when do you give saline?

[usalsfyre]

Agreed.

As to the "what do I do until I have experince" question? Rely in others, and....get it wrong. The dirty little secret of medicine is that it requires it's providers screw up to learn.

 

[DV_EMT]

I worked IFT for nearly a year before moving to 911. I can't tell you how many simply mundane BLS calls turned in to a pseudo-911 ALS call. Treat each nursing home call as a 911. One day you might actually catch something and save a life... or make it slightly more bearable. Little piece of advise: SNFs aren't known for their ability to care for acute patients and pass big things off as "electrolyte inbalance"

That's the truth!!

 

[Nervegas]

I worked IFT for nearly a year before moving to 911. I can't tell you how many simply mundane BLS calls turned in to a pseudo-911 ALS call. Treat each nursing home call as a 911. One day you might actually catch something and save a life... or make it slightly more bearable. Little piece of advise: SNFs aren't known for their ability to care for acute patients and pass big things off as "electrolyte inbalance" ... especially since I can think of several potentially life threatening "electrolyte inbalances" that we can fix/change/reduce in the field. Hell, this patient very well could have had hyponatremia (lower BP, confusion) and while we can't "fix" it, giving NS (hypertonic would be better) can go some length at diminishing the symptoms/ preventing death for a little bit.

Or you could be dispatched to a "BLS" transfer out of a shall remain unnamed level 1 trauma center going to Childrens and when you get there the kid is breathing 50+, tachy at 150-180, using accessory muscles and wheezing like an 80 y/o smoker, the RT has given 35mg of albuterol and 3 of atrovent and there isnt any prednisone or solumedrol to be found, and during Tx the kid looks at you and tells you that they are tired and want to sleep now... yea, it isnt just nursing homes...

 

[usalsfyre]

I'm discovering "specialty" hospitals (which we didn't have in the backwoods of East Texas) provide a whole 'nother level of "interesting" patients as well.

 

[the_negro_puppy]

Giving IV normal saline is a simple task/concept but on a second glance is much more complex. The dynamics of fluid shifts, osmosis, electrolytes and different conditions and injuries need to be taken into account.

We don't give out much NS here. Its indicated for inadequate tissue perfusion/shock.

Just remember you can always titrate more fluids, err on the side of caution by giving less.

 

[johnrsemt]

Be careful treating numbers: I had an ED doc order 1L fluid bolus on me; when I was in with Anaphalaxis due to my BP being at 92/50. Didn't ask, I had other things on my mind to ask why the high flow fluid. Later when I was asleep (after 2nd attack, same stay in ED) same doctor ordered Dopamine, due to BP of 88/48.
I woke up when the nurse bumped my arm, hanging the bag, looked at it and pinched the line off myself and asked to see the Doctor. The nurse got upset, told me that she wouldn't get the doc until I let the IV go: so I did, she left and I pulled the IV pole/pump closer and turned it off.
When the doc came in I asked him if he takes patient hx before he orders extra meds; when asked why I told him that my normal BP was 86-94/50. He said that he wouldn't have thought of that because so few people are that low.
GET PATIENT HX before treating numbers.

 

[BandageBrigade]

Wait..stop.. What?

I dont even think this lpn was the pt's nurse. She gave me a packet with the pt's labs and walked off. No report. I had to follow and ask what was going on. she said "abnormal labs." She didnt even tell me the pt had a bag hanging which my partner dc'ed and told me it was saline. Turns out it was a med and he forgot the name. Pt had a picc line which i cant use so i could either start an iv and give fluids or wait until the ed so they can use the picc and not need to stick her again. Pt was at around 102 sbp the whole trip. Bp was stable but low. ll other vitals stable and wnl so i chose not to stick her again.

My original question restated is, where is that line between needs fluid rescusitation, and doesnt. (for hypovolemia)

Im sorry, am I the only one who caught this? Is your partner a medic? If not, he has no business d/cing a med, told to by a nurse or not. Was this med supposed to be d/ced before transport? Was it finished infusing? If the answer to either of those is no then 2 emts had no business transporting this patient. Why did you not attempt to find out what med it was? You obviously had time and were able to figure out that it was a medication and not saline...

 

[systemet]

If they have fluid in their lungs but they're a little hypotensive, you may consider holding off on giving fluids and may opt for placing them trandelenberg.

So if they're hypotensive with pulmonary edema, it's not ok to raise their CVP / preload with fluid, but it's ok to do it by raising their legs?

And at the same time, it's going to be just fine to compress the diaphragm, increase the intrathoracic pressure and reduce the FRC?

 

[systemet]

I dont even think this lpn was the pt's nurse. She gave me a packet with the pt's labs and walked off. No report. I had to follow and ask what was going on. she said "abnormal labs." She didnt even tell me the pt had a bag hanging which my partner dc'ed and told me it was saline. Turns out it was a med and he forgot the name. Pt had a picc line which i cant use so i could either start an iv and give fluids or wait until the ed so they can use the picc and not need to stick her again. Pt was at around 102 sbp the whole trip. Bp was stable but low. ll other vitals stable and wnl so i chose not to stick her again.

Ok. You've got a little bit of a harsh reception, because some of the thing you did weren't that smart. You can choose to be offended by that, or you can listen. Judging by the fact that you recognised there was something to learn here, and posted a question, you're probably going to be a good EMT / medic.

You have some pretty major issues here:

* You didn't get an adequate history. This is your job. The LPN does not sound very professional or easy to deal with. But you have to get the necessary information from her. This may mean refusing to move the patient on to your stretcher before she gives you the details. It may mean looking for an RN or a physician in the facility. It may mean calling your supervisor and having them call the unit. But you can't just take a patient like this (potentially an ALS patient, btw), without better information.

* Your partner d/c'd a medication, without orders, without finding out what the med was!? You're now responsible for finding out what the med was, whether it needs to be re-initiated, whether the patient should be going ALS, and exactly what's going on! Would it mean something to you if that IV bag said "Dopamine 1600 ug/ul?", or "Cefuroxime 750mg"?

* You can't just throw your hands up in the air and say the LPN was unhelpful, or the sending facility were a bunch of retards. This might be true, but it won't get you out of trouble if and when something goes wrong --- because, believe me, if you keep doing this, it will happen. Someone will die, complaints will be made, the doctor's will circle the wagons, and unless there's demonstrable gross incompetence the attention will focus on the nurse's, the sending and receiving facilities and your company will all point fingers at each other, likely no one will get disciplined, but the one person left when the music stops without a get-out-of-jail-free card will be you!

My original question restated is, where is that line between needs fluid resuscitation, and doesn't. (for hypovolemia)

This is a difficult question to answer, because it's not a set number:

* Someone with a migraine headache may have a pressure of 150 systolic and benefit from a liter of fluid.

* Someone young with gastroenteritis who's been puking their guts out might benefit from a couple of liters but have a normal pressure.

* The hyponatremic marathon runner might just get pushed over the edge with a liter of saline.

* Your decompensated CHFer may need dopamine more than fluid.

To try and answer, it depends on a couple of factors.

(1) Is there a current disease process that is likely to be improved by fluid administration? -- here, we don't know what the disease process is, but it's sounding a lot like pneumonia.

(2) Is there a low risk that a current condition exists that would be worsened by fluid therapy?

(3) Does the potential benefit of fluid therapy outweigh the potential risk of fluid therapy in all situations, and if not, is the likelihood of a situation in which fluid therapy going to be detrimental small enough that you're willing to accept the risk for the patient?

With the situation described there's basically no history. So it makes it really hard to answer any of these questions. My suspicion is that this is a patient with pneumonia, that the med discontinued was likely an IV antibiotic, and that the "wet lungs" are probably rhonchi. She's probably dehydrated, and probably not truly septic, although she might be. If there's no history or indication of renal failure / CHF here, and other findings/history support dehydration, she'd get a 12-lead to do a quick due diligence check for STEMI, and I'd probably run through 500-1000ml fluid and reassess - depending on the 'lytes and how hypokalemic she is.

[If the hypokalemia is truly that bad, I'd consider a call to the receiving facility regarding initiating potassium at the sending facility, while recognising that their response is probably going to be, just bring her here, she's been compensating for hours, 30 minutes will be ok, which it probably is.]

 

[mikie]

Thanks MIEMSS

The only saline we give is in the flush (syringe), otherwise it's Lactated Ringers' for everyone!

 

[DV_EMT]

So if they're hypotensive with pulmonary edema, it's not ok to raise their CVP / preload with fluid, but it's ok to do it by raising their legs?

And at the same time, it's going to be just fine to compress the diaphragm, increase the intrathoracic pressure and reduce the FRC?

Hey, Im a basic... if their condition worsens...I can at least undo it by lowering their legs unlike you ALS guys... with your IV fluids an stuff