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

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

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

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

3. Hoffman JR, Reynolds S: Comparison of nitroglycerin, morphine and furosemide in treatment of presumed prehospital pulmonary edema. Chest 1987;92:586-593 Here is the reference pulled from the article. This way you can read and interpret this article on your own. JJ

I am pleased to see my many hours of work is being reviewed and considered for advancing the quality of care in other communities. I will be the first one to admit that evaluating a patient in resp distress is challenging and sometimes downright scary. We have to fight the urge to do something just because we can...ie giving lasix because we feel like we are helping. This Review "study" was conducted because I was involved on one unfortunate day to not be successful in saving 2 individuals who received lasix for their "rales" when their resp noises where from sepsis. I did a fairly exhaustive review of the literature while preparing the manuscript and was saddened to find a very good article by hoffman et al. that showed we have known since 1988 in the literature that diuretics in CHF work only as preventative treatments, there is ZERO evidence that once someone is decompensated they will get improvement with any medication except Nitrates, and there is some suggestion that CPAP, or other pressurized modes of ventilation can also help...one caveat with this is if the Pulmonary edema is from Acute Coronary Syndrome, Bipap has been shown to strain the heart enough to cause Cardiac Arrest!! All of the physicians that I talk with I have been able to sway their practice to hold lasix, and be more aggressive with NTG. As for the individuals comment or question on morphine. Hoffman et al found very poor prognosis in individuals who received Morphine. It will make someone in resp distress feel more comfortable, but will suppress resp drive enough to potentially cause harm. I would Use this with extreme caution! Unfortunately we all practice in a fish bowl and will be criticized for poor outcomes, and potentially sued because we are not up to date with the most recent evidence. I have presented this topic as well as my fellow authors at several venues in the past 2 years, and am surprised by how many EMS directors tell me that they had pulled Lasix from the rigs long ago. Perhaps they were seeing what we saw more frequently that we even know. I only reviewed EMS runs for one calendar year that had received lasix and followed their cases through the hospital course. I know that not all communities are aware or are even applicable to my review, but in case your community transport time averages less than 20 minutes I would strongly encourage you to never give lasix...because there is no evidence to date it helps, and now my review makes the second article to suggest we see harm. The comments on vasodilation and preload reduction is on health animals in the lab, if you use the best indicator for medication use which is increased renal perfusion the best available time is 20 minutes and that is why we chose to use 20 minutes as our recommendation. As for the person who mis-read the study. We looked at BNP and were trying to find some use for this test. There is no consensus use for this lab test, and we also know that for any given level of BNP it does not correlate with the symptoms a patient will exhibit. In my opinion it is best used only as a guide when you have a baseline level for each individual patient. For example a person whose BNP is always around 1000 is clearly not decompensated if their level is still around 1000, however someone whose level is around 700 and presents with a BNP of 1000 is PROBABLY decompensated. We did not use BNP in our classifications, judgments, or in anyway to make determinations of appropriateness to giving lasix. I have moved to a new community since the publication of this article and am happy to say, my new community does not have lasix available for use prehospital and they had already found funding for CPAP. CPAP and NTG are making drastic improvements in length of stay for CHF patients in this community. Please encourage your respective EMS directors to review the article and consider reviewing some cases of patients in your communities that received lasix to see if the results I found in Kalamazoo Michigan are similar in your area. When you go to your bag of tricks please grab the NTG, your patients lives, and your career could depend on it. Jason Jaronik MD