when do you give saline?

[Handsome Robb]

Uhm... That's exactly like saying "treat the patient not the monitor". for the OP: What makes more sense to me is "treat the patient, not just the monitor.

I feel like we agreed but with different verbage...

Woohoo!!! I'll have Rob's snickerdoodle, please

This guy!!! I can haz halfs?

As for the elevated WBC + HypoTN I'm thinking infection. Like someone said, geris are immunocompromized therefore lacking the compensatory mechanisms to combat infection such as fever. Pneumonia with the unilateral rhales in the lung maybe?

 

[fast65]

Geez, I take one little nap and end up missing an entire page of discussion...

Anyways, you two will have to split the cookie PJ and Rob


Sent from my iPhone using Tapatalk

 

[DV_EMT]

Actually, you would be better off doing a fluid challenge of, say, 250cc and re-checking, and going from there.

Few CHF patients have pulmonary edema due to hypervolemia. Infact, most CHF patients are actually HYPOvolemic. Giving some fluid will hopefully bring up that BP a bit, 'priming the pump' to kick in Starling law, and keep more fluid from backing up due to inadequate contractile force. That fails and we move on to inotropes such as Dopamine.


And good luck laying a CHFer flat on their back / trendelenberg.

I agree, 3 things to note though:

1. EMT-B... only can transport NS, D5W, & LR. Drugs out of the questions aside from pt's own.

2. Refrencing trandelenberg - I meant it as if they were on a stryker gurney... only lifting the legs up... not putting them on their back (i've seen that go wrong a few times)

3. I know that CHF is indicative of decreased cardiac output, not necessarilly low blood volume (and in turn blood pressure).

 

[JPINFV]

2. Refrencing trandelenberg - I meant it as if they were on a stryker gurney... only lifting the legs up... not putting them on their back (i've seen that go wrong a few times)

Think about how trendelenburg is supposed to work and basic fluid dynamics. If the heart is above the legs, how are you increasing venous return to increase end diastolic volume?

 

[DV_EMT]

Think about how trendelenburg is supposed to work and basic fluid dynamics. If the heart is above the legs, how are you increasing venous return to increase end diastolic volume?

If the legs are higher than the heart but the patient is still reclined and tolerating it alright, then the fluid dynamics should work (ie: legs are at a 30-45 degree angle with the gurney and the head is reclined at around 15-30%). It may not be a huge difference, but you should in theory get some blood return.

 

[mycrofft]

Parse.

We are assuming you are not going to be determining whether they go to the hosp or not, you are there to transport a living person for admission.
So, what is the rationale for a NS IV, to save the ER some trouble? Or is the transport time long enough and the situation declining quickly enough that a TKO is necessary?
Are "challenges" and procedures exhibited necessary in the transport time, or ways of padding billing, or impressing the new ER nurse, or "just keeping my skills sharp" (no pun intended), or "just in case" (that's called a tort and a battery)?

1. What exact mechanism and benefit will the NS IV provide?
2. Is it rational in this setting?
3. Is it allowed?

Some people feel the need to have an IV swinging above every patient they bring in, useful or not. That might be called "Whackerism Level II".

 

[Shishkabob]

This wasnt a 911 call it was a BLS non emergent to the ed. The pt didnt have much going on except for the low bp and labs. Anyway, time for bed. I will come up with a different question for tomorow.

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.

 

[Aidey]

Did anyone else catch the fact that this is a 50 year old female in a SNF? I'm guessing she has a significant medical history, which is being completely left out of the picture here.

 

[paradoqs]

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.

I recently worked a marathon and the MD said never to treat hyponatremic runners with ns. So the question is, why would you give ns for some hyponatremia and not other hyponatremia?

 

[Shishkabob]

I recently worked a marathon and the MD said never to treat hyponatremic runners with ns. So the question is, why would you give ns for some hyponatremia and not other hyponatremia?

Normal sodium levels are 135-145. If you get in to the 120s, that's getting pretty severe. That shows how narrow of a range sodium is kept at in the body.

I don't know why the doctor told you that, that's your thing, but he was probably on the "I don't want an EMT-IV jacking with something they don't understand" spiel. But if I have a runner, at a run, who admitted to only drinking water and is in severe cramps, maybe a PVC or two, guess what they're getting? NS for sodium replenishment, as that's high on my differentials.



Confusion, 'hypotension', and low sodium levels... sounds like symptomatic hyponatremia should be on your list of differentials. Like I said, hypertonic saline would be more ideal, but most places don't carry anything aside from NS and Ringers. Though I don't advocate jacking with electrolyte balance if you don't understand what you're doing and the idea behind it, and can back up your decision.

 

[JPINFV]

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.

According to the OP, the patient was hypokalemic, not hyponatremic on the labs.

I wouldn't go about fixing sodium issues without labs as sodium concentration disorders are normally do to changes in total body water than total body sodium. Hyponatremia patients often have either too much water or not enough circulating volume while hypernatremic patients normally have not enough water. With out a basic metabolic panel (chem 7), where you can calculate serum osmolality among other things, you're most likely shooting in the dark with some causes. The runner following a race is an exception due to the recent history.

Another thing is for chronic (>24 hours) hypo/hypernatremic patients, you don't want to fix the condition too quickly or else really bad things will happen (osmotic demylenation syndrome and cerebral edema respectively).

 

[JPINFV]

Did anyone else catch the fact that this is a 50 year old female in a SNF? I'm guessing she has a significant medical history, which is being completely left out of the picture here.

Could be for rehab for something.

 

[Aidey]

Could be for rehab for something.

I know. But if she just had a hip replacement that would be pretty significant wouldn't it?

*facepalm* Semantics issue. Significant = relevant, not significant = major.

 

[Shishkabob]

According to the OP, the patient was hypokalemic, not hyponatremic on the labs.

All this talk about sodium and I got stuck on it

I wouldn't go about fixing sodium issues without labs as sodium concentration disorders are normally do to changes in total body water than total body sodium.

Agreed, I'm not advocating people just go out and bolus patients for the heck of it because a number is off or they're confused, but as stated, I'm not adverse to giving NS to things such as muscle cramps, which technically can be hyponatremia, as part of the differential.


I'm not going to bolus a SNF patient with a serum sodium level of 130

 

[usalsfyre]

Somehow the relevance of "elevated temp" and "altered labs" gets missed in EMS training programs.

It gets tiresome explaining to green providers why this patient needs an IV and a liter of saline, only to have them respond "no other medic does it that way" :facepalm:

I give saline a lot. Outside of the ESRD crowd, there are very few patients who can't take 500-1000mls without any affect other than a transient increase in UO.

 

[paradoqs]

Agreed, I'm not advocating people just go out and bolus patients for the heck of it because a number is off or they're confused, but as stated, I'm not adverse to giving NS to things such as muscle cramps, which technically can be hyponatremia, as part of the differential.

What about a runner with altered mental status that tells you they havent eaten today, and just finished a marathon and has s/s of hyponatremia. You would then give saline? If so, that is odd because the race MD told 50 medics/emts and captains that saline is an inappropriate tx for hyponatremia in this situation.

 

[Aidey]

I also had a MD tell me that he will continue to give all of his AMI patient's O2 because he had seen it help and if we could squeeze a couple more O2 molecules past the blockage that was a good thing.

Just becuase they have MD after their name doesn't make them infallible. As Linuss said the MD may have been dumbing it down for his audience.

 

[Shishkabob]

What about a runner with altered mental status that tells you they havent eaten today, and just finished a marathon and has s/s of hyponatremia. You would then give saline? If so, that is odd because the race MD told 50 medics/emts and captains that saline is an inappropriate tx for hyponatremia in this situation.

So many variables. They haven't eaten, so what's the BGL? Medical history? Meds? What other signs / symptoms? Maybe the doctor just didn't trust you guys?


If someone just got done doing a physical activity, haven't been hydrating well, and are complaining of cramps / things of that nature, yes, I am doing some fluids.




At the risk of annoying JP... Just because someone has MD / DO at the end of their name doesn't mean they're the end-all / be-all of intelligence. You'll meet plenty of, well... silly... doctors, medics and nurses in your career. That's why you need to further YOUR education, so you can know when something is or is not called for. There are EMS agencies that have medical directors that have no other experience in emergency medicine aside from the rotations they did during medical school decades ago and just do it to collect the easy check, not for proper patient care. Granted, if that physician is your med control, that really constrains what you can do, but still.

 

[usalsfyre]

To be fair, I'd have to think long and hard about treating hyponatremia with 0.9%. In dilutional hyponatremia you do actually stand a chance of increasing TBW and worsening the issue. If the patients actually dehydrated your safe treating with NS, if the patients been hydrating well but has not been taking electrolyte, tread carefully.

Given the situations above? I'd make the runner eat if able and I'd let the ED sort out the SNF patient. The only time I'd start adjusting sodium would be an extended CCT where I had 3% saline and an iSTAT available. There's much badness to be had from getting it wrong.

 

[Shishkabob]

To be fair, I'd have to think long and hard about treating hyponatremia with 0.9%. In dilutional hyponatremia you do actually stand a chance of increasing TBW and worsening the issue.

Given the situations above? I'd make the runner eat if able and I'd let the ED sort out the SNF patient. The only time I'd start adjusting sodium would be an extended CCT where I had 3% saline and an iSTAT available. There's much badness to be had from getting it wrong.

Agreed fully.

But the Ops question wasn't about fixing, but more so when it a fluid challenge, or ever TKO warranted, and it comes back on a "case by case basis", determined by your knowledge and experience. You know me, usual, I don't go around bolusing every altered patient... well... not with NS anyway