Lasix protocols in acute pulmonary edema

[bulldog217]

Only a bottom limit for Nitro- 150 systolic with no line in place.

B.S.: Systolic for Nitro is 100, not 150, 100 is National Standard and is taught in every EMT-B class that I know of.

No mention of line in place.

KNOW YOUR PROTOCOLS IF YOU DO NOT HAVE THE EDUCATION TO KNOW ANYTHING ELSE.

Good morning. FNG here with a first post.

Our Statewide (MA) Treatment Protocols also use a SBP of 100 mmHg as the low limit for NTG as well as Lasix. But locally, our Medical Director prefers us to use OLMC and get orders prior to giving NTG to a pt. with a SBP of less than 120 mmHg. So, although 150 sounded a bit high to me, the 100 mmHg "National Standard" may be a little less than standard.

Additionally, back to Lasix, at a recent in-service for our new CPAP (Emergent's PortO2Vent) system, it was mentioned that we will probably be seeing a change or possibly outright removal of Lasix from the CHF protocols in the near future. The rational was better pt. outcomes with the use of CPAP and aggressive nitrates, as well as the limited pre-hospital benefits of Lasix (time to onset of action vs. our relatively short urban transport times) and new studies reporting rebound acute CHF in the ICU s/p ER/Pre-hospital Lasix. I have not yet had a chance to pull or read these studies so I can't speak to the details yet, but as soon as I find out more, I will pass it on.

Best,

John

[sledogg1]

How's things in your neck of the woods Connie...........we as well peep them here as well.

[Connie31079]

Good, dear, good!

Chris, thanks for asking, buddy!!

I've never had the chance to use our PEEP valves yet, actually.....was told we could only use it if we intubated someone with acute pulmonary edema. Would it work if you were just using BVM (no tube) for flash-PE too?? Somehow I don't think it would, because the airway isn't properly secured?

Take care, keep saving lives in Amherst! Say "hi" to Adam McNeil for me, he went to Holland College the same time as I did (10 long years ago.....)

Connie

[kevkei]

Only a bottom limit for Nitro- 150 systolic with no line in place.

B.S.: Systolic for Nitro is 100, not 150, 100 is National Standard and is taught in every EMT-B class that I know of.

No mention of line in place.

And there is a reason Basics shouldn't be giving NTG, but that is a whole other thread.

Good, dear, good!

I've never had the chance to use our PEEP valves yet, actually.....was told we could only use it if we intubated someone with acute pulmonary edema. Would it work if you were just using BVM (no tube) for flash-PE too?? Somehow I don't think it would, because the airway isn't properly secured?

Connie

It will also work just with the BVM. If you need to assist ventilations or if the patient will tolerate the mask being held to their face, you can utilize the PEEP (although not often practical).

[Connie31079]

Thanks kevkei! That's good to know. I learn something new everyday, and today, it was you who taught me.

Have a great day!

Connie

[tniuqs]

Hold urine horses there guys and gals!

PEEP should be used with the same approach as a Drug, tube or no tube (non-intubated patient is very seriously dependant on the Practitioners abilities to deliver this without aggravating the situation, this can very difficult to accomplish in a moving truck) a patient fighting an attempt of manueal delivery of ventilatory support may just be the trigger to an arrest. Think of it as a manual BIPAP, and watch the duck valve very closely, it will assist in the timing of the breath. In fact Practice on each other this will give you a good appreciation of the timing required to be successful, it can be a very good tool in the arsenal of kit, in the educated hands.

Positive Expiratory End Pressures can and do seriously affect B/P and very rapidly change the compliance curve, so drop your volumes and try to keep PIP Peak inspiratory pressures less than 40 cmH2O, (cheap gauges are available) or you will be dealing with esophageal opening pressures and the very serious consequences, remember do no harm.

A protocol should be developed for the use of this "new to most providers" tool and don't ask me for one the background research just has to be learned on your own...no exceptions.

ps the idea of "matching auto peep" is a hint, average measurement auto peep in COPDs in one study was + 14 cmH2O

cheers

kevkei Posted: Thu Mar 01, 2007 4:47 pm Post subject:

Lasix is being removed from our inventory. Cited reasons are that it poses more risk than benefit and that even in the in hospital environment with radiographic imaging, pulmonary edema is only correctly diagnosed 40% of the time.

That is a retrograde step, so those that need Lasix don't recieve it? Yea lets just intubate them put them on a vent instead that a way better method........NOT! and I want to read that study to be sure, in hospital or out?

Is this a S.S. deal or what?

[Connie31079]

Even though I've never used our PEEP valves yet, I know we're only allowed to go as high as 10cmH2O, and this in a normo-tensive or hyper-tensive patient. Hypotensive patients, PEEP is contraindicated for us.

We can also use PEEP for near-drownings, as well as acute pulmonary edema.

http://www.gov.ns.ca/health/ehs/Medical_Di...ls%20Master.pdf

(look under "near drowning" and "Pulmonary Edema-CHF" of PROTOCOLS)

Connie

[kevkei]

That is a retrograde step, so those that need Lasix don't recieve it? Yea lets just intubate them put them on a vent instead that a way better method........NOT! and I want to read that study to be sure, in hospital or out?

Not my position, and it was in hospital.

Is this a S.S. deal or what?

:dontknow:

We are getting CPAP though (finally)

[sledogg1]

Could have used it the other night on a call....but it wasn't my shift Used PEEP twice last summer on drowning's and it was sweet to hear the difference and complience of venting. The new bag valve masks in which u just screw on the PEEP on the side and medication port is handy.

[sledogg1]

Could have used it the other night on a call....but it wasn't my shift Used PEEP twice last summer on drowning's and it was sweet to hear the difference and complience of venting. The new bag valve masks in which u just screw on the PEEP on the side and medication port is handy.