IV fluids for stroke pt's

[1EMT-P]

Why would a saline lock prevent pushing fluids?

A saline lock does not prevent you from pushing fluids, but there are some places that do not hang IV fluids on CVA patients. They start saline locks only!

[Kaisu]

I am not a big fan of starting saline locks only on CVA patients, especially if they are neurosurgical patients & going to be going to the OR. I can tell you from experience that during neurosurgical cases for cerebral aneurysms that they will sometimes induce moderate hypothermia by rapidly infusing IV fluids for cerebral protection.

And a lock prevents this how? In the hospitals I deliver patients to, if I don't put a lock on (prior to hanging a bag IF NECESSARY) the line has to be disconnected to allow a lock to be attached to the catheter hub.

OOPS.. beat me to it 1EMT-P.

What he said

Edited January 24, 2010 by CrapMagnet

[medickim]

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.

it's been in my experience that administering IV fluids ( normal saline ) at a t.k.v.o rate is not harmful and infact , if they need to admin T.P.A ( clot buster ) well they then have an IV access already established with your line and fluid running. I believe that as long as doing the line isnt delaying transport then its an acceptable practice and usually the nurses are thankful a line is running for them upon handover in the ER.

An intravenous line is inserted to provide drugs and fluids when needed at the hospital anyhow.

[kohlerrf]

Fluids here is contraindicated. I also noticed you did not check the blood glucose of this AMS patient? My first option would be a saline lock, if you don't have those I'm on the fence as to whether I would start a hypotonic solution like d5w or an isotonic like normal saline. I have heard that glucose is bad for a CVA but I think that came from the day when we use to give 25 grams of D50 to all patients who had an altered mental status, but we haven't done that since I climbed down from my dinosaur. I would have started a D5 line and kept is kvo, the small amount of actual glucose she would have received would be immaterial and d5w diffuses across the membrane not contributing to increasing the b/p.

Lastly if you going to hydrate someone then do it. To stand in front of your medical control doctor and explain why you gave a "little more than kvo but not enough for a fluid challenge" would be a waste of breath and a wrath coming from the doctor for my indecision would be more that I could bear. I think you made the right call not giving fluids at all.

[1EMT-P]

Fluids here is contraindicated. I also noticed you did not check the blood glucose of this AMS patient? My first option would be a saline lock, if you don't have those I'm on the fence as to whether I would start a hypotonic solution like d5w or an isotonic like normal saline. I have heard that glucose is bad for a CVA but I think that came from the day when we use to give 25 grams of D50 to all patients who had an altered mental status, but we haven't done that since I climbed down from my dinosaur. I would have started a D5 line and kept is kvo, the small amount of actual glucose she would have received would be immaterial and d5w diffuses across the membrane not contributing to increasing the b/p.

Lastly if you going to hydrate someone then do it. To stand in front of your medical control doctor and explain why you gave a "little more than kvo but not enough for a fluid challenge" would be a waste of breath and a wrath coming from the doctor for my indecision would be more that I could bear. I think you made the right call not giving fluids at all.

If you would please explain your rationale for saying that fluids are contraindicated. The purpose of IV fluids is to 1. allow fluid replacement & 2. provide for medication administration. The usual indications for IV fluid administration are as follows cardiac emergencies, dehydration, diabetic emergencies, respiratory emergencies, stroke, poisoning, seizures & trauma.

Edited January 26, 2010 by 1EMT-P

[1EMT-P]

I am sorry, but you must of have misunderstood what I said... I did not say that saline locks prevent you from pushing fluid. What I said was that I am not a big fan establishing saline locks only in these patients without fluids. As I am sure you are aware strokes are a leading cause of death & disability in the US. There are an estimated 700,000 strokes that occur each year in the US. It has been reported that over $23 Billion is spent each year on the care of these patients. In many parts of the US EMS agencies have stroke protocols & they work hand in hand with designated stroke centers to not only rapidly assess these patients in the field, but to also get them to one of these designated stroke centers so they can be treated aggressively. If a patient is going to be taken to the Cath Lab or OR for immediate treatment then it is important that we in EMS do everything we can to "prep" the patient, including having IV access x2.

Edited January 26, 2010 by 1EMT-P

[tskstorm]

Fluids here is contraindicated. I also noticed you did not check the blood glucose of this AMS patient? My first option would be a saline lock, if you don't have those I'm on the fence as to whether I would start a hypotonic solution like d5w or an isotonic like normal saline. I have heard that glucose is bad for a CVA but I think that came from the day when we use to give 25 grams of D50 to all patients who had an altered mental status, but we haven't done that since I climbed down from my dinosaur. I would have started a D5 line and kept is kvo, the small amount of actual glucose she would have received would be immaterial and d5w diffuses across the membrane not contributing to increasing the b/p.

Lastly if you going to hydrate someone then do it. To stand in front of your medical control doctor and explain why you gave a "little more than kvo but not enough for a fluid challenge" would be a waste of breath and a wrath coming from the doctor for my indecision would be more that I could bear. I think you made the right call not giving fluids at all.

We do not have gucometers on our trucks, so checking the bgl is out of question.

As far as the fluids go, we have no protocol dose for fluids, there are maximums for certain type of patients but the lowest maximum is 500cc for cardiogenic shock, after that the lowest is 2L ... Our protocols leave a lot of room for fluid interpretation, but the best answer I would give that medical director was I was titrating the fluids to maintain a b/p of xxx/xxx or to just maintain the blood pressure where it is.

[kohlerrf]

If you would please explain your rationale for saying that fluids are contraindicated. The purpose of IV fluids is to 1. allow fluid replacement & 2. provide for medication administration. The usual indications for IV fluid administration are as follows cardiac emergencies, dehydration, diabetic emergencies, respiratory emergencies, stroke, poisoning, seizures & trauma.

Perhaps I was not clear. I would by all means gain IV access. I would avoid administering any significant amount of fluid if I had to hang a bag and could not use a lock. The rate would be no more than KVO. This patient had no indication of fluid loss and secondly fluid administration does not provide for medication administration IV access does and the latter can be achieved with out fluid administration. In the absence of any signs of hypovolemia I am unaware of any indication or protocol that tells us to run fluids with no reason,if done this can very often lead to an adverse condition.

We do not have gucometers on our trucks, so checking the bgl is out of question.

As far as the fluids go, we have no protocol dose for fluids, there are maximums for certain type of patients but the lowest maximum is 500cc for cardiogenic shock, after that the lowest is 2L ... Our protocols leave a lot of room for fluid interpretation, but the best answer I would give that medical director was I was titrating the fluids to maintain a b/p of xxx/xxx or to just maintain the blood pressure where it is.

Our fluid protocols are a little more conservative than yours but I see your point. The titrating thing is a good though process but you have no indication of a falling blood pressure? Lastly you should lobby to get blood glucose monitors on the truck. A good portion of our elderly population is living on a fixed income while expenses are rising disproportionaly. Often times the first expense to be cut out is the regular check up with the doctor, next either some of the medications "that don't do anything" ,or, food and diet. I cant tell you how many malnourished elderly home alone patients were discovered with "slurred speech unable to walk" buy the niece that came to visit just to find they were hypoglycemic from poor nutrition. Administration of D/10 and 100mg thiamine made them right a rain and able to speak to social services at the hospital to get meal on wheels or some other correction. Most of all we did not have to set the wheels in motion for a Stroke Alert which would have cost hundreds or thousands of dollars. There are companies that give you BG monitors free all you have to do is ask. Check it out I think you'll have some success here.