Sodium Bicard admin post arrest

[mycrofft]

Nitpicky: resp rate is assumed to be normal or greater volume, and regular, and unimpeded as evidenced by absence of stridor, rhonchii, or (ausc the chest) areas of absent sounds, right? Not arguing, I am presuming.

Sidebar: back in the day, bicarb was like "mother's milk" in many minds, and pts were being received alkalinized. Alkalinated? RBC's were stingy getting rid of O2 where it was needed.

 

[rhan101277]

When I gave it I was thinking about down time and trying to fix acidosis quickly instead of just letting ventilation fix the problem. I made a mistake giving it post arrest and everyone makes mistakes, I don't think it did any harm but I thought my thinking was sound when I gave it.

 

[mycrofft]

The jury says "YES"! Good luck on the next one, done good.

 

[rhan101277]

SODIUM BICARBONATE (BICARB)
1. Classification: systemic alkalizer, electrolyte buffer
2. Physiologic Effect: buffers H+ ions in metabolic acidosis
3. Major Indications:
3.1. preexisting metabolic acidosis (perfusing patient)
3.2. hyperkalemia
3.3. tricyclic, phenobarbital, or aspirin overdoses
3.4. during cardiac arrest, after prolonged resuscitative efforts
4. Primary Contraindications:
4.1. metabolic alkalosis
4.2. hypokalemia
4.3. simultaneously with calcium chloride
4.4. simultaneously with catecholamines
5. Side Effects:
5.1. metabolic alkalosis
5.2. CHF (edema secondary to sodium overload)
5.3. hypernatremia
6. Additional Information: administration should be guided by arterial blood gas analysis in a perfusing
patient...

 

[Handsome Robb]

So I'm not sure why you're getting defensive...you can't ask for opinions then get grumpy when they don't tell you what you want to hear.

The last post solidified the fact that you even admitted were wrong by giving it post arrest.

 

[rhan101277]

So I'm not sure why you're getting defensive...you can't ask for opinions then get grumpy when they don't tell you what you want to hear.

The last post solidified the fact that you even admitted were wrong by giving it post arrest.

Yeah I was, you've never made a mistake?

 

[Handsome Robb]

Yeah I was, you've never made a mistake?

I never said I haven't. I make them all the time.

 

[Veneficus]

Yeah I was, you've never made a mistake?

If it makes you feel any better, I don't think it was a big deal.

Like I said, perhaps not optimal, but of no negative or great consequence.

 

[rhan101277]

If it makes you feel any better, I don't think it was a big deal.

Like I said, perhaps not optimal, but of no negative or great consequence.

Thanks, I read that one amp decreases pH by .1 . I didn't think it was doing harm especially after thinking about the lab values that the internal medicine doc had when he approached me asking about the call. The pH was 6.9 PaCo2 was 44 and bicarb was 28. I thought it was sound thinking at the time.

Thanks for all of the replies

 

[MSDeltaFlt]

Thanks, I read that one amp decreases pH by .1 . I didn't think it was doing harm especially after thinking about the lab values that the internal medicine doc had when he approached me asking about the call. The pH was 6.9 PaCo2 was 44 and bicarb was 28. I thought it was sound thinking at the time.

Thanks for all of the replies

With a pH of 6.8, PaCO2 of 44, and HCO3 of 28, he had an anion gap acidosis. Either his Na, Cl, or K is out of whack. Post arrest my money's on K.

 

[Dwindlin]

With a pH of 6.8, PaCO2 of 44, and HCO3 of 28, he had an anion gap acidosis. Either his Na, Cl, or K is out of whack. Post arrest my money's on K.

You can't tell if there is a gap with the information given. All you can say with those values is he has a mixed acidosis (low pH with relatively normal pCO2 and HCO3 values) unless I missed the lytes given somewhere.

 

[BLS Systems Limited]

"We only hyperventilate possible herniations over here, we can't hyperventilate someone based on ETCO2 readings. "

As a respiratory therapist, I am an little concerned about the discussion of "hyperventilation". Hyperventilation is breathing over and above what is necessary to maintain normal PCO2 to maintain normal pH. Tachypnea is fast breathing. If anyone is suffering from acidosis, whether its metabolic or respiratory based, increased respiratory rate normally occurs. This is not hyperventilation.

Back in the day, we used to hyperventilate head traumas to create blow off more CO2, which decreases blood flow top the brain. Unfortunately this decreases blood flow to the brain...

 

[MSDeltaFlt]

You can't tell if there is a gap with the information given. All you can say with those values is he has a mixed acidosis (low pH with relatively normal pCO2 and HCO3 values) unless I missed the lytes given somewhere.

Actually you have a strong indication of one going on. Because, although It is calculated on ABG's, a bicarb of 28 and a pH of 6.8 one should have a PaCO2 a lot higher than 44; generally speaking some near 80-100. That is me trying to do a Henderson-Hasselbach in my head, but you get my point.

Therefore, assuming those ABG's are temperature corrected (Charles's Law still works even in blood), then the only way for the pH to be that low would be for something else making the blood acidic. Lactic acid dump off from ROSC would bring bicarb down immediately. The only other acidosis state I am aware of is anion gap acidosis. Check the CMP. Again my money's on K being off kilter.

 

[NomadicMedic]

I think we might be reading too much into the original post. The OP stated he pushed the bicarb due to a high ETCO2... Nothing else. We have info that says the ETCO2 was 90 after ROSC and nothing really substantive after that.

I still think the bicarb push after ROSC was the wrong call. I believe that the high ETCO2 most likely could have been managed with increased ventilation, not a bicarb push.

 

[triemal04]

Given that the patient arrived with a pH of 6.9, giving the bicarb was the correct thing to do. Of course, it was done for the wrong reasons, which means, in essence, the OP got lucky. That won't happen every time.

If there was a known disease process going on prior to the arrest that caused/contributed to it, then giving bicarb might be a potential treatement. But even then, without knowing what the pH is, it's still a crapshoot.

 

[KellyBracket]

Sodium bicarbonate - why is there so much passion around this bulky box in the code cart?

A discussion elsewhere on the internet prodded me into looking at the 2 studies that the AHA cited as supporting the use of bicarb in out-of-hospital cardiac arrest. Pretty interesting stuff. If you want the longer review, check it out: "Sodium bicarb in a code - still no evidence." My very quick version of my review is this:

The first study really compared EMS agencies that gave bicarb early & often in cardiac arrest, versus agencies that gave it late, or not at all. Not randomized, not controlled, not nuthin'. They found that, yes, the patients treated by the the "high sodium bicarb users" tended to survive more often. The thing is, those same agencies were also better at getting in the first shock quickly, at getting in epi quickly - they generally had their s__t together. So, was it the bicarb, or was it the well-organized EMS team?

The other study compared the save rate for Seattle EMS in two time periods: from 1981-1982, and 1983-1985. In the later period, they either used epi or lido in cardiac arrest, while in the earlier period they just started a drip of bicarb. The funny thing is that, while bicarb was associated with getting ROSC/admitted to the hospital, the use of "no drug" improved survival to discharge.

That's a conclusion we've seen a few times in EMS...

 

[Smash]

I don't think there is too much passion about it. I'm fairly sure that most of us are well aware of the lack of any effect sodi bic has during arrests (or any drug for that matter)

However the OP posted a scenario where the sodium bicarbonate was used to manage post arrest acidosis, which is not an unreasonable question.

I personally love having sodium bicarbonate, but only for certain toxicological issues.

 

[TatuICU]

In my opinion, caponography paints the absolute best prehospital picture of ventilation status

This is true, but if your patient is dead and you're doing CPR, then capnography readings actually tell you more about how good your CPR is as ventilation doesn't mean anything if blood is not circulating. That said, a CO2 reading like 98 after ROSC would probably tell you that compressions were less than ideal more than it would ventilation status.

 

[TatuICU]

I don't think there is too much passion about it. I'm fairly sure that most of us are well aware of the lack of any effect sodi bic has during arrests (or any drug for that matter)

This

 

[Veneficus]

I don't think there is too much passion about it. I'm fairly sure that most of us are well aware of the lack of any effect sodi bic has during arrests (or any drug for that matter)

Why is it when you suggest it you are a hero, when I do i am a heretic?