Inappropriate LASIX use in the field???

[jaronik]

Just as if I can not know all medics, or their respective skills I can not discuss your abilities. However, I would challenge anyone to 100% accuracy on diagnosing decompensated CHF with use of any tools, especially a stethoscope (I know I will not make a claim that I would be right more than 50%). Rales specifically, the classic finding of CHF lung exam is also found in Pneumonia and COPD to name a two possibilities. My paper and my caution to all prehospital and EM physicians has been to focus on NTG it has been shown to work, is indicated in Decompensated CHF as the best pre-load reducer, is safe, and most importantly has a rapid half life so if wrong will not linger. We are in a medical age since the strong push to aggressive management of Sepsis to push fluids, and in the case of Pneumonia sepsis, I found we lost ground rapidly when lasix was given. This was the primary reason for the study. I also do not make a claim that this was ground breaking or even the best done study in the field...As I previously posted I was not happy when I found the Hoffman study to suggest what I was unmasking had been known for 10+ years. Medicine is the slowest of all technologies to except change as most people involved are type A people and stubborn. I do feel most of us have taken on the job as a calling/vocation and would not do something to a patient that may be harmful.

Unfortunately for prehospital individuals as well as myself, follow up is often limited. We do not know what happens to our patients after they are dropped off, or admitted to the floor.

I offer this comparison for Lasix with CHF to be considered like Albuteral and Asthma. Much like Asthma a chronic disease we treat with Albuteral the "rescue" medication. You nor I give Pulmicort or any of the inhaled steroids as they do not help in the decompensated asthmatic, they are intended to control the asthma to avoid an attack. I view this as a similar problem with CHF. If the Lasix or diuretic of choice did not prevent the attack or an attack developed despite the use then one must think, why would it work now...which is why the "rescue" medication, which is NTG is given and effective. This brings up the reasoning I used the wording in the paper to suggest "consideration". There are many single cases that anyone can say Lasix will help, the well known CHF, non-compliant patient who ran out of Lasix a couple days ago, is slowly gaining weight, and has been worsening all day...push away on the lasix if he is also clinically in failure and is not febrile, and is HYPERTENSIVE...not normotensive (you will help this patient tremendously). We don't see any patients like this because all of our patients listen to their doctors and always take their medications, and never run out before notifying their physician at least 2 weeks in advance...but I can imagine it happens elsewhere.

The prehospital job is not an easy one, and I feel sorry for you if your communities physicians are blaming you for problems...unless you push lasix and are wrong, then you should be blamed, as should I or any medical personnel who are guilty of this. Use caution, think twice, and if you still strongly feel diuretic would help you are your patients advocate.

Stay Safe.

JJ

[Ridryder 911]

I would say it is very easy to diagnose CHF with HNBNP and a CXR in front of me. If you have Paramedics administering Lasix in a septic patient something is wrong (unless they have both). More attention should be given to educating assessment techniques and history. As well, I do wonder how much and what truly had to be done to "save" a patient in sepsis with a single dose of Lasix.

I routinely administer Lasix of those that do not meet the requirements or in the need of CPAP as well as those that have history of CHF, increased edema, weight gain and after a thorough H & P. It would be foolish for the patient to be administered Lasix immediately upon arrival and then have to wait an additional 20 minutes to diurese. There have been times, the patient has started diuresing after arrival to the ER, and this has prevented additional treatment. Treatments like Lasix such as CPAP, and NTG, can also prevent needless intubation, possible ICU and hospital admissions. Early thorough accurate assessment and history, should be the key in administering any medication pre-or inner-hospital.

We may not have any "literature" at this times that proves Lasix has made any true difference. This does not mean it does not work or should be immediately deleted. Obtaining and performing quantitative studies, other than anecdotal reports is hard to perform in the prehospital arena. Let's not throw the baby out with the bath water yet...

R/r 911

[jaronik]

Very True Rid,

I appreciate the response and dialog on the subject.

So your resources allow you CPAP as a treatment option? Do you use this after Lasix, with Co-administration, Ever only CPAP, and how do you factor in NTG into your treatment?

Your posting I have seen sound like you are a very capable, and knowledgeable. I will add an additional point for others reading (I suspect you may already know or have read) that NTG and Lasix are synergistic in diuresis. The prehospital NTG use facilitates additional diuresis in the hospital setting if this is decided is a beneficial therapy.

I want to clarify, that I am not out to remove Lasix from prehospital use, because it does have good uses. I cannot emphasize enough that the community I was reviewing had limited runs in excess of 20 minutes, we were averaging 12-14 minutes. We also did not have CPAP/BIPAP as a prehospital tool. I think this may make a huge difference in the future as more services make this available...it is even conceivable that small communities with long transport times may enable EM physicians to discharge decompensated CHF patients from the ED. I am hesitant to support widespread use of lasix...openly admit bias as I am specifically trained with an emphasis on ICU management and care. I often felt crippled caring for hypotensive patients, who access is problematic, who are actively diuresis, and knowing the clock is ticking with organ failure...leading to death. I will grant you have a VERY valid point that this group of patients may not survive, but it is still unacceptable to actively facilitate death. I have come into contact with many medics (will use medic to encompass all prehospital, I know it is not accurate) who are very qualified and are good clinicians. These are the people I would like to see using NTG more often because it will make a more profound impact on their patients care, length of stay, and for me time in emergency department.

I am also curious on your thoughts of BNP (is your HNBNP, something else). Please refer to previous post on my BNP comment so I do not keep filling this forum. I will try to clarify if necessary.

JJ

[Connie31079]

Hmmmm, very interesting read indeed!

Funny, my protocols state that we give NTG prior to Lasix (naturally), but also advocates administration of morphine prior to Lasix as well.

I'd only give Lasix as a 3rd-line drug here in Nova Scotia, after NTG and morphine for CHF. And only if their systolic BP remains @ at least 120 after administration of both NTG and morphine.

Needless to say, I haven't given Lasix that often in the field. Just a couple times, I believe.

And we just recently finished a CPAP trial in Halifax, with good results, so we're hopefully going province-wide with this in the near future. But as of right now, it's not available to us pre-hospital here yet.

Connie

[Ridryder 911]

Let me as well, welcome you to this forum. We welcome your expertise and knowledge. We have several experience and multiple educational and license levels (as well as a few physicians). We are glad you are here and appreciate your posts.

I am usually more aggressive of treatment of CHF, seeing the outcomes in CCU/ICU as well. Again, I am not stating that Lasix is not being possibly used wrong and inappropriately. I too see this too often in EMS and as well at the physician level.

Personally, on presenting clinical findings of CHF: i.e. nocturnal dyspnea, increasing dyspnea on exertion, increasing weight gain or edema, as well as physical findings such fine crackles (rales) and possibility of gallop of S[sub:130fba0288]3,[/sub:130fba0288] S[sub:130fba0288]4[/sub:130fba0288].

Personally I think tere should be more empathises in assessment teaching and education. Along with a PMHX of CHF and and post- AMI. and poor ejection fractions.

Personally, I have found the use of Lasix in patients with early indications, may decrease the pre-load pressure such as in the initial right side before the shift to the left side, if caught early enough. We have just started the use of Nitrates and yes, I definitely agree with the use of it, especially those of having moderate to high hypertension levels. I too agree, anecdotal that most true or symptomatic patients are hypertensive. I of course come from the old school of Morphine thoughts of promoting venous dilation, which has been demonstrated not very effective. Of course, when I first started, we used rotating tourniquets, in which I have read is being studied again only in a different approach.

Our protocol is of course obtain baseline values, and after assessment and determination of degree and dept of CHF, the determination of treatment is made. The amount and degree of respiratory distress, the patient is then placed on CPAP if needed i.e. respiratory distress, such as tachypnea, restless, etc. If there is severe distress that patients needs true ventillatory support, and intubation (RSI if needed)is indicated we will perform that. Intravenous Lasix of 40 to 80 mg. (if patient is on p.o.) and of course if they are normotensive as well, and then 1/2-1" NTG paste topically. We operate in an urban area, but it is routine for us to have transport times of greater than 20 to 30 minutes as well. (I did work at a rural service that we used Inocor, and yes we placed Foley as well :wink: ).

We have had CPAP for about 10 months and have used it about 40 times, all with great success. Many of these patients demonstrated those if treatment had not been initiated early, would had been probably been placed on a vent. I have even some that with dieuresis was actually discharged, instead of admission. So yes, this tool is one of the best piece of equipment (next to capnography). Like in ER where many have been diverted from aggressive intubation and ventilatory support.

I do believe we are going to have to start examining and study aggressive treatment of CHF in EMS. With the gross number of diagnosed cases of CHF and the increasing percentile of "baby boomers" with potentially undiagnosed CHF, we need to look at more aggressive treatment.

Footnote: BNP= HBNP the old way of saying immunoreactive human brain natriuretic peptide (hBNP or BNP)...LOL

Again, welcome to the City...

R/r 911

[jaronik]

What you report as effective is the exact same thing I use in the ED. I use NTG first line, often using Sublingual (have found with paste it is less reliable as these patients often "squirm" and can inadvertently remove their nitro). Followed with NTG IV, I personally use a drip of 10mcg and I do not titrate this (mostly for ease of nursing...22 bed Ed with 6 nurses) I quickly initiate BIPAP. Currently I am only giving Lasix if BP is Greater than 150 sys, off NTG, greater than 120 on NTG...with Hypoxia, and dependent edema. Or once everything labs, images, and with continued assessment of NTG with BiPAP.

I completely agree that we are going to see much greater numbers of people affected with CHF, and we are already seeing a large push by Medicaid and Medicare to limit Admissions for these people. The current reimbursement for hospitals allows for one CHF exacerbation a month. If there is a tool that could help I feel it might be CPAP/BIPAP. It will be interesting to see if that takes off, if it does we may see more use of Morphine again as plenty of people may need the MS for comfort with CPAP/BIPAP. I have yet to be connected myself, but understand it can be uncomfortable.

For other people reviewing these posts please post If your protocols use NTG for CHF (or resp distress), as well as How many people out there are using CPAP/BIPAP for this same problem?

I am very interested in streamlining care in the ED, and keep finding pretty good models in the EMS systems. Many ED's have now switched to using multi-discipline accepted care plans...fancy way of saying standard of care orders for people admitted. These are helpful, as it is nearly impossible to stay up to date on the changes and new publications that are constantly coming out.

JJ

[firefighter523]

Awesome point Rid about the shark fin, I will definately use that next time!!!

[firefighter523]

Our protocols suggest 1 nitro ev 3 to 5 if they meet criteria, up to 3, and 80mgs lasix SIVP if they have rales, tachypnea, or peripheral edema. Febrile pts are contraindicated for lasix if they are not in HF. CPAP is also a great tool for us. It is put in use if there BP is above 90 sys, they have rales, and a hx of HF, they also have to have 2 of the following: SPO 95 or less, 25 resp per min, and use of accessory muscles.

[tniuqs]

Just a curious here:

What setting (s) do you initially start the with on your patients with CPAP or BIPAP?

And (in your respective areas) do you have criteria established that excludes the use of CPAP or BIPAP, especially in Hypotensive states.

Just a personal comment here: I have found that most ventilators can be used for NON Invasive Positive Pressure Ventilation usually those that are more expensive, the criteria being those that have adjustable PEEP settings, and Pressure Support Mode, and Peak Inspiratory Flow rates exceed 50 lpm. Adjustable "slope" or "% rise time" are superior in regards to "titration" to patient comfort levels and tolerance in my experience.

NEJM Jan. 14, 1999-- Vol. 340, No 2.

Question posed would be what types of Machines are being implemented in the Pre-Hospital Care World?

EDIT

Rereading the prior discuss:

You nor I give Pulmicort or any of the inhaled steroids as they do not help in the decompensated asthmatic, they are intended to control the asthma to avoid an attack

.

There is some evidence that early administration may be beneficial in the asthmatic patient and on spec. it has been used here, the actions of steroids an not fully understood as of yet, but does stabilize cell membranes.

Granted Asthma is not the topic here (although stimulation of key receptors in the airways may be triggered with a flash PE) Beta 2 adrenergics as well are used to improve oxygenation, but caution should be excersised in regards to the degee of distress (heart rate commonly can be a used as a guideline) although in passing: MOST of these patients are on Beta Blockers these days further complicating this pathphysiology.

Evidence does exist to support this theorem in a similar related topic NEJ MED 1994:331:286-9

cheers

[kevkei]

I find it interesting to say that there is no evidence of positive outcomes from diuretic treatment pre-hospital. Personally, I do not have enough fingers or toes to count the many patients I have witnessed first hand improving from the use of various diuretic agents. I am sorry to say this, but your study is indicative of what many ED physicians do...........blame the pre-hospital folks for patients gone bad. Removing Lasix is not the answer and most of us do not have any urge to give something just because we can, again, typical ED physician's false belief. A proficient examination utilizing adjuncts available to all medics (i.e eyes, hands, ears, thermometer, stethoscope, etc.) WILL reveal the difference between CHF and Pneumonia. Citing half assed points and creating it into a study will work for some, but for the rest of us who actually know what we are doing, this is just another "study" that will fizzle off into the wind. Now using Morphine on the other hand, well that is a whole different thread..........................

One point of clarification if you may. How do you know that it was the diuresis that resulted in the improvement and not the result of concominant therapy or nitrates themselves?