Treatment for Asthmatics that are on MAOI's or TCA's

[Dustdevil]

How many of you, when treating hypostensive CHF patients, administer a small fluid bolus to increase the BP to a level which permits treatment of the underlying CHF? This is illustrative of a therapy that runs the risk of at least temporarily worsening the patient’s condition in order to treat a more life threatening condition

Please define hypotension, in the context of this particular patient. I'd also like to know why you feel it is life-threatening, as well as why a fluid bolus might correct it.

[captainstandup]

This statement was unrelated to the asthma / MAOI discussion. I was trying to make a comparison between patients in congestive failure who are marginally hypotensive preventing nitrate administration. These patients can benefit from a small fluid challenge which temporarily improves their overall hemodynamic state to a point allowing other therapies without causing harm.

With this said I understand that we do not rely on BP alone in determining a course of action There are several additional considerations including determining whether the overall problem is related to rate, pump, container or "relative container" problems.

Due to the "fact" there seems to be few meds a person taking MOAI's can utilized in treating acute asthma attacks, I was wondering of this isn't simply an issue where the potential for gain outweighs the risk.

[Dustdevil]

This statement was unrelated to the asthma / MAOI discussion. I was trying to make a comparison between patients in congestive failure who are marginally hypotensive preventing nitrate administration. These patients can benefit from a small fluid challenge which temporarily improves their overall hemodynamic state to a point allowing other therapies without causing harm.

Right, I understood the context. What I would like to understand is, by what physiology would a fluid bolus be expected to correct hypotention in CHF? And would this apply to all types of CHF?

[Connie31079]

Does this discussion pretain more to the MAOI/asthma med combo, or the TCA/asthma med combo?

Reason I'm asking is I'm an asthmatic. I treat myself with ventolin puffer p.r.n., and occasional ventolin/atrovent combo via nebulizer @ work when I feel an attack coming on, and my lungs sounds especially "tight".

I'm also on Elavil for migraine control.

I haven't found any problems with administration of the 2, either consecutively or concurrently.

[Connie31079]

Right, I understood the context. What I would like to understand is, by what physiology would a fluid bolus be expected to correct hypotention in CHF? And would this apply to all types of CHF?

I asked this specific question to my Q & L coordinator a few years ago, because I, too, wondered why we were giving a "small fluid bolus" to a patient in acute CHF, when I figured the fluid was the problem, and that was what we were trying to eliminate!

Here's the link to my protocol: http://emergency.medicine.dal.ca/ehsprotoc...?ProtID=6285.03

My Q & L coordinator told me that a "small" fluid bolus (250-500 cc) to a CHF patient helps determine if it's a "pump, rate or volume" problem, and "it gives the heart something to pump" (before going to a vasopressor, like dopamine?)

This would, I suppose in theory, raise the BP somewhat. Maybe not enough to de-classify them as being hypotensive anymore, but just to see how the body would react to it? Still might need that vasopressor, I suppose, if the "small" fluid bolus didn't bring up their BP.

Made me scratch my head, thinking I was doing more harm that good to a CHF patient, but if it's in our protocols, it must be there for a reason! Our Provincial Medical Director wouldn't have given us that protocol if he knew it was going to kill anybody. Afterall, he's the doc, and I'm not.

[triemal04]

Right, I understood the context. What I would like to understand is, by what physiology would a fluid bolus be expected to correct hypotention in CHF? And would this apply to all types of CHF?

I'll take a stab at it. For left heart failure anyway. In both systolic and diastolic CHF stroke volume has decreased; a bolus of saline would increase cardiac preload, which should in turn increase cardiac output, and possible raise the BP. I think. With systolic failure the left ventricle has problems contracting, while diastolic has problems relaxing after contracting preventing proper filling of the ventricle; either way, if the preload get's increased and myocardium stretched, I'd think that the output would increase.

The problem with that is that the goal to treating CHF as I learned it is reducing preload and eventually reducing afterload; decreasing preload will decrease the pressure in the pulmonary capillaries and slow the amount of fluid leaking, reducing afterload should help to increase cardiac output, which should then also decrease the pressure in the capillaries. Giving nitro (and lasix, though the effect is delayed) helps to decrease preload on the heart through dilation; lasix does it through getting fluids out of the body and a bit of venous dilation as well. So giving saline, while it should increase output due to the increased preload, it'd also possible increase the pressure within the pulmonary capillaries and push more fluid into the lungs. Don't know, but I'd think that giving a small bolus to a pt who was hypotensive to raise their pressure high enough to give nitro would help overall; initially I don't think it would, but as the nitro took effect it should help more.

As an aside, I do know one paramedic that gave a hypotensive CHF'er (on a doc's orders) a dose of SL nitro. And then after the pt's pressure increased, another dose. And another... Which makes some sense, but definitely doesn't sound right when you hear about it.

[courageheartx]

1.High flow oxygen

2.Comfort.

3.Transport

[JPINFV]

1.High flow oxygen

2.Comfort.

3.Transport

Damn, so easy a 16 year old high school student can do it.

[courageheartx]

Damn, so easy a 16 year old high school student can do it.

You would think so eh?

[JPINFV]

Only because our sixteen year olds are teh smert. S-M-E-R-T smert. America's hat need not apply.