Battle for the Loop

[Niftymedi911]

I'm curious to seek a response on this issue. I brought it up in chat and got a good response. My agency has been talking for a while about removing Lasix for our guidelines. We practice evdience based medicine and always are looking to see what's good and what's not so good. I myself rely on early SL NTG and CPAP with Tridol Drips. I want to see what other providers think about this. Vote on the poll and then DISCUSS wether or not the use of pre-hospital Lasix is beneficial, harmful,or a back-in-the-day TX that should of been removed ages ago.

Here's some food for thought references and studies:

http://http://chestjournal.chestpubs.org/content/92/4/586.full.pdf From 1987

http://http://emergency-medicine.jwatch.org/cgi/content/full/2006/613/1 From 2006

To take it a step further... What do you think about the removal of MS in tx for pulmonary edema?

Edited December 29, 2009 by Niftymedi911

[Kiwiology]

I don't support lasix pre-hospital; it might have been a good treatment a decade or two ago (but heck so were M*A*S*H pants (MAST) and prophylactic lidocaine right?).

A patient with a CPE is going to be third spaced and may infact be hypovolemic, so if we dose up him on lasix he's going to piss like a racehorse at the Kentucky Derby and deplete more volume. We also run the risk of causing him to become [more] hypokalemic or hyponatremic.

Differential diagnoses is also really important and something I anecdotially hear a lot of medics are pretty bad at; it doesn't take a rocket scientist to work out a chest infection from a CPE yet apparently it's out there! The Los Angeles study cited includes differential diagnoses of LOWER BACK PAIN and HYPERVENTILATION as those who may or may not recieved GTN, laxis and morphine as the Paramedic assessment was a CPE. Does anybody see the problem with potentially loading up somebody on these drugs, and, more overarching, working up LOWER BACK PAIN as a pulmonary edema? It's 5am here and I tell you what in my semiconscious state, I can differentiate a CPE from wait for it, LOWER BACK PAIN! Now, where did I see LACoEMSA pull frusemide from lately, ah yes, Los Angeles .... suprised?

I'm mixed on morphine use in CPE. Now I did see one study (retrospective) on CPE outcome in hospital where ambo had dished out morphine but it was poorly designed and I bet was riddled with false positivies.

http://www.ncbi.nlm.nih.gov/pubmed/18973635?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=18

http://www.ncbi.nlm.nih.gov/pubmed/19234030?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=14

These studies suggest it may infact be of harm and not benefit. I was educated that morphine is not an effective treatment for CPE and is used for relief from anxiety and (possibly?) some of its bronchodialatory effects but I bet you there's better bronchodialators out there than morphine, salbutamol anybody?

[Niftymedi911]

I too agree with Lasix being a back-in-the-day Tx. With all the same issues you have presented.

The big thing I have with MS is simple. Fundementally, If you got someone who's already working their butt off to breathe, why in the heck to do you want to kick their drive to breathe out from underneath them?? MS does have vaso and bronco dilatory effects, but they do not have enough effects for the Dx you are trying to treat. I think that further sedating their ability to breathe to maintain their own PEEP, its a definate FAIL. Leading to the increased mortality in patient's seen in every study that has utilized MS. WARNING: Last statment is my opinion and generalization.

[Niftymedi911]

Waht in the world is going on? What's with nobody besides Kiwi posting? Am I that bad?

[spenac]

I personally feel there is a time and place for lasix. I disagree with the complete removal of it. Why in EMS do we do everything based on tradition and if we make a change instead of just changing guidelines we go to the other extreme?

[Kiwiology]

I personally feel there is a time and place for lasix. I disagree with the complete removal of it. Why in EMS do we do everything based on tradition and if we make a change instead of just changing guidelines we go to the other extreme?

Now for you out in the sticks it may be different as onset of action is generally 15-30 minutes IV

In what situations do you think frusemide is appropriate?

[chbare]

Lasix remains quite popular in many areas of the country; however, many patients are in fact not fluid overloaded by conventional wisdom. It is exceedingly difficult to detect electrolyte derangements and traditional fluid overload in the conventional EMS environment. Many newer guidelines seem to suggest preload and afterload control before considering lasix in the setting of cardiogenic pulmonary edema. In addition, therapies that are starting to become popular in EMS such as non invasive positive pressure techniques can help in selected cases. Therefore, lasix may not have as big a role in the pre-hospital environment. However, I would not say the use of loop diuretics is down and out just yet. With that, I see a push for newer modalities such as ACE inhibitors.

Take care,

chbare.

[mobey]

Now for you out in the sticks it may be different as onset of action is generally 15-30 minutes IV

In what situations do you think frusemide is appropriate?

Non-Cardiac Pulmonary edema, such as kidney failure.

As a side note.

I agree that Lasix is not curing the problem in heart failure induced PE, however.... when your out in the sticks like me and spenac, removal of ANY tools can be very dangerous. Lasix may mean the difference between a et tube or a foley out here in no-man's land. Even if I AM dehydrating the patient, (in a true heart failure patient) dehydration is waaaay more practical then tubinmg them.

Lasix has recently been pulled off of the "Big" city services around here..... rumor is, the med director was sick of pneumonias getting Lasix by mistake.

Lasix (Furosemide)

Class: Non-Potasium sparing loop diuretic (Sulfonamide)

Indications: Treatment of edema associated with heart or renal failure

Contraindications:

Special precautions:

Pregnancy safety:

[Kiwiology]

...even if I AM dehydrating the patient, (in a true heart failure patient) dehydration is waaaay more practical then tubing them.

Lasix has recently been pulled off of the "Big" city services around here..... rumor is, the med director was sick of pneumonias getting Lasix by mistake.

I agree with what you are saying mate, although we could also argue if you're running out this guys volume over an extended period (say an hour or two hours for transport) is that going to be worse? Well, then again, whats worse, dehydration or death?

Edited December 31, 2009 by kiwimedic