Septal infarct > Flash Pulmonary edema > Code

[Tigger]

Trendelenburg actually did help the pt during this episode and then he was out back to semi Fowler's position for rest of transport (until resp issues started)

I would not count on that position to ever help an ill patient. It is definitely not ideal for a patient with significant pulmonary edema.

 

[E tank]

... some patients will benefit from a liter or more...

Defend this statement.

 

[Tigger]

Defend this statement.

Initial management of burns at 500ml/hr will get there. DKA patients (not with NS, but we are getting away from NS anyhow), in fact this was today's little review for me. Profound diarrhea and heat stroke come to mind. Conceivably an inferior MI in need of preload support though I suppose there are also pharmacological measures as well.

Is it common to give more than a liter of fluid prehospitally? I hope not. But I think to empirically say it won't happen is a bit much.

 

[E tank]

Initial management of burns at 500ml/hr will get there. DKA patients (not with NS, but we are getting away from NS anyhow), in fact this was today's little review for me. Profound diarrhea and heat stroke come to mind. Conceivably an inferior MI in need of preload support though I suppose there are also pharmacological measures as well.

Is it common to give more than a liter of fluid prehospitally? I hope not. But I think to empirically say it won't happen is a bit much.

Oh, OK...had me going for a second there. I thought the statement was in regard to someone having an MI, not care in general. Yeah, a liter or more of fluid is sometimes appropriate in cases other than cardiac, but I can't think of a single instance where that would be a good idea in someone that was having a heart attack.

 

[Peak]

I can't think of a single instance where that would be a good idea in someone that was having a heart attack.

Some cardiac patients will be dry and require some volume replacement, especially those who dont have enough volume for preload.

In these cases we would generally prefer cell saver (obviously not relevant to field medicine as this is typically leftovers from CPB) or 5% albumin, then plasmalyte, LR, NS, and last D5. It should also be giving in 5mL/kg to a max of 250 mL per dose unless there is hypotension with a low CVP/RAP with immanent collapse (or chattering of the ECLS) in which a 10mL/kg bolus may be needed.

Relavently to field MIs I would mostly think of patients who are dry and hypotensive, and require preload support, especially to the RV.

 

[E tank]

Some cardiac patients will be dry and require some volume replacement, especially those who dont have enough volume for preload.

In these cases we would generally prefer cell saver (obviously not relevant to field medicine as this is typically leftovers from CPB) or 5% albumin, then plasmalyte, LR, NS, and last D5. It should also be giving in 5mL/kg to a max of 250 mL per dose unless there is hypotension with a low CVP/RAP with immanent collapse (or chattering of the ECLS) in which a 10mL/kg bolus may be needed.

Relavently to field MIs I would mostly think of patients who are dry and hypotensive, and require preload support, especially to the RV.

An immediately post (heart lung machine) cardiac patient isn't who we're talking about here, and how ECMO comes in to all of this, I have no idea.

The question at hand is volume resuscitation in the setting of acute, symptomatic MI. And using more than around 500 cc's of crystalloid to try to stabilize hemodynamics (which is not really volume resuscitation anyway) is chasing zebras, especially if you're not actively getting ready to have an inotrope in hand. Like I said, it's more to buy time than anything else and if you get to the hospital before you escalate, so much the better.

 

[Peak]

An immediately post (heart lung machine) cardiac patient isn't who we're talking about here, and how ECMO comes in to all of this, I have no idea.

The question at hand is volume resuscitation in the setting of acute, symptomatic MI. And using more than around 500 cc's of crystalloid to try to stabilize hemodynamics (which is not really volume resuscitation anyway) is chasing zebras, especially if you're not actively getting ready to have an inotrope in hand. Like I said, it's more to buy time than anything else and if you get to the hospital before you escalate, so much the better.

ECMO transport does exist.

You said you couldn't think of a single time when someone is having a MI, I provided you examples including a 911 presentation.

 

[E tank]

ECMO transport does exist.

You said you couldn't think of a single time when someone is having a MI, I provided you examples including a 911 presentation.

Giving volume into a V-A ECMO circuit isn't giving a liter of fluid to an ischemic heart. It isn't even in the same zip code.

 

[Peak]

Giving volume into a V-A ECMO circuit isn't giving a liter of fluid to an ischemic heart. It isn't even in the same zip code.

Relavently to field MIs I would mostly think of patients who are dry and hypotensive, and require preload support, especially to the RV.

Patients who are dry and require preload will need fluids in the field. Inotropes don't provide preload in the dehydrated or third spaced patient.

 

[E tank]

Patients who are dry and require preload will need fluids in the field. Inotropes don't provide preload in the dehydrated or third spaced patient.

Are we posting on the same thread? Is this thread not about hypokinetic, ischemic myocardium in pump failure (not on ecmo)? When you see a patient like the one the OP references (the only context in which I'm commenting) , do you rule out hypovolemia as a cause of the hypotension? If so, how?

 

[Peak]

Are we posting on the same thread? Is this thread not about hypokinetic, ischemic myocardium in pump failure (not on ecmo)? When you see a patient like the one the OP references (the only context in which I'm commenting) , do you rule out hypovolemia as a cause of the hypotension? If so, how?

Oh, OK...had me going for a second there. I thought the statement was in regard to someone having an MI, not care in general. Yeah, a liter or more of fluid is sometimes appropriate in cases other than cardiac, but I can't think of a single instance where that would be a good idea in someone that was having a heart attack.

Your post didn't reverence only the situation that was orrigonally presented but rather in any person who was having a heart attack. Your words.

I presented multiple cases where fluids are indicated in patients who have myocardial infarction.

 

[silver]

An immediately post (heart lung machine) cardiac patient isn't who we're talking about here, and how ECMO comes in to all of this, I have no idea.

And I would rather press that patient anyway...How often do you see a patient thats vasoplegic following CPB responsive to fluids? Even if they are responsive its like 20 mins before they 3rd space it. And 2 days later you'll be diuresing or dialyzing out all the fluid you dumped in them as they mobilize it back.

 

[Peak]

And I would rather press that patient anyway...How often do you see a patient thats vasoplegic following CPB responsive to fluids? Even if they are responsive its like 20 mins before they 3rd space it. And 2 days later you'll be diuresing or dialyzing out all the fluid you dumped in them as they mobilize it back.

Have you actually cared for ECLS patients? Ultrafiltration and dialysis are the least of your concerns if the patient is so sick that they require VA ECMO, you're luck if you get them off pump in two days. Pressors don't give you volume, you have to have volume if the vascular space, it will probably be third spaced, that donsn't mean that the volume isn't needed. Its like saying you'd rather give pressors than fluid in a sepsis patient. You don't want to overload the patient, but if they are dry then they require volume. Fluid status in the vascular space and third space are not equal.

 

[silver]

Have you actually cared for ECLS patients? Ultrafiltration and dialysis are the least of your concerns if the patient is so sick that they require VA ECMO, you're luck if you get them off pump in two days. Pressors don't give you volume, you have to have volume if the vascular space, it will probably be third spaced, that donsn't mean that the volume isn't needed. Its like saying you'd rather give pressors than fluid in a sepsis patient. You don't want to overload the patient, but if they are dry then they require volume. Fluid status in the vascular space and third space are not equal.

Referencing post hearts not on ECMO/CPB, as noted by the quote and also my statement...

 

[Peak]

Referencing post hearts not on ECMO/CPB, as noted by the quote and also my statement...

And I would rather press that patient anyway...How often do you see a patient thats vasoplegic following CPB responsive to fluids? Even if they are responsive its like 20 mins before they 3rd space it. And 2 days later you'll be diuresing or dialyzing out all the fluid you dumped in them as they mobilize it back.

?

 

[Summit]

How did we get treating cardiogenic shock due to acute LVF with fulminate pulmonary edema due to septal AMI... to fluid resusc in specialty center management of ECMO?

Non-sequitur continued: How about if your patient has one of these and arrests?

"Will someone get the surgeon in here or I'm gonna open the damn chest myself." -Intensivist-about-to-poo-his-pants

Not super EMS relevant though...

 

[Peak]

How did we get treating cardiogenic shock due to acute LVF with fulminate pulmonary edema due to septal AMI to specialty center management of ECMO?

How about if your patient has one of these and arrests? Get the cart! Not super EMS relevant though!

That would be because some people like to make sweeping generalizations, and I'm a stubborn smart aleck who doesn't let things go. Sorry.

 

[silver]

?

Yes following CPB, as in not requiring support. As you mentioned being on mechanical support is a totally different world.

Going back to the original thread. I agree with you on small amounts of fluid in patients like this (with RV infarct) who may improve hemodynamically with higher RV preload. However, abandoning that if its not working or if you note worsening clinical signs of HF.

 

[Peak]

Yes following CPB, as in not requiring support. As you mentioned being on mechanical support is a totally different world.

Going back to the original thread. I agree with you on small amounts of fluid in patients like this (with RV infarct) who may improve hemodynamically with higher RV preload. However, abandoning that if its not working or if you note worsening clinical signs of HF.

I misunderstood, I thought you meant as in they were just put on pump.

 

[Tigger]

Let's keep this on the topic of prehospital, non-ECMO base care.