Sigh...Is there anyone who can add 2+2 here?

[scubanurse]

No no no. Never give hypertonic saline to someone who is hyponatremic unless they are seizing. If you correct hyponatremia too quickly you will cause central pontine myelinolysis. Dehydration by itself is treated with fluid replacement. If there are electrolyte issues that is where you have to start getting fancier.

Sorry, I just went back and re-read this... That's what I was saying. Symptomatic hyponatremia... the only symptom we were taught to watch for was seizing.

[Arctickat]

I got a question for ya though: Could/Should Arcticat treat this patient with Normal Saline while transporting to the city?

(I have NO idea if he did or not..... this is NOT an excersise in judging my Sk brother, just getting some juices flowing amongst my peers)

I'll let you know what I did after some answers come in.

[HellsBells]

In reference to the LR, are you talking about now, after the damage has been done or initially with the hypoglycemia?

I was refering more to the clinical setting where the pt received the 9L of fluid with his dextrose.

[ERDoc]

Sorry, I just went back and re-read this... That's what I was saying. Symptomatic hyponatremia... the only symptom we were taught to watch for was seizing.

There are many other symptoms of hyponatremia. Seizures are the end-stage, worst case scenario. As for what should have been done for the pt in the OP, the physician should know how to calculate the rate at which the sodium should be corrected to determine fluid rate. Arctic should not have treated it on his own unless he knew how to properly calculate the proper drip rate. HypoNa is pretty complicated to instead of going into superficial details, check out the emedicine article:

http://emedicine.medscape.com/article/242166-overview

[Just Plain Ruff]

This scenario sounds like this one

Transfer by ground ambulance - birds can't fly in a blinding blizzard. Guy has a significant leaking AAA and he's going to die, it's just a matter of time.

I'm the driver, I have three nurses in the back of the ambulance.

They are given 9 units of blood to give to the guy during the transport. Were told if they can get all 9 units in so be it, but get as much in as you can.

Takes us 2 hours to get to the big guys, about 20 minutes out of the big hospital the AAA pretty much ruptures and we end up doing cpr on him the rest of the way. On arrival they crack his chest and a shitload of blood goes everywhere, the proverbial bloodbath.

All i hear from the ED Staff and the docs is "What the hell was that Ambulance crew thinking dumping all that fucking blood in him" and the nurses at least stood up to that criticism and said that our docs were told by your doc to put as much blood in him as possible to keep his pressure up. It shut them up.

We dumped 7 units in the guy.

The main criticism that was levelled after the fact because they did get him out of the ER alive was that his blood levels were so far out of whack because we didn't give any of the other fluids that were needed (I draw a blank as to what those were) in order to keep his electrolytes and fluid levels at a safe level. forgive me for not having those additives in my head right now.

But the guy survived only to die two days later from DIC or some other nastiness.

[ERDoc]

The retroscectroscope is always 100% acurate. I think your example, Ruff, shows the disconnect between EMS and many physicians. They don't seem to understand that you only have what is available to you in the ambulance. You don't have a fully stocked pharmacy or pyxis that can send you what you need.

[Just Plain Ruff]

The retroscectroscope is always 100% acurate. I think your example, Ruff, shows the disconnect between EMS and many physicians. They don't seem to understand that you only have what is available to you in the ambulance. You don't have a fully stocked pharmacy or pyxis that can send you what you need.

But couldn't the receiving doctor have asked us to add those additional items that would have helped the guy out. I'm not sure what those items were but they were the talk of the ER at that moment. Help me with the names of the additives that would have been beneficial to the patient because we were going from one ER to another and our pharmacy would have had those items at it's disposal to have us give to the patient wouldn't they have?

[ERDoc]

To be honest Ruff, I have no idea what they were talking about. When we transfuse someone slowly were will give it with LR but for a massive, life threatening bleed, you dump the blood in. There are potential issues from massive transfusions of blood but nothing you can do about it in an ambulance or an ER and there is minimal evidence to support anything anyways.

[Just Plain Ruff]

Ok, they were just talking about additional electrolytes that would have possibly kept him from going into DIC and not having such a bad Outcome, I mean a fatal outcome. But I wasn't sure either.

Either way, our hospital looked bad in their eyes. But we did what they asked and that's all we could do at the time.

[ERDoc]

Unless they were talking about clotting factors/platelets. The chances of your hospital having them, if they had to transfer someone like this, is pretty low. Again, that is speculation.

Edited March 11, 2013 by ERDoc