ERDoc

Argh. You are right Mobs. All of this discussion has confused me as to the status of the OP. You are correct, if you have asymptomatic hypervolemic hyponatremia you would treat with fluid restriction and diuretics. The same goes for euvolemic hyponatremia. The only exception being in pts with neurological issues. Then your first concern is to fix the sodium to stop the seizures with hypertonic saline. Hyponatremia management is one of the more difficult concepts to understand much less try to discuss in an internet forum as we have seen here, lol. Please never be afraid to challenge me. I enjoy it and sometimes I am wrong and it needs to be pointed out so that people don't learn the wrong thing.

For the US providers, is there any reason you have not joined NAEMSP? I am not recruiting for them, nor am I a member. I'm just curious.

Bonjour Secouriste! Welcome to the site (yeah, I'm a little late. What else is new?) What part of France are you from?

You are right and wrong Mobey. EMS should not attempt to start correcting the sodium, unless the hospital has already PROPERLY calculated what the proper correction is. Again, the only time hypertonic saline should be used is when there are neuro symptoms such as seizures, confusion or ataxia (not enough info in the OP to say if this is indicated). Otherwise normal saline should be used. NS has 154mmol/L of sodium versus 130mmol/L for LR, so you get more sodium for your volume. You will want to slowly correct the sodium using one of the accepted formulas (http://www.medcalc.com/sodium.html). SInce this pt is probably hypervolemic, lasix would be appropriate also but you will need to check lytes every 2-3 hours so this is obviously not something you can do in the field. We could do the calulations to see what the rate would be if we knew the pt's weight and chem 7.

I'm not a sponsor (hangs head in shame), but I don't think it's working.

I'm not sure but I think our newsbot has electronic new diarrhea.

I guess I was thinking more like organizations that include MDs, DOs, RNs, etc and deal with emergency medicine in general, not just prehospital.

I'll leave that for the majority to decide.

Unless they were talking about clotting factors/platelets. The chances of your hospital having them, if they had to transfer someone like this, is pretty low. Again, that is speculation.

To be honest Ruff, I have no idea what they were talking about. When we transfuse someone slowly were will give it with LR but for a massive, life threatening bleed, you dump the blood in. There are potential issues from massive transfusions of blood but nothing you can do about it in an ambulance or an ER and there is minimal evidence to support anything anyways.

I will let you know but this summer I'm going to experiment with giving it lots of caffiene and nicotine and telling it about becoming nonconformist and feeling pain.

The retroscectroscope is always 100% acurate. I think your example, Ruff, shows the disconnect between EMS and many physicians. They don't seem to understand that you only have what is available to you in the ambulance. You don't have a fully stocked pharmacy or pyxis that can send you what you need.

I was just curious if anyone here was a member of one of the national organizations in emergency medicine. I realize this is more directed at the other US residents on here. Anyone belong to NAEMSP? I was a little saddened when I looked at the ACEP website and realized that they don't have a preshospital membership category even though they have an EMS section and now EMS is becoming a subspecialty. It seems to me like they may want to start involving those that will be affected most by their decisions.

This is a topic where if you ask 10 people their opinion you will get 12 different answers. I've seen both sides of the coin while in the field. I've seen people whose head barely fit through a door they were so big that would stay and play on all scenes and then people who were so insecure in their skills that everyone was load and go. I think this is where the old art vs science of medicine comes in. You will never find a perfect answer. Prehospital RSI is debated in the literature and on internet forums ad nauseum. While the current evidence is leaning away from RSI, you do have to look at the current situation. It is one thing to load and go with an unstable airway when the hospital is 10 minutes away with competent docs waiting with airway equipment at the door versus being 90 minutes aways from a competent doctor at some form of trauma center. The first pt is probably better served by loading and going (which I would argue is supported by the current literature) while the second one is not going to make it half way to the hospital without a stable airway. As pointed out, the staff at the closest hospital will also affect your decision. A FM trained person who has never had to care for a difficult airway will shit bricks and probably butcher the airway (overgeneralization, I know) while your EM trained doc will be ready, tube in hand, chomping at the bit to get in there, with the scalpel only feet away, ready to go. I feel bad for any of you guys who get reamed in cases like this. There is no right answer. I try not to criticize the EMS crews for things that don't make sense to me when they come in, unless it is blatant stupidity. I wasn't there and was not part of the thought process (of course I've been on both sides so I have a little extra knowledge of what happens in the field).

As a Yankees fan, you have my sympathies but at least you get to have the All-star game this year. I am thinking about making a trip back home to watch the game. It's 45 degrees at 9am here and all of the snow is melting. I can see my grass again and it is just begging for a good trim. Can't wait to get out there and cut it. I say that now, but usually around August I start wishing my lawn was emo so that it would cut itself.

There are many other symptoms of hyponatremia. Seizures are the end-stage, worst case scenario. As for what should have been done for the pt in the OP, the physician should know how to calculate the rate at which the sodium should be corrected to determine fluid rate. Arctic should not have treated it on his own unless he knew how to properly calculate the proper drip rate. HypoNa is pretty complicated to instead of going into superficial details, check out the emedicine article: http://emedicine.medscape.com/article/242166-overview

You are correct, those would have been much better options.

Always glad to help. Let me know when one of those smart doctors joins the site.

No no no. Never give hypertonic saline to someone who is hyponatremic unless they are seizing. If you correct hyponatremia too quickly you will cause central pontine myelinolysis. Dehydration by itself is treated with fluid replacement. If there are electrolyte issues that is where you have to start getting fancier.

This is probably one area where EMS has more expertise than docs do. I have never done a nasotracheal tube. In the hospital we have so many back ups that it is almost unheard of (either that or I am just that good ). I've seen a handful of nasal tubes come in and I switch them over to orotracheal as soon as possible. I can't say there is a reason other than comfort level.

There is no right answer. IV fluids have been debated since the early 20th century and every few years a new article pops up that reignites the debate.

I agree with you Dwayne, they are in it to make money so why wouldn't it be about profit? It's well know that they are not a not-for-profit outfit. To the OP, I think your experience will vary depending on the specific site you work for more than it will on working for AMR in general. My MIL worked for them in NY where all they did was nursing home transports and renal roundup (no 911). As long as you did your work they didn't give you any problems. Your best advice will come from those who have actually worked at the site you are interested in. Good luck.

Agree on all points. Show me the evidence.

In reference to the LR, are you talking about now, after the damage has been done or initially with the hypoglycemia?

The issue here is not the dextrose at all, it is the water that is being given. This pt has either euvoloemic or hypervolemic hyponatremia (I'd go with hypervolemic). Giving free water without electrolytes will lead to hyponatremia. Remember that woman that died in the "Hold your pee for a Wii," contest? This is pretty much the same thing.