Fluid resuscitation

[emt4life]

I am curious as to how aggressively your service treats hypotension?

Here is why I ask:

46y/o M described by family as a "heavy drinker" who stopped drinking approx 3 days prior to your call. This day the pt was loading things into a truck when he had a syncopal episode and "seizure like" activity. Family states it was approx 15 min prior to him coming around enough to get up. Family also states pt has not been eating or drinking much of anything the last couple of days due to not feeling well. When you speak to the patient he is seated in the truck and is lethargic, slightly confused. He denies any pain anywhere, states only that he feels tired.

Your first set of vitals are BP 86/52, P 72, R 12, SaO2 99% on 10L/min (once you are able to warm his fingers). No past medical history except drinking, no meds, no allergies. Pt is still very lethargic, but opens his eyes when you ask him to.

What would you do as far as treatment?

And how long can after a "heavy drinker" stops drinking can he experience withdrawls or DT's?

 

[Ridryder911]

First this is not a hypotension situation. This is an association with Delirium Tremors (DT's) and the patient is post ictal. As well as probably dehydration and associated electrolyte imbalance and poor nutrition .

The patient is need of fluid therapy with associated electrolytes (remember those cations and anions? ) so a little D50w (2 amps (50mg) into a 1 Liter of NSS (D25w) and Mg+, Thiamine(100mg IV and 100 mg into the liter of saline) .. It is not a Rally pack but similar. Infuse over an hour. One needs to be sure to administer the Thiamine before administration of high concentration glucose, due to Wernicke's encephalopathy. One needs to be cautious of administering high volumes of fluid in alcoholics due to portal hypertension and possible underlying CHF. As well, they are prone to bleeds (GI, Esophageal Varices, Hep C and G.I. and head bleeds.

Monitor ECG since your are giving Mg+ and for seizures , and cautiously give either Ativan or Valium.

Patients usually start having alcohol withdraws anywhere from 24 to 72 hours. Common average is 48-72 hours after the last ingestion .. all dependent upon the metabolism, the quantity of ETOH.. etc.

R/r 911

 

[trauma1534]

We are very agresive with everything... or atleast we were taught to be. Some are not. For this situation, I would establish an IV line, listen to lung sounds, if clear, go ahead and give a 500cc fluid bolus, then run @ KVO, if there is an improvement. We only cary Normal Saline on our trucks, so that's what it would be. If the B/P continued to drop, I would trendelenburg. Also, you want to keep a check on the lung sounds for fluid. Watch sats and B/P and mental status. I would also obtain a Blood sugar, as I do with every patient as a part of my vitals. If low, treat accordingly.

 

[Ridryder911]

I am curious why you think he is shocky ? ...(Saline tx. is not agressive Hespan, or Polyheme, or O- is agressive treatment)

R/r 911

 

[Fedmedic]

I am curious why you think he is shocky ? ...(Saline tx. is not agressive Hespan, or Polyheme, or O- is agressive treatment)

R/r 911

Polyheme or Hespan is aggressive treatment if dealing with hemorrhagic shock, usually secondary to trauma. But this patient is not a trauma patient therefore normal saline or ringers would be the fluid of choice that we carry in the field.

 

[Fedmedic]

First this is not a hypotension situation.
R/r 911

Actually, unless this guys BP is normally this low, this is a hypotension situation. It may be secondary to DT's or dehydration, but it is still treated as such in the field. Paramedics aren't allowed to diagnose, therefore we treat supportingly according to signs, symptoms and physical assessment. Of course we always should know what is going on, but this shouldn't alter our treatment is patient presents with such. Either way, the family stated he had not been eating or drinking for the last couple of days and now he is having DT's with associated hypotension. I'm sure he is probably dry and could use some fluids.

And as far as the diagnosing in the field. We should never start doing that unless we start doing lab work, abg's, CT's, x-rays, MRI's and a whole lot more diagnostic testing MD's in the ER use to make a diagnosis.

Got to run insulin line...be back later

 

[emt4life]

My thought and the way I treated it was as he was post ictal from a withdrawl seizure and hypotensive due to dehydration, so here's what I did:

-O2
-Vitals
-ECG and 12 lead (nothing significant)
-IV 18g in AC
-BGL - 181mg/dl (from the IV stick)
-IV running open for a 200ml NS bolus (it was pretty positional, so it took a while to go in) and when calling into the hospital they asked to keep the fluids running, so I changed the bag, since what we primarily administer 250ml bags
-was prepared to give him ativan if needed

Anything else I should have done?

Thanks for the info on DT's and withdrawl, around here you don't often deal with those who actually stop drinking.

 

[Fedmedic]

My thought and the way I treated it was as he was post ictal from a withdrawl seizure and hypotensive due to dehydration, so here's what I did:

-O2
-Vitals
-ECG and 12 lead (nothing significant)
-IV 18g in AC
-BGL - 181mg/dl (from the IV stick)
-IV running open for a 200ml NS bolus (it was pretty positional, so it took a while to go in) and when calling into the hospital they asked to keep the fluids running, so I changed the bag, since what we primarily administer 250ml bags
-was prepared to give him ativan if needed

Anything else I should have done?

Thanks for the info on DT's and withdrawl, around here you don't often deal with those who actually stop drinking.

Sounds good to me. That's the same way I would have treated it.

 

[jeepmedic]

My thought and the way I treated it was as he was post ictal from a withdrawl seizure and hypotensive due to dehydration, so here's what I did:

-O2
-Vitals
-ECG and 12 lead (nothing significant)
-IV 18g in AC
-BGL - 181mg/dl (from the IV stick)
-IV running open for a 200ml NS bolus (it was pretty positional, so it took a while to go in) and when calling into the hospital they asked to keep the fluids running, so I changed the bag, since what we primarily administer 250ml bags
-was prepared to give him ativan if needed

Anything else I should have done?

Thanks for the info on DT's and withdrawl, around here you don't often deal with those who actually stop drinking.

Sounds like you ran it the way ALS providers would. Not much else you could do in the back of the truck.

 

[Ridryder911]

I totally disagree with Paramedics don't diagnose int the field. Do you call s/s in and then have physician order treatment ? No, you make an assessment, interpret the data (which is diagnosing) and apply treatment.
Call it whatever you want clinical impression, interpretation, that is all semantics; whatever it is a diagnoses. Please, I know I have heard the "old only Dr.'s only can diagnose".. which is really not correct by far.

There are multiple health care practitioners that can diagnose within their own specialty. Even nurses have their own diagnoses.

I agree the final diagnoses should rely upon lab and all the other data, but initial diagnoses can be made without such, other wise there would be no direction on what specific tests to order.

Although the patient is not compensated ( MEAN and pulse rate), I agree he probably he is dry from poor intake. Second, DT's are not caused from hypotension. It is caused when ethanol is withdrawn, and there is a decrease in neurotransmitter of chloride GABA. This causes an increase in catecholamines. Therefore one of the side effects may be hypotension, as well as the other symptamology.

For me aggressive treatment is more treatment of etiology such as electrolyte replacement and vitamins. Some of this can be performed in the field with Mg+, Thiamine (which may prevent further seizures).

R/r 911

 

[prizonmedik]

I didn't see where anyone said DT's were caused by hypotension. I hope at no point in your life does anyone talk down to you as you do everyone on this site.

 

[Ridryder911]

I was'nt trying to be demeaning, just trying to see if people can justify their treatment other than "it protocols". Sorry, I didnt have to google. It is called advanced pathophysiology and organic chemistry...

p.s. there is a cure for stupidity, it is called education

R/r 911

 

[Fedmedic]

I was'nt trying to be demeaning, just trying to see if people can justify their treatment other than "it protocols". Sorry, I didnt have to google. It is called advanced pathophysiology and organic chemistry...

p.s. there is a cure for stupidity, it is called education

R/r 911

I worked EMS for 15 years and I haven't even looked at a protocol book, other than to make sure I didn't deviate too far. That's what I call "cookbook" medics, the ones that can quote protocols and everything is done because protocol says so. You know the type of protocols the "christmas tree ones", if A go to B, if B go to C. I hate protocols. Our protocols in our region in VA, basically for everything it is O2, monitor and ALS(whatever you think the appropriate ALS is). That makes for critical thinking medics, which are the best medics. I treat according to what I learned in paramedic school, not according to protocols. The reason he would have gotten fluid is because he was dehydrated because he is an alcoholic, hasn't been eating or drinking and his lytes are all screwed up. Not because protocol says with a low blood pressure you give fluid. I'm not a rookie. And unfortunately the last couple of years on the truck that is all we were getting is cookbook medics. Even when I went and took AMLS, I didn't like it, because it basically taught the cookbook method.

 

[Ridryder911]

Actually FedMedic, I agree with you 100%. Was not insuating you were one, rather on most EMS forums that is always the usual shot out response. Even when questioned why their protocols would be designed as such they cannot give a response. Nor have they reviewed new techniques, studies for possible up-dates and changes.

I believe many EMS personnel are like "sheep" and will follow the easiest and least resistant route. Most do not not have any true beliefs or rationale in patient care. Even though one may not perform or even agree in treatment, I at least will respect their view point if they can justify it by rational decision making process.

If one can justify anything they do and why they do it, then it demonstrated they have thought processes and not just "following". As you would probably agree, there are always to skin a cat, but that does not mean you will always will follow the same route each time.

EMS personnel has the mechanism and means as well the responsibility to question why they are doing things.

R/r 911

 

[trauma1534]

Rid, my diffinition of aggressive treatment is when you don't withhold treatment and when you get ahead of the game before that game beats you. Now, some providers I know would have placed a lock instead of hanging a bag of fluid. Some would have just hung the bag and kept the rate at KVO. I would have ran it WO as long as the lungs stayed clear. I don't hold back, in most cases if I see a patient heading south, I start things as a prep for keeping them out of the drain so to speak.

Do we are not MD's in the field. We don't diagnose, we just go with what the patient presents with. We treat symptoms. Yes, there are times when we can diagnose. For instance... when a patient has a fx that goes throught he skin, it is no longer a poss. fracture, it is a fracture. When a patient becomes pulseless and apnec, then it is a code. But there are other times when a patient might present with one thing, and we treat the symptoms but those symptoms we are treating are secondary to the core problem.

 

[Ridryder911]

To me aggressive treatment is treatment that is not within the "norm" or standardized treatment. Performing a procedure or diagnosing without clear cut symptoms and performing prophylatically.

R/r 911

 

[trauma1534]

To me aggressive treatment is treatment that is not within the "norm" or standardized treatment. Performing a procedure or diagnosing without clear cut symptoms and performing prophylatically.

R/r 911

Wouldn't you consider it aggressive if a provider get's ahead of the game verses setting there twiddleing thier thumbs waiting for the next problem to happen? Man come on!!! You just want to argue! Let's stop this thrashing!!! You are not God, stop trying to make people think that you are! LOL

 

[Ridryder911]

There was no argument. You can interpert as anything you want to. I just voiced my opinion, and if it is different from yours, you therefore interpret as an argument.

No, I would not consider "doing" or "performing" my job as one should be doing naturally as "aggressive". It should be the standard of care to prepare and be prepared for unexpected. Twiddling ones thumbs would be considered neglect. In hospital care "aggressive" would be defined as going above the "standards'.

Even Websters define it as :

1 a : tending toward or exhibiting aggression <aggressive behavior> b : marked by combative readiness <an aggressive fighter>
2 a : marked by obtrusive energy b : marked by driving forceful energy or initiative : ENTERPRISING <an aggressive salesman>
3 : strong or emphatic in effect or intent <aggressive colors> <aggressive flavors>
4 : growing, developing, or spreading rapidly <aggressive bone tumors>

5 : more severe, intensive, or comprehensive than usual especially in dosage or extent in treatment <aggressive chemotherapy

One does not have to be an M.D. do not diagnose as well. Everyone needs to expand their local horizons. This is what is "looking outside" the box means. There are several health care professionals that diagnose daily that are not M.D. or D.O.'s. Part of the intent of this forum is to learn.

R/r 911

 

[Jon]

In Rid's defense... I can see where he says that NS isn't really "agressive" when it comes to therapy. I agree that PolyHeme or a blood transfusion probably isn't NEEDED, but it would be agressive


As for treatment - a little bit - 500cc's or so of NS shouldn't hurt, and might help the guy. If you have Thiamin and can give it because of protocols, then it would probably be a good idea. What this guy probably needs is a Banana bag.

 

[Airwaygoddess]

that is pretty much what these kind of patients receive in house for at least 48 hours along with Haldol, a bath, and if they are really fun, the lovely matching 4 point restraints with the cute matching Posey vest. Oh what fun! Weeeeee! (Oh Boy!:wacko: )