urinary excretion.  Glucose and ketones pull fluid with them when they are eliminated by the kidneys (oncotic pressure if I remember correctly?).  This is where you get the polyuria and, subsequently, polydipsia.  Electrolyte imbalances can then follow, which can be compounded by nausea and vomiting.  DKA patients are sick and critically ill.

Treatment of these patients involves fluid resuscitation/rehydration, and correction of electrolyte imbalances.  Insulin drips are started as well, sometimes only after fluid resuscitation is done.  Insulin drips and fluids are continued until the BGL reaches a certain level, then sugar (for example, D5W) is added to the fluids so the insulin drip can continue so that the anion gap can close.  Once the anion gap has closed and sugars are under control, the patient should be switched to sliding scale insulin.

Management of these patients isn't necessarily easy, and they need to be monitored very closely.  Electrolytes (especially K+) need to be monitored throughout treatment (remember, insulin drips lower potassium levels, and may lead to hypokalemia).  The whole process is actually fascinating.


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## medichopeful (Feb 18, 2017)

Handsome Robb said:


> I read something interesting recently regarding fluid resuscitation in septic patients, it made even have been on here. It was a number of "myths" that the Surviving Sepsis campaign has in their guidelines and one of them was aggressive fluid resus for everyone. We do 20mL/kg instead of 30 and start pressers really early. Like the same time we start the fluids early.
> 
> 
> Sent from my iPhone using Tapatalk



I think StCEMT is right.  I believe that was in an EMCrit podcast.

I also saw an interesting article on pressors in sepsis recently (possibly on EMCrit).  Although norepi is a great drug for sepsis, it isn't always the best.  I can't find the page, however.


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## medichopeful (Feb 18, 2017)

VentMonkey said:


> Agreed with @medichopeful regarding "liberal" fluid boluses in the septic patient. Oftentimes the sequence of events leads to interstitial fluid shifts in these patients bed confined in an ICU TMK. Ask any ICU nurse and I am sure they can attest to the nightmare that these patients can become.
> 
> Where we fail with paramedic students is all too often we only teach a "treat what we see" method, and some people can't think beyond that; that's a huge problem for another thread if anyone wants to start an actual discussion on it.



With enough fluids, I swear they start 4th and 5th spacing.  They seriously blow up like a balloon, which may then lead to issues with weaning, which leads to badness.

I'm going to start a discussion on the "treat what we see" issue that you pointed out.  I'd be interested to see what people's thoughts are on the issue.


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## Dennhop (Feb 22, 2017)

Tigger said:


> Wouldn't a hot pack have worked much better?



We don't carry hot packs, just the chemical cold packs.  Our truck is the only one in our service that happens to have a warming drawer, so the quickest way to warm up the pts extremities was to use a warm bag of fluid.  Winter time, we also started keeping a bag of d10 in there, as one of the medics on our truck had issues pushing air temp d10 one day.


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## Tigger (Feb 22, 2017)

Dennhop said:


> We don't carry hot packs, just the chemical cold packs.  Our truck is the only one in our service that happens to have a warming drawer, so the quickest way to warm up the pts extremities was to use a warm bag of fluid.  Winter time, we also started keeping a bag of d10 in there, as one of the medics on our truck had issues pushing air temp d10 one day.


How would you push D10? Must be a real bear to push room temp D50 then.


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## medichopeful (Feb 22, 2017)

medichopeful said:


> Pretty much correct.  The respiratory system doesn't blow off any glucose, however.
> 
> The issue with DKA is that the body can't use sugar for energy (due to the fact that insulin isn't there).  The patient will continue to eat sugar, however.  The body, in place of sugar, will break down fats for energy, which leads to the presence of ketones in the blood.  These ketones lead to a metabolic acidosis (hence the name, "diabetic ketoacidosis").  The body, sensing this imbalance in pH, attempts to compensate by blowing off excess CO2 (here is where you get Kussmaul's respirations).  That's why you should avoid RSIing a patient in profound DKA.  If they can't hyperventilate, they'll become even more acidotic and you'll be working an acidotic arrest.  Bad news bears.
> 
> ...



Was re-reading this thread, and realized I forgot to mention that long-acting insulin might be added in as well.


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## Dennhop (Mar 2, 2017)

Tigger said:


> How would you push D10? Must be a real bear to push room temp D50 then.



Can't say anything about d50, as we don't use it in our service.  As far as pushing d10, in my limited experience with it, I've only seen it pushed by squeezing the bag by hand through the line set.  I wasn't on the run, so I don't know what the situation was, but I do know it was a cold day, and room temp in the back of the truck may not have been optimal room temp.


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## bwat16 (Apr 26, 2017)

haha. tricked me


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