Inappropriate LASIX use in the field???

[Dustdevil]

Hmmm... I am seeing some confusing concepts here that I honestly cannot relate to. Number one among them would be the inability to accurately differentiate decompensated CHF from even the most serious case of pneumonia. Anybody that can't do that shouldn't be on an ambulance, period, much less pushing drugs.

Almost everytime I have given furosemide, I have seen a positive impact on the patient's condition, especially in rural settings. Of course, there are certainly those patients who are so severely decompensated that simple diuresis is not going to be enough to turn the tide. And, of course, there are those patients who are given a hefty dose of furosemide, which immediately take affect, but the patient is not catheterised (but still in control of their bladder), and it only causes the patient more distress. And then there are those patients who don't get furosemide at all simply because the system doesn't allow catheterisation, and the medic doesn't want urine in his ambulance.

Because of that, there is probably just as much inappropriate witholding of furosemide as there is inappropriate use.

[Asysin2leads]

Okay, playing devil's advocate here, what is the worse that could happen if you gave a patient who had rales from pneumatic sepsis rather than CHF?

[jaronik]

Worst thing that could happen is that you take already poorly perfused tissues such as the brain and kidneys, you decrease blood pressure and overall perfusion...leading to increased lactic acid production thereby increasing respiratory effort and drive causing worsening symptoms in the patient. You are also tipping the tide of the overall homeostasis away from stability and doing this for SIX HOURS, sufficient time to allow irreversible organ failure and death. I know you are playing devil's advocate, but we have to realize that just because we are seeing diuresis this does not necessarily mean we are doing the patient a favor. Even a severely dehydrated and septic patient will have diuresis if given a diuretic and they still have any perfusion to the kidneys. I agree with one of the most recent postings that we can not be sure what is helping and what is harming when we use a multi-modality approach. Oxygen alone may be making the patients improve, or the placebo affect of "now help has arrived" may be helping the patient. I still feel strongly that it is dangerous to be giving lasix if your transport time is less than 20 minutes, and if you have NTG available.

I will state again there is NO possible way anyone can be expected to differentiate decompensated CHF from pneumonia with resources available out of the hospital at an accuracy of 100%. The best trained medic, nurse, or even physician will approach accuracy in the 90% range, but will make some mistakes. In medicine we bury our mistakes. If you think you can reach 100% accuracy, you are dangerous. Both patients can have the exact same vital signs and symptoms. You are gambling, I will grant that your risk is going to be lower on the gamble if the blood pressure is elevated sys >150. I will also mention that COPD can present very similar as well. NTG is fast off if you guess wrong, CPAP can be turned off if you guess wrong, Albuteral wears off rapidly... Lasix on the other had has a six hour half life, which means if you happen to give 80mg, in six hours there is still 40mg circulating, 12 hours later there is still 20mg in the system couple that to poor circulation and you have a deadly cocktail. You cannot give enough fluids to a person who is in active diuresis, try to fill up your sink with water when the plug in the bottom is removed. When blood pressure starts to decline, if you grab pressors in a hypovolemic patient you have just vasoconstricted the vessels to the kidneys and bowel to raise the number (BP) you are actively causing organ death. Organs are like dominoes, when one falls more often follow.

Well this post had a little passion in it, it should spark some conversation.

JJ

[UMSTUDENT]

Worst thing that could happen is that you take already poorly perfused tissues such as the brain and kidneys, you decrease blood pressure and overall perfusion...leading to increased lactic acid production thereby increasing respiratory effort and drive causing worsening symptoms in the patient. You are also tipping the tide of the overall homeostasis away from stability and doing this for SIX HOURS, sufficient time to allow irreversible organ failure and death. I know you are playing devil's advocate, but we have to realize that just because we are seeing diuresis this does not necessarily mean we are doing the patient a favor. Even a severely dehydrated and septic patient will have diuresis if given a diuretic and they still have any perfusion to the kidneys. I agree with one of the most recent postings that we can not be sure what is helping and what is harming when we use a multi-modality approach. Oxygen alone may be making the patients improve, or the placebo affect of "now help has arrived" may be helping the patient. I still feel strongly that it is dangerous to be giving lasix if your transport time is less than 20 minutes, and if you have NTG available.

I will state again there is NO possible way anyone can be expected to differentiate decompensated CHF from pneumonia with resources available out of the hospital at an accuracy of 100%. The best trained medic, nurse, or even physician will approach accuracy in the 90% range, but will make some mistakes. In medicine we bury our mistakes. If you think you can reach 100% accuracy, you are dangerous. Both patients can have the exact same vital signs and symptoms. You are gambling, I will grant that your risk is going to be lower on the gamble if the blood pressure is elevated sys >150. I will also mention that COPD can present very similar as well. NTG is fast off if you guess wrong, CPAP can be turned off if you guess wrong, Albuteral wears off rapidly... Lasix on the other had has a six hour half life, which means if you happen to give 80mg, in six hours there is still 40mg circulating, 12 hours later there is still 20mg in the system couple that to poor circulation and you have a deadly cocktail. You cannot give enough fluids to a person who is in active diuresis, try to fill up your sink with water when the plug in the bottom is removed. When blood pressure starts to decline, if you grab pressors in a hypovolemic patient you have just vasoconstricted the vessels to the kidneys and bowel to raise the number (BP) you are actively causing organ death. Organs are like dominoes, when one falls more often follow.

Well this post had a little passion in it, it should spark some conversation.

JJ

JJ,

I think you'll be happy to know that Maryland has just instituted Nitro, Captopril, and CPAP as the treatment of choice in the pre-hospital environment. CPAP is now an optional jurisidictional protocal and will be mandatory on all units by 2008.

[tniuqs]

When blood pressure starts to decline, if you grab pressors in a hypovolemic patient you have just vasoconstricted the vessels to the kidneys and bowel to raise the number (BP) you are actively causing organ death. Organs are like dominoes, when one falls more often follow.

Just a question here (at this part of movie I usually eat popcorn)

If one is hypotensive, even from hypovolemia and not trying to put words in ones mouth here.... BUT would it not be logical that they are already hypotensive (not producing pee pee) therefore the kidneys are already hypo-perfused?

I was always under the impression that Dopamine (#1 trope on the hit parade) improves renal and mesentaric artery dilation? Dopamine can (defendant on dose delivery) affect the drain size as well, (in reference to your analogy).

So just for argument sake, why not start with Dopamine?..... after the Dr. Placebo and Oxygenation concerns are resolved, whatever way one wishes to deal in that regard.

Fact of the matter may be that a trope may be more beneficial in the decompensated (circling the drain crowd) whether it be from septic shock OR cardiogenic....just thought I would throw that out there. Perhaps a study even, could put a mark on the wall for EMS practitioners? :wink:

As for the reference to percentile in correct Dx of experienced, well trained Medics out there, by your own admission as well 90% is pretty good odds I'd say?

Quoting Asysin2leads: Okay, playing devil's advocate here, what is the worse that could happen if you gave a patient who had rales from pneumatic sepsis rather than CHF?

First off no point in even trying to answer this Asysin2leads.....you are playing the village idiots helper their and I won't bite at that hook...I do read YOUR posts....lol.

The confusion some time exists as "rales"......Rales are wet, crackly lung noises heard on inspiration which indicate fluid in the air sacs of the lungs. Rales are often indicative of pneumonia. See also rhonchi, wheezing. rales is a 'very old term'

and sounds are more indicative of course secretions ......if the rattle improves with cough and have the patient "hork"(an approved medical term :twisted: ) in a K basin the picture this can become quite a bit more clear.

"Creps" are far more indicative of pulmonary oedema, (sometimes the give away is pink frothy sputum!)

bit of an D.G.A. (dead give away)

cheers

note: edited due to sub therapeutic caffeine level on initial posting.

[bassnmedic]

At my service here in Florida, we are having remarkable results using CPAP with the 10cm H2O peep valve in pulmonary edema patients. Intubations in these patients are notably fewer than those not given CPAP enroute. As far as Lasix is concerned it is a 4th line medication in our protocols behind NTG(SBP >120), Morphine and Xopenex.