# Fluids for CHF?



## rhan101277 (Aug 19, 2009)

Our instructor was talking about an example of how to think of things different.  He said 99% of paramedics will say no to giving fluid to a CHF patient.

He gave me a new way of thinking of it, CHF patients who are decompensated will be hypovolemic, dehydrated etc. and it will get worse with a lasix dose.  He explained the fluid is there just in the wrong place.  So give them normal saline.


Now for people who haven't got to the decompensated point I do know.  Again this is just an example and this instructors opinion who is a flight medic.

Anyhow just wanted to see if any others have this thought

I am sure he probably has never done this, but it is just his thought.


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## ResTech (Aug 19, 2009)

I have heard that it is okay to give CHF patients a small fluid bolus if they are hypotensive and showing hemodynamic compromise. Maryland protocol indicates a 250mL bolus for CHF in these situations. 

I have yet to start cardiology (will next week) but it makes sense. I'm interested in hearing others thoughts as well.


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## Katie (Aug 19, 2009)

one of our instructors said a similar thing.  if your pt is hypovolemic/dehydrated and as ResTech said "showing hemodynamic compromise," then they need fluids.  but their respiratory status has to be monitored closely for obvious reasons.  really with any pt it's important to make sure they're not fluid overloaded, but with the CHF pt it's even more critical and a lot easier to do.


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## Akulahawk (Aug 19, 2009)

So what if the patient has CHF? If the patient happens to be decompensating because they're too hypovolemic, you treat them for the hypovolemia, but you have to modify the fluid administration to small boluses and watch for the effects. You just don't want to drive them to fluid overload. Then Lasix is appropriate... 

The problem is that many times these patients start off with the "tank" being a little dry to begin with. If they go too dry... but the question is: what are you treating the patient for? Their history of CHF? Or for the signs and symptoms of what they're presenting with now? with an eye towards their history?


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## MrBrown (Aug 19, 2009)

I'd give a small bolus (~250 to 500ml) to a patient in cardiogenic shock provided they don't have any serious crackles or hard out SOB.  If they became SOB / developed crackles I'd stop the fluid.


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## Ridryder911 (Aug 19, 2009)

One of the best scenario is a severe rectal bleeding (shocky state) with the patient also in severe CHF. I have had this unique call, and alike described one has to treat shock to maintain cellular functions. Now, with this comes responsibility to ensure fluids and respiratory compromise is closely monitored but in most cases a 250 ml bolus. Just alike those with a GI bleed or trauma in which CHF may be produced from; I may give Lasix in between administration of blood products. Many fail to remember that blood as well increases volume. 

R/r 911


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## rhan101277 (Aug 19, 2009)

Ridryder911 said:


> One of the best scenario is a severe rectal bleeding (shocky state) with the patient also in severe CHF. I have had this unique call, and alike described one has to treat shock to maintain cellular functions. Now, with this comes responsibility to ensure fluids and respiratory compromise is closely monitored but in most cases a 250 ml bolus. Just alike those with a GI bleed or trauma in which CHF may be produced from; I may give Lasix in between administration of blood products. Many fail to remember that blood as well increases volume.
> 
> R/r 911



How do you give a 250ml bolus if you only have 500ml fluid pouches?  Do you simply titrate?  Maybe just use a smaller gauge catheter.  Hmm I got a long way to go.


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## vquintessence (Aug 19, 2009)

rhan101277 said:


> How do you give a 250ml bolus if you only have 500ml fluid pouches?  Do you simply titrate?  Maybe just use a smaller gauge catheter.  Hmm I got a long way to go.



The gauge of the catheter simply dictates the rate at which you're able to infuse.  A 14ga will be able to infuse much faster than a 24ga.  The gauges (and locations of insertion sites) we choose are determined by what procedure is intended.

Regarding IV fluid sizes, yes you can infuse 250cc from a 500cc bag.  As long ast the container is larger than the intended purpose, it'll work.

Infusion rates all depend on situation and purpose.  Do they need it *now* for hemodynamic instability?  Then ideally get a 18ga+ and let it flow wide open.  Just go to KVO or whatever rate is required once your 250 bolus is achieved.  You've already addressed PMHx of CHF and other complicating factors dictating your vigilence of careful/continous lung auscultation along with your clinical judgement on how fast you truly want that bolus administered.

On the other hand, are you transporting a burn pt to another facility?  Then they'll need fluids over a longer period, so yes, titrate to appropriate rate.  (Some say the Parkland Formula is outdated, but it's worth looking at)  Anyways, chances are they've recieved plenty already if it's an IFT, but you still want to give an almost continous basis (initially).  Think of it like this:  You can drink 1L of water in the course of a day, and probably be sufficiently hydrated and only urinate a few times.  OR you can drink that 1L in twenty minutes, and piss most of it out, and possibly hurting yourself in the process.

Look up hyponatreamia.  It's vaguely related but pretty fascinating.


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## marineman (Aug 19, 2009)

rhan101277 said:


> How do you give a 250ml bolus if you only have 500ml fluid pouches?  Do you simply titrate?  Maybe just use a smaller gauge catheter.  Hmm I got a long way to go.



I have 2 options for that, first option is to watch the bag. All bags (that I've seen) have measurements on them so you can tell where you are. Once it get's down to 250 bring it down to KVO, this requires more operator input but all you have to do is pay attention to your patient which is what you should be doing anyway. My other option is to set up a pump to run a 250 bolus then switch to KVO. This doesn't require you to watch as much, just make sure the pump is operating correctly but takes a little bit longer to initiate. Most medics on my service don't like to use pumps on 911 calls but it's a tool that is there for us to use, I will use any tool I can to provide better patient care. 

Personally with CHF patients I will run a 100cc bolus then reassess, then run an additional bolus if indicated by patient condition. Nothing wrong with doing 250 at a time as those with much more experience than me are comfortable with it but I'm a little gun shy there.


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## mikie (Aug 19, 2009)

*Tko?*

Can someone explain KVO?  Is it the same as TKO? (not total knock out )   Is that different than "wide open?"  Thanks


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## vquintessence (Aug 19, 2009)

mikie said:


> Can someone explain KVO?  Is it the same as TKO? (not total knock out )   Is that different than "wide open?"  Thanks



KVO = keep vein open
TKO = to keep open

Totally interchangeable.


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## Akulahawk (Aug 19, 2009)

Actually, drinking 1L of water, in a healthy individual, won't cause hyponatremia. Regardless of how fast or how slow it is consumed. The reason for this is absorption time. It'll take about an hour or so for that water to be absorbed. It's when you drink far beyond your fluid losses that you can develop hyponatremia, and it develops over a few hours, when it's caused by water ingestion.


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## el Murpharino (Aug 19, 2009)

mikie said:


> Can someone explain KVO?  Is it the same as TKO? (not total knock out )   Is that different than "wide open?"  Thanks



KVO: Keep Vein Open
TKO:  To Keep Open

The drip rate is minimal - only to keep the vein open and to prevent obstructions from forming so future infusions will properly flow.  TKO and KVO are interchangeable.

Wide open:  to infuse the fluid as fast as the vein/cannula/gravity will allow


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## Shishkabob (Aug 19, 2009)

Are we talking treating PE caused by CHF, or just plain ol' treatment of CHF?

Fluid challenge, but at the same time, if you have them, use CPAP or PEEP.  

This should increase the pressure in the lungs, and combined with a lower pressure in the vessels because of the administered nitro / morphine, should help push the fluid back in to the blood vessels.


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## Akulahawk (Aug 19, 2009)

PE caused by CHF is one animal... however someone who is hypovolemic who has a history of CHF is another entirely different animal. Withholding fluids from someone who has CHF is a LOT like withholding O2 from someone who has COPD. Both can be very necessary to helping the patient, but you also have to watch for the side effects.


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## rescue99 (Aug 19, 2009)

rhan101277 said:


> How do you give a 250ml bolus if you only have 500ml fluid pouches?  Do you simply titrate?  Maybe just use a smaller gauge catheter.  Hmm I got a long way to go.



Bags have ml measurements marked. Burettes are available in some places which allows for a more controlled bolus without having to watch it quite as close.


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## Kendall (Aug 19, 2009)

Yes, IV bags are conveniently marked with fluid levels. I'm on board with marineman, I like to give 100mL boluses through a volutrol admin set and reassess.


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## Katie (Aug 19, 2009)

nevermind posted above


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## Ridryder911 (Aug 19, 2009)

el Murpharino said:


> KVO: Keep Vein Open
> TKO:  To Keep Open
> 
> The drip rate is minimal - only to keep the vein open and to prevent obstructions from forming so future infusions will properly flow.  TKO and KVO are interchangeable.
> ...



TKO and KVO is usually adjusted between 5 and 25ml/hr as stated to prevent the vein from clotting off. 

R/r 911


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## ResTech (Aug 19, 2009)

I always have to do a double take when I see PE referencing pulmonary edema. I believe PE is standardized to mean pulmonary embolism while APE, for acute pulmonary edema, is used to refer to CHF. 

How many are still using morphine for CHF? We dont have it as part of our protocol and I have been reading a lot of bad information on its use in CHF. We are using high dose nitro, captropril, and CPAP. 

Is ne one else using SL captopril for CHF?


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## Shishkabob (Aug 20, 2009)

We do Nitro .4 and Lasix .5-1mg/kg, and then we do titrated Morphine after we max on the Nitro.   CPAP and PEEP are also allowed.

Though there is a discussion some of us are having on a Texas EMS website where morphine induced respiratory depression with pulmonary edema is "bad".


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## ResTech (Aug 20, 2009)

Here is the Maryland high dose NTG protocol for CHF....

.4mg (preparing CPAP)
.8mg (Pt. education to CPAP)
.8mg (Pt. acclimatization to CPAP)

Total dose is 2mg... if B/P is greater than 110 then captropril follows it up. 

CPAP Not Tolerated - Nitroglycerin Dose 
(Dose at 3-5 minute intervals.)
(i) give 1 dose of 0.4 mg NTG 
(ii) give 1 dose of 0.8 mg NTG
(iii) give 1 dose of 0.8 mg NTG 
(iv) give 1 dose of 0.8 mg NTG
(v) give 1 dose of 0.8 mg NTG
(vi) give 1 dose of 0.8 mg NTG
(vii) complete dose= 4.4 mg
(viii) Then follow with captopril (SBP is equal to or greater 
than 110); administer albuterol (medical consult if 
there is cardiac history); and apply Nitroglycerin paste. 

Lasix is no longer in the protocols for Maryland nor is morphine (CHF).


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## Melclin (Aug 20, 2009)

Linuss said:


> should help push the fluid back in to the blood vessels.



You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.


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## el Murpharino (Aug 20, 2009)

Melclin said:


> You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.



The sad part is that what Linuss said is what many instructors are teaching about CPAP.  I've heard it in a few lectures and cringe when I think that there are providers out there who are going to take that information home.


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## Shishkabob (Aug 20, 2009)

Melclin said:


> You mean reduces preload by increasing intrathoracic pressure, splints the alveoli open and increases lung compliance.



I still don't see how my wording is wrong and yours is right considering it says basically the same thing...  semantics on the word "push" I guess.


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## Melclin (Aug 20, 2009)

Linuss said:


> I still don't see how my wording is wrong and yours is right considering it says basically the same thing...  semantics on the word "push" I guess.



Well in this case I think semantics is important. Bit like the difference between someone falling off a cliff and getting pushed off a cliff. 

Besides fluid isn't pushed of moved _back into the blood stream_ in any sense by the ventilation itself as far as I know. 

It stops the problem from getting worse (the pre-load part) and provides better gas exchange by splinting the airway and making inspiration easier amongst other things. If the fluid dissipates it is because there is no longer too much fluid where it shouldn't be to overwhelm the drainage capacity of the lymphatic system.

As always happy to be proven wrong by some decent evidence.


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## VentMedic (Aug 20, 2009)

Linuss said:


> I still don't see how my wording is wrong and yours is right considering it says basically the same thing... semantics on the word "push" I guess.


 
The word "push" is not correct terminology when discussing hemodynamics and cardiopulmonary pressures. 

Redistribution of fluids, primarily preload, through changing intrathoracic pressure and splinting of the airways.   The lymphatic system helps remove the fluid from the area.

CPAP has been around for at least 60 years. It has been used in home care for 30 years to reduce right heart failure. 

Google Scholar or any good medical search engine will give you a wealth of information. 




> The sad part is that what Linuss said is what many instructors are teaching about CPAP. I've heard it in a few lectures and cringe when I think that there are providers out there who are going to take that information home.


 
This goes with the lecture about Lidocaine numbing the heart.


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## Melclin (Aug 21, 2009)

> This goes with the lecture about Lidocaine numbing the heart.



Haha..oh....eh...oh dear. Never heard that little chestnut. That's quite disturbing.


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## Shishkabob (Aug 21, 2009)

Melclin said:


> Haha..oh....eh...oh dear. Never heard that little chestnut. That's quite disturbing.



Neither have I.  Rather freaky.


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## marineman (Aug 21, 2009)

We are not using morphine in our CHF/ Pulmonary edema treatment. We do have furosemide as well as nitro. We have no max dose on sublingual nitro as long as pulmonary edema is still noted and SBP is >100. We also have nitro paste that we can use.


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## medic_texas (Aug 25, 2009)

When people say things like "push the fluid back" or "numbing the heart"; I'm sure they are just repeating things they've heard from preceptors, instructors, or other uneducated morons who "know it all".  

We don't have CPAP on the ground units here.  NTG, Albuterol, Morphine, and Lasix are all in the protocol for CHF exacerbation with sedation/intubation if needed.  

Unfortunately, many medics rip through the protocol without waiting for relief just to intubate the patient.


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## VentMedic (Aug 28, 2009)

> This goes with the lecture about Lidocaine numbing the heart.





Melclin said:


> Haha..oh....eh...oh dear. Never heard that little chestnut. That's quite disturbing.


 

http://www.emtlife.com/showthread.php?t=9299


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## cm4short (Aug 28, 2009)

Our protocols don't list giving fluids to a CHF patient. Instead, we initiate CPAP or PPV a our first line treatment for the hypotensive CHF'er. For the hypotensive patient, we also give Dopamine under medical direction. 

A fluid bolus of 300ml can be administered with clear lung sounds(if you can get em) per out cardiac protocol, or a 500ml bolus per our shock protocol. But, I'd steer away form that one as I'll most likely end up drowning the patient in their own fluids.


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