IV fluids for stroke pt's

[tskstorm]

Yesterday my partner and I had a patient, 90 year old female, found on the floor unresponsive by granddaughter. The granddaughter stated she stepped out to make something to eat, and when she got back her grandmother was no longer sitting but but was on the floor. We found patient on the floor awake, but disoriented, no motor weakness on left, but minor facial droop, slurring speech (as per grand daughter) and deviating tongue to the left, no arm drift. PMH High Chol, and 2 strokes granddaughter didn't know if there was a lasting defect. Meds: ASA and lipitor. V/s: B/p 130/90, 68 HR, 14 RR, pupils PERRLA CTC, pale, moist, warm, ECG NSR 12 lead I wish I had saved it to post however it was NSR no elevations depressions, only thing I had noticed was the QTC was 521. We treated with local stroke protocols, which is oxygen, Iv, notification and Diesel therapy (load and go.) During transport I looked at my partner, and said, want to give her some fluids as well? He asked a great question, why? My only answer was, I remember someone(I don't remember who) saying to do so, but the physiology behind it was a mystery, so we skipped the fluids. At the end of the night, My partner and I had just clocked out, and were throwing around a football in the snow, trying to burn off some energy, after a long night. One of the Dr's come's out of the hospital and joins our game, and proceeded to tell us the Stroke notification we brought in went right up to cat scan and they found only old damage, but after coming back down to the ER they found she was having a Non-STEMI MI ! They found an Elevated troponin level. Of Course this is not relevant to the main question, which is why or why would you not give IV Fluids to an acute stroke patient, and what the reason behind it is.

[treaux]

This one is pretty simple. Considering a stroke pt is either having a blockage or a bleed, why would you want to raise the pressure in the blocked or bleeding vessels by adding fluids?

Sounds like the call was a good learning experience and an inadvertent discovery with the MI. What was the cause of the acute ALOC then?

[Kiwiology]

I think you did the right thing witholding the fluid; IV fluid, like oxygen, has no "magic" properties and if I venture a guess, is probably given to patients when it is not clinically indicated in quantities above what is required

[NRPinNEPA]

With a stroke, you're going to have hypertension, so why would you want to add more volume to the container? I would just throw in a lock or (if my service didn't have locks) a 250cc bag of NSS KVO.

[tskstorm]

First, every job is a good learning experience, all depends on what you take from it.

Secondly I feel I should clarify, I'm not talking about a fluid challenge that would significantly raise b/p, more like a 500cc/1L bag set to a little more than Kvo, a little less than wide open. Our transport time from scene to stroke center was less than 5 minutes, I would approximate, even wide open, in this time the patient would have received no more than 300cc's. It seems I'm trying to justify myself, guess that's because it doesn't make sense and I'm trying to make it make sense.

Going to have to dig up more information on this.

[Kiwiology]

It seems to me in my looking around that "IV NS (or D5 or LR or whatever) TKO" is as ubiquidos as "O2 @ 15lpm NRB" meaning most people seem to get it.

There is nothing magic about IV fluids (except in a specific subset of patients) and I venture a guess that people recieve it, in quantities that are above what is required when not clinically indicated.

IV fluid only has benefit (as I see) in patients who

- are shocked and need volume replacement

- are dehydrated and need water replaced

- are on IV mediciatoons that are mixed with D5

Where are Shires and Pepper Jenkins when you need them?

[chbare]

Your best bet is to establish a line at KVO of an isotonic (non-dextrose ) containing solution assuming a normal blood sugar. While the concept of HHH therapy may apply in some cases, doing so in the pre-hospital environment is not a good idea. In fact, staying away from messing with blood pressure is a good idea. If hypotension or a fluid volume deficit exists, give fluids by all means, but overhydration with IV fluids and all that crazy stuff is not for the pre-hospital environment.

Do not get crazy with fluids guys unless you need to correct a deficit.

Take care,

chbare.

[treaux]

When you are considering giving IV fluids, medications or whatever, the question should be "Why am I giving this medication?" instead of "Why not give this medication?"

There's the old saying I also received in medic school which is "Everyone can use a cup," but I think times have changed and a fluid bolus requires a reason just as oxygen does.

I start saline locks on my stroke pts since if I hang a bag it will simply be removed upon my arrival at the hospital and I can start two saline locks in the time it takes for me to set up one 1000cc bag (don't ask why this is so because you'll just get my rant about employers buying cheap equipment).

[SHARK1]

lETAS LOOK AT THE PATHOPHSIOLOGY OF A CVA. YOU HAVE A THROMBUS, EMBOLUS, LUCANA, ANYERUSIM,PONTINE HEMMEROGAE IN ANY CASE THEY ARE ALL CLOSED HEAD INTERVENTIONS. I HAVE NEVER SEEN A PERSON WITH HPOTENSION GET A STROKE , MAYBE HYPOTHERMIA WITH A RECIRCULATION DISPBRITUTION BUT FOR ALL INTENTS AND IMPRESSIONS HER BP WNL WHICH BASICALLY RULES OUT LUCANA AND WITH HER EYES PERRLE R/O PONTINE AND DID YOU SEEK ANY ADDITIONAL HISTORY PERTINENT LIKE EAR INFECTIONS SINUS INFECTIONS OR ANY OTHER TYPE OF BRAIN DISORDER LOU GERIG, MYASTHINIA GRAVIS ETC. THIS WILL HELP YOU IN YOUR QUEST HER ECG WAS NSR AND NO POSSIBILITY OF STOKES ADAM. IT SEEMS LIKE A STOKES ADAM WITH A UNDERLYING POSS MI DIN'T SAY ANYTHING ABOUT DIABETES. GERIATRIC MEDICINCE IS A BRANCH ALL IN ITS OWN AND REPEAT EXPOSURE AND GOING OVER YOUR ALS REPORT WITH YOUR MD WILL HELP IN HONING YOUR SKILLS. a FLUID CHALLENGE TO R/O SOMETHING IS NOT PRUDENT IN THIS SITUATION.

CAPT MITCHELL STERN, AS, MPH, EMT-4, NCEMT-4 (RET)

Edited January 9, 2010 by SHARK1

[treaux]

I can't even begin to comprehend what shark here posted, but I feel it's safe to say his caps lock key is on.