CHF - no more Lasix?

[Kaisu]

I have caught a rumor of a shift in some parts of the country to decreased emphasis on diuretics in cases of CHF. Does anyone have information on this? I'm thinking specifically of studies and/or the reasoning behind this. Any help or info you can provide would be greatly appreciated.

[JakeEMTP]

I have caught a rumor of a shift in some parts of the country to decreased emphasis on diuretics in cases of CHF. Does anyone have information on this? I'm thinking specifically of studies and/or the reasoning behind this. Any help or info you can provide would be greatly appreciated.

While we have Lasix available to us, just recently under the "new and improved" State wide protocols, we have to receive orders to administer it. Previously, we didn't require the orders. We consider ourselves fortunate as some services have had it removed from their bag of tricks. Now we are to, and rightfully so in my opinion, treat CHF, Pulmonary Edema with nitrates and CPAP. If the patient can't tolerate the CPAP, we can administer Versed or Valium to make it somewhat more tolerable. The thinking is, Furosemide is of no real benefit in the pre-hospital arena. Let me state that I am a firm believer in total pt. care and do not need to see a result of an intervention to think I benefited the pt. somehow. Now though, if Furosemide is not benefiting my patient and in fact, maybe doing harm, I will be hesitant to use it, or at least think about it.

I can't seem to find but a few links to articles about Lasix and it's use in the pre-hospital setting which support it's non use. (if the truth be told, there are several, but they for the most part say the same thing)

http://www.ncbi.nlm.nih.gov/pubmed/16531376

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

Because diuretic's work slowly as compared to nitrates, there really isn't a benefit to it's pre-hospital use according to the articles. In fact, pt. outcomes have not been shown to improve with the administration of diuretics in the field.

As I stated earlier, we still have it due to the fact our Medical Director still want's it on the ambulance. In order for it to be approved though by the powers that be in Raleigh, we now have to obtain orders from Medical Direction to administer it. Got to love politics.

Here is a link to the NC Pulmonary Edema Protocol.

http://www.ncems.org/pdf/Pro28-PulmonaryEdema.pdf

Edited February 5, 2010 by JakeEMTP

[Kaisu]

These studies seem to indicate harmful when an inappropriate field diagnosis is made. In the case of the CHF patient, as opposed to pneumonia, etc. I do not have the luxury of CPAP. My concern was that the one thing I have available is a diuretic. (short of weird crap like nasal intubation.) The only downside I could discern is causing an electrolyte imbalance in this patient.

At this time, I do not have to get orders for lasix. This change appears to be precipitated by the "we got idiots in the field so let's write a protocol based on the lowest common denominator" thinking that makes me nuts.

[JakeEMTP]

This change appears to be precipitated by the "we got idiots in the field so let's write a protocol based on the lowest common denominator" thinking that makes me nuts.

I disagree. I don't think it for the reason you state at all. If it is of no benefit to the patient, then why are we giving it? Why do you give diuretics? Because you can? It is possible you are doing your patient's a disservice by it's administration. Just food for thought. No flame intended.

Here is another article I found.

http://www.jems.com/resources/supplements/eagles2009/meds_under_scrutiny.html

[Kaisu]

I disagree. I don't think it for the reason you state at all. If it is of no benefit to the patient, then why are we giving it? Why do you give diuretics? Because you can? It is possible you are doing your patient's a disservice by it's administration. Just food for thought. No flame intended.

Hey none taken. I appreciate open disagreement. How else would I ever learn anything?

[JakeEMTP]

Hey none taken. I appreciate open disagreement. How else would I ever learn anything?

With that statement, I am in total agreement. We learn from each other constantly, one of the things that keeps me coming back here. Many threads I can't even enter, but I will always take something away from them.

[JakeEMTP]

I do not have the luxury of CPAP.

This is something however that does work. Your service and Medical Director should really look into acquiring it.

[Kaisu]

This is something however that does work. Your service and Medical Director should really look into acquiring it.

No kidding. I used it on CHFers in the progressive state I was trained in. I'm still trying to get 12 leads on our rigs here.

[JakeEMTP]

I'm still trying to get 12 leads on our rigs here.

[treaux]

We recently got rid of Lasix where I work as well, and I'll tell you how it was explained to me. Keep in mind, I don't feel I have enough information to say one way or another. I'm just repeating what I was told.

Prehospital lasix administration in patients with rales has caused numerous complications in patients suffering from pneumonia. According to our medical director, it is near impossible to accurately rule out pneumonia without blood work and a chest x-ray. Even the acute onset patients in the SNFs can't be given lasix due to the fact that they often have underlying cases of pneumonia as well.

This was the reason they gave us. I haven't done much research on it however. If anyone knows more, feel free to post it.