More harm than good

[chbare]

This is how I look at this situation:

We essentially have three outcomes to consider:

1) IV fluids help

2) IV fluids do not help

3) IV fluids harm

Because there is a lack of good evidence, I have to give equal weight to all three concepts and whatever concepts fall in between.

I can further consolidate these into two groups:

1) Helpful

2) Not helpful

Giving everything equal consideration, I have a 1/3 chance of helping, but the extent of this pro is unknown. However, I have a 2/3 chance of not helping with the extent being unknown.

Going by the numbers, I feel safer to error on the side of caution as I have to assume a 2 in 3 chance of not helping the patient.

Take care,

chbare.

[Just Plain Ruff]

I have also gone this route. I have seen enough whited out chest x-rays and then finding out that 1-3 liters of fluids have run in over the course of a code that I have limited my fluids to keeping the vein open and flushing the medication through the system.

I will open the iV to flush the meds, and then turn it down.

Pink frothy sputum seems to make me think that this is a bad outcome especially if the patient was walking around the local mall or ball park and collapsed in arrest. I tend to think that pulmonary edema was not the root cause of the arrest. Especially when the guy was a 44 year old very very active coach of his little league team.

[Richard B the EMT]

Thank you, "D-Man", it has been quite a while from when I had heard of what you described as the "H and Ts". I just never had them called that before.

[stcommodore]

You really have to operate off your protocol. If you give 3 liters in a trauma or code how many is actually used? 3:1 anyone?

[chbare]

You really have to operate off your protocol. If you give 3 liters in a trauma or code how many is actually used? 3:1 anyone?

I think you misunderstand the concept of 3:1? The fluid you administer does not magically disappear approximately an hour after administration. Much of the fluid may leave the vascular compartment, but that fluid goes somewhere and if not actively eliminated or changed via the various metabolic pathways, it remains within the body.

Take care,

chbare.

[Paramagic]

It's an interesting question, and not, I would think, one that is going to be answered anytime soon due to the massive numbers of confounding variables that come in to play in pre-hospital cardiac arrest.

Personally, I do not routinely push fluids during the arrest unless I have reason to suspect that volume depletion is an underyling cause of the arrest (eg PEA as presenting rhythm), but I will allow it to run TKVO and to use as a flush following drug boluses.

However we have been inducing hypothermia for several years now with 2 litres of ice cold normal saline given as rapidly as possible, and our experience has been that there has not been the problems with pulmonary edema that many were expecting. Now, part of the rationale behind using ice-cold fluid as opposed to other methods is that we are mounting a three pronged attack in the post-arrest patient: Hypothermia (which we should all be conversant with now), Hypertension (to maintain adequate cerebral perfusion - hypertension being a relative term, we are looking for 'normal' BP/MAP rather than just accepting any kind of perfusion as adequate) and finally, Hemodilution.

The main cause of further neurolgical injury in the post-arrest patient is reperfusion injury. Following the arrest there are large amounts of nasty stuff like calcium, glutamate and so on that is suddenly being moved around the brain to areas that may not have initally been as ischaemic or injured. The principle in managing this is to dilute these factors to minimize their impact: in essence 'flushing them out' before they can cause further injury.

As a result of our aggressive management of the post-arrest patient (as well as public education, co-response from fire, and a tiered system with well trained EMTs) we have a survival to neurologically intact discharge rate from bystander witnessed VF/VT of about 30%

We are soon to start a trial of cold saline induced hypothermia during the arrest, in effect managing the reperfusion injury before the reperfusion injury takes place, so it will be interesting to see how this pans out. It will take a number of years to complete however.