Hypertonic saline

[Alan L Serve]

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.

 

[VentMonkey]

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.

 

[NomadicMedic]

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.

 

[VentMonkey]

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.

 

[DesertMedic66]

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.

 

[TXmed]

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.

 

[TXmed]

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

 

[E tank]

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.

 

[StCEMT]

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.

 

[Operations Guy]

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.

 

[DesertMedic66]

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.

 

[E tank]

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.

 

[E tank]

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.

 

[Operations Guy]

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

 

[Operations Guy]

@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.

 

[LaAranda]

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.

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.

 

[E tank]

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.

 

[VFlutter]

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.

 

[E tank]

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.

 

[VFlutter]

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.