Memorable Misdiagnosis

[CBEMT]

What I failed to appreciate was that CHF patients sometimes have a compensatory bronchoconstiction. They are basically giving themselves PEEP. They are attempting to keep enough pressure in their alveoli to hold out a tidal wave of edema. When my partner bronchodialated this patient, she could no longer hold back the fluid.

An excellent analogy. Fortunately, prior to getting my ALS license I learned from a veteran medic the dangers if Albuterol in the CHF patient. I've yet to have a wheezing CHFer whose wheeze was not relieved by nitro and Lasix. (By protocol I can get away with skipping the Albuterol, can't avoid the Lasix yet.)

[pyroknight]

I am a member of the EMS steering committee for my fire and rescue department. We brought up the topic of removing furosemide from the rigs earlier this month. It will be brought up again next month and I fully expect we will decide to remove it. In the pre-hospital setting, we feel like the evidence is mounting that it has the potential for harm and little potential to help.

[Dustdevil]

I am a member of the EMS steering committee for my fire and rescue department. We brought up the topic of removing furosemide from the rigs earlier this month. It will be brought up again next month and I fully expect we will decide to remove it. In the pre-hospital setting, we feel like the evidence is mounting that it has the potential for harm and little potential to help.

Really? You must be in a pretty urban setting for Alaska then.

I've seen Lasix work miracles in rural settings with extended transport times.

[akflightmedic]

He is in Juneau....

Cant get very rural when you are on a small island....

I say this as a former Ketchikanite.

Now when I was in Nome, different story.

[UMSTUDENT]

Really? You must be in a pretty urban setting for Alaska then.

I've seen Lasix work miracles in rural settings with extended transport times.

What you say is interesting, because many of the veteran paramedics I've run into swear by Lasix in the rural prehospital environment. In MD, it is now like a 4th or 5th tear drug and only with medical direction. High-dose nitro sublingually is first line, followed by CPAP, transdermal nitro (Nitrobid), captopril, and then Lasix.

What I was taught was that furosemide doesn't reach peak effect for over an hour and "should" show little effect in the prehospital environment. Clinically, I would say, most paramedics disagree.

[AZCEP]

The peak effect you speak of is for the diuresis. Lasix is a most useful vasodilator, and achieves this rather quickly. Lasix can make the bad situation worse, but NTG by itself is not always a good answer either. Even adding some doses of morphine have proven effective in the cases that I've needed them.

Nothing quite like working the nursing home CHF patient that has actually aspirated liquid nutrition (Ensure). Direct tracheal suctioning never looked so creamy.

[p3medic]

had a guy with multiple gsw's, hypotensive, air hungry, left cx sounded clear, right was completely silent....dropped a needle in his r cx, no change, turns out i had a small tear in the tubing of my stethoscope where the bell attaches, when i listen over the left, the tear was closed, to reach over to his right caused it to open, resulting in no sound transmission through the diaphram...didn't change his long term outcome (dead) but was a misdiagnosis i was a bit embarrassed about....

[AZCEP]

Can't really prove it wasn't there to begin with though. :oops:

[UMSTUDENT]

The peak effect you speak of is for the diuresis. Lasix is a most useful vasodilator, and achieves this rather quickly. Lasix can make the bad situation worse, but NTG by itself is not always a good answer either. Even adding some doses of morphine have proven effective in the cases that I've needed them.

Nothing quite like working the nursing home CHF patient that has actually aspirated liquid nutrition (Ensure). Direct tracheal suctioning never looked so creamy.

First off, I'd like to edit my last post:

Tier...instead of tear. Duh. I don’t like this new 90 minutes to edit thing.

Secondly, good point. I was just presenting what I've been told in instruction. There was a great crusade down here against Lasix during the last protocol roll out and it may be true that they pumped their chest a bit to give EMS providers a reason to hate it. I had rather forgot about the initial vasodilatory response. I did know that it does sometimes potentiate the effects of other PO antihypertensives.

[paramedicmike]

My understanding of the thought process behind removing lasix is not that's it's not a good drug to use but that's often times given when the provider mistakes pneumonia for CHF.

Lasix to a pneumonia patient doesn't do him/her much good. Not that this needs saying in this crowd.

-be safe