I was working an arrest the other day with an experienced als provider and the first drug we gave was vaso. Then I look up and my partner was giving the pt sodium bicarb. So naturally, I was thinking to myself "what kind of crap is this, bicarb in the first 5 mins!!!!, is this guy nuts?" Then something strange happened. We got a pulse back and from what I hear, grandma is still doing well. Back in the "old days" paramedics would give bicarb like candy, early and often. Now, ACLS guidelines call for bicarb later in the arrest if at all. The guy I was working with is finishing up his masters degree in nursing, and says that when he gives bicarb early, he gets better results. This guy also happens to be known for his resuscitation rate which is very good. My question to the experienced ALS providers here is, what do you think about this? Could there be any truth to it? How often do you use bicarb? What else is bicarb good for? I've heard it's also good for unclogging trach tubes if you squirt a little down the tube instead of saline.
Sodium Bicarbonate
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Ridryder911
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I think he is lucky on resuscitation. Now, if the patient is a dialysis patient or has hx of hypokalemia, or has been down ... then it is advisable. Yes, the old ACLS algorithm was Epi / NAHc03 q 5 minutes.. then they found out it did not work... I agree.
Now to address Bicarb down the ET tube... here is a answer I ope I can make clear
NEVER, NEVER, NEVER EVER INJECT BICARB DOWN AN ENDOTRACHEAL TUBE ! PERIOD !!!!!!!!
Hope that was clear enough, I testified against an Intermediate whom did. The lungs actually bubbled back through the tube... never the less, we can say he lost his license, job, career and some personal belongings.. since no company advises such and he was acting on his own accordance. Yeah, the EMS company attorneys dropped him like a hot potato.
I use bicarb for ASA O.D.'s sometimes for Tricyclic O.D's and those I suspect with acidosis such as DKA, Hypokelemia (displaying Chevosteks's sign and some Trasseu's) .. usually I get an oder for such.. then it is usually diluted in a drip solution...
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Now to address Bicarb down the ET tube... here is a answer I ope I can make clear
NEVER, NEVER, NEVER EVER INJECT BICARB DOWN AN ENDOTRACHEAL TUBE ! PERIOD !!!!!!!!
Hope that was clear enough, I testified against an Intermediate whom did. The lungs actually bubbled back through the tube... never the less, we can say he lost his license, job, career and some personal belongings.. since no company advises such and he was acting on his own accordance. Yeah, the EMS company attorneys dropped him like a hot potato.
I use bicarb for ASA O.D.'s sometimes for Tricyclic O.D's and those I suspect with acidosis such as DKA, Hypokelemia (displaying Chevosteks's sign and some Trasseu's) .. usually I get an oder for such.. then it is usually diluted in a drip solution...
R/r 911
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Lungs bubbled though the tube, wow, that's a career ender if I ever heard one. If ridryder is testifying against you, you better bring your A game people.
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If Ridryder is testifying against you, you better bring bus fare because someone else is going to be driving your vehicle home.
VinBin
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Just curious, how do lungs bubble back through the tube? Does the Bicarb destroy the alveoli or some similar action?
I had no idea what in the world Rid was talking about in the two signs he referred to, so I googled them if anyone is interested...
http://en.wikipedia.org/wiki/Chvostek's_sign
http://en.wikipedia.org/wiki/Trousseau_sign
Both signs seem to refer to hypocalcemia. Is Bicarb a treatment for hypocalcemia?
I had no idea what in the world Rid was talking about in the two signs he referred to, so I googled them if anyone is interested...
http://en.wikipedia.org/wiki/Chvostek's_sign
http://en.wikipedia.org/wiki/Trousseau_sign
Both signs seem to refer to hypocalcemia. Is Bicarb a treatment for hypocalcemia?
Ridryder911
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Calcium loss and potassium loss is common in acidosis, as well as many other electrolyte imbalances. Aww...Remember the cations and anions of electrolyte shifts, and the mechanism of the sodium pump in the acid base & Krebs cycle? (you should be familiar with this if you have been through the electrolyte portion of the Intermediate level ) As well we need to remember the 20:1 ratio in correcting the acid base according to the oxyhemoglobin curve and as well the increase in lactic acid in Stage II-III shock phase? .... Been a while, huh?... brushing cob webs....LOL
Sodium bicarbonate at the adult strength 25-50 meq/ causes necrosis and sloughing of tissue if lost in mucosa, and tissue, skin. If infiltrated at the IV site, it may rot out the skin from necrosis. Hence... lung tissue is comprised of soft, mucosa type tissue...I have squirted some on adipose fat tissue.. and yes, it bubbled. Hence... the "bubbling & foamy"... as testified by the ER Doc...and the pathology report was not much better....
Now, with that saying don't be surprised if when suturing lacerations they might use some Sodium Bicarbonate (12.5% solution) when using Lidocaine injection ... it removes the burning and stinging. But, recall this is a diluted solution... as well when administering Bicarb all IV tubing should be flushed.. very well... after injection of med.s.... it does precipitate (turns into a chalky substance in the IV line)... Sodium Bicarbonate has it's uses.. ( especially on car battery terminals...LOL) but it also can be like any other med. has benefits and disadvantages...many we never see in EMS arena.
There are only a few med.s that are recognized safe to be able to put into the tube... (which is now very discouraged by AHA) I use the acronym LEAN... Lidocaine, Epinephrine, Atropine, Narcan .. Remember NO electrolyte solution such dextrose or D50W, Bicarb.. etc. Good simple rule the med.s are usually 10 ml or less.. never 25 or 50ml..
Even NSS is a debatable subject... many ICU's and RT's disagree on using saline as well. It is no longer recommended by some experts.
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Sodium bicarbonate at the adult strength 25-50 meq/ causes necrosis and sloughing of tissue if lost in mucosa, and tissue, skin. If infiltrated at the IV site, it may rot out the skin from necrosis. Hence... lung tissue is comprised of soft, mucosa type tissue...I have squirted some on adipose fat tissue.. and yes, it bubbled. Hence... the "bubbling & foamy"... as testified by the ER Doc...and the pathology report was not much better....
Now, with that saying don't be surprised if when suturing lacerations they might use some Sodium Bicarbonate (12.5% solution) when using Lidocaine injection ... it removes the burning and stinging. But, recall this is a diluted solution... as well when administering Bicarb all IV tubing should be flushed.. very well... after injection of med.s.... it does precipitate (turns into a chalky substance in the IV line)... Sodium Bicarbonate has it's uses.. ( especially on car battery terminals...LOL) but it also can be like any other med. has benefits and disadvantages...many we never see in EMS arena.
There are only a few med.s that are recognized safe to be able to put into the tube... (which is now very discouraged by AHA) I use the acronym LEAN... Lidocaine, Epinephrine, Atropine, Narcan .. Remember NO electrolyte solution such dextrose or D50W, Bicarb.. etc. Good simple rule the med.s are usually 10 ml or less.. never 25 or 50ml..
Even NSS is a debatable subject... many ICU's and RT's disagree on using saline as well. It is no longer recommended by some experts.
R/r 911
Ridryder911
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P.s....if you are to use saline for inhalation or ET tubes, it should be the respiratory type,(without preservatives) not the bottle or IV Bag type...
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VinBin
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Ah...thanks for the info..
Was reading something about how hypocalcemia occurs with hyperkalemia in arrest situations (and assuming in other situations that result in asidosis). When you referred to hypokalemia, did you mean hyperkalemia? Thats what seems to be tripping me up, because it seems to be commonplace to treat hyperkalemia with SBicarb.
Nice summary of experiment done...
http://cat.inist.fr/?aModele=afficheN&cpsidt=1872558
"Conclusion: Ionized hypocalcemia and hyperkalemia occur during prolonged resuscitative efforts and may be related to dysfunctional transcellular ionic transport mechanisms. These cations play important roles in cardiac electrical and contractile activity and may play a role in refractory postcountershock rhythm disturbances."
Was reading something about how hypocalcemia occurs with hyperkalemia in arrest situations (and assuming in other situations that result in asidosis). When you referred to hypokalemia, did you mean hyperkalemia? Thats what seems to be tripping me up, because it seems to be commonplace to treat hyperkalemia with SBicarb.
Nice summary of experiment done...
http://cat.inist.fr/?aModele=afficheN&cpsidt=1872558
"Conclusion: Ionized hypocalcemia and hyperkalemia occur during prolonged resuscitative efforts and may be related to dysfunctional transcellular ionic transport mechanisms. These cations play important roles in cardiac electrical and contractile activity and may play a role in refractory postcountershock rhythm disturbances."
Ridryder911
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Thanks for the clarification Yes, you are right...sorry a long 36 hr straight shift. As well remember metabolically, and different specific types of conditions may alter the electrolytes.. .. point being very few times Sodium Bicarbonate will be administered on a routine basis in the field. Second, it is not unusual to see in-house bicarbonate replacement for patients with an electrolyte imbalance.
Also remember, that since there is sodium as well as bicarbonate, one has to be cautious in patients with expected hypernatremia. Some neonatologist might even use (pediatric concentration) sodium bicarbonate as a volume expander, due to the sodium level.
If one want s to see somebody with messed up lab values, just check out a dialysis patients lab's in comparison to the 'Normal lab".
I have actually had patent's respond just to NaHc03, in a full arrest when they had just received dialysis therapy. Many will have "too much fluid" pulled off and as well, sodium and other electrolytes. So in addition to the routine ACLS medication, I will give sodium bicarbonate, magnesium, and maybe D10W.
I once worked in a large burn center, as a burn nurse, and had several years of practice as a Paramedic under my belt and felt comfortable with codes. So when a male patient with a 95% TBS 3'rd degree coded (yes, should had a DNR, different story) I was amazed of the physician administering sodium bicarbonate, magnesium and yes, even potassium !..... I be darn, the patient immediately responded!... I had never seen such med.'s administer in an arrest...especially in such an order and amount. I was impressed and let the Dr. know it .. he taught me something that day... "treat the cause, not the effect".... The burn patient was a 30 year old with a healthy heart.. it was his electrolyte imbalances that caused him to go into fib... not an occlusion. I remember him reviewing his chart and labs during the code.. From that day on I started seeing patients as a whole.. not just one specific problem.
I do believe we need a better understanding of body chemistry and the effects. There are many clues, and symptoms we in EMS cold pick up on with patients, that are diabetics, or have history of vomiting, diarrhea, dialysis history, etc...
R/r 911
Also remember, that since there is sodium as well as bicarbonate, one has to be cautious in patients with expected hypernatremia. Some neonatologist might even use (pediatric concentration) sodium bicarbonate as a volume expander, due to the sodium level.
If one want s to see somebody with messed up lab values, just check out a dialysis patients lab's in comparison to the 'Normal lab".
I have actually had patent's respond just to NaHc03, in a full arrest when they had just received dialysis therapy. Many will have "too much fluid" pulled off and as well, sodium and other electrolytes. So in addition to the routine ACLS medication, I will give sodium bicarbonate, magnesium, and maybe D10W.
I once worked in a large burn center, as a burn nurse, and had several years of practice as a Paramedic under my belt and felt comfortable with codes. So when a male patient with a 95% TBS 3'rd degree coded (yes, should had a DNR, different story) I was amazed of the physician administering sodium bicarbonate, magnesium and yes, even potassium !..... I be darn, the patient immediately responded!... I had never seen such med.'s administer in an arrest...especially in such an order and amount. I was impressed and let the Dr. know it .. he taught me something that day... "treat the cause, not the effect".... The burn patient was a 30 year old with a healthy heart.. it was his electrolyte imbalances that caused him to go into fib... not an occlusion. I remember him reviewing his chart and labs during the code.. From that day on I started seeing patients as a whole.. not just one specific problem.
I do believe we need a better understanding of body chemistry and the effects. There are many clues, and symptoms we in EMS cold pick up on with patients, that are diabetics, or have history of vomiting, diarrhea, dialysis history, etc...
R/r 911
VinBin
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heh...no worries, after 36hrs, I would be just about unconscious...
And on a followup question, anyone had a patient "overdose" on Bicarb? I'm guessing the most common situation to admin it would be in an arrest, and its hard to observe "adverse" effects in an arrest...
:blink:
Very true...Ridryder911 said:
And on a followup question, anyone had a patient "overdose" on Bicarb? I'm guessing the most common situation to admin it would be in an arrest, and its hard to observe "adverse" effects in an arrest...
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Wow rid, this is chock-full of great info. Read up kiddies, you might actually learn something about the art of providing real advanced life support, I know I did.
Ridryder911
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I have only seen a few metabolic alkalosis in comparison of course acidosis, which is more common in the emergency situation.
Now, think how one could become alkalotic ?..........
?
?
?
?
?
music please....Tum...tum... Tum......tum....... yep, that's it Tums, Rolaids.. etc.. many people will eat several an hour, like after dinner mints. Not, realizing they are "screwing up " their pH level. Some older people still baking soda.. which is a neutralizer and can cause alkalosis in large amount.
The only other time was I was working in a hyperbaric chamber (HBO) at the burn unit.. and somehow, the patient become slightly akalotic...?
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Now, think how one could become alkalotic ?..........
?
?
?
?
?
music please....Tum...tum... Tum......tum....... yep, that's it Tums, Rolaids.. etc.. many people will eat several an hour, like after dinner mints. Not, realizing they are "screwing up " their pH level. Some older people still baking soda.. which is a neutralizer and can cause alkalosis in large amount.
The only other time was I was working in a hyperbaric chamber (HBO) at the burn unit.. and somehow, the patient become slightly akalotic...?
R/r 911