Would you push fluids or not?

[Kaisu]

This came up in run review the other day. It was not my patient, so unfortunately, I won't be able to answer your detailed questions. I was too intimidated (it being my first run review) to question the medical director about this. I would appreciate your comments tho - and if you think yes or no - please provide reasons.

The patient was a late 50s professional truck driver. He called 911 for blood loss. EMS arrived to find him in the cab of his rig with blood and feces all over the interior. (estimated loss of 1.5 liters or so). The man had had black tarry stools and hemoemesis. He was feeling "pretty weak". BP was 98/60ish, HR of 95 (or so - he may have been slightly tachy at some point). 2 large bore IVs established and about 200 ml infused by the time they got to the hospital.

Blood work done in ED - hemoglobin 8.2

The medical director had pulled this run because he felt medics should have put in at least 1L of fluid, and if they had pushed 2nd liter he would not have said a thing.

My problem - would turning this patient's blood to kool-aid have helped at all? I mean, a hemoglobin of 4 would be useful how? The second point I have is wouldn't increasing the BP just make MORE blood run out of whereever it was running out of. I think a systolic of 98 is fine. Medics got out of the line of fire by stating that the line was wide open and it was a short transport but to me that begs the question.

This is important to me because I want to know if I can trust my medical director. He is not the kind of guy I am comfortable with asking the question. I really appreciate your help.

[spenac]

My way of thinking would be maintain BP above 90 systolic. By increasing BP to much could actually cause what ever was bleeding to start bleeding more. So I think they did right by limiting amount of fluid. There have been trauma studys that suggest our old wide open boluses may have done more harm than good by not allowing bleeding to clot or even cause internal bleeding to increase.

[ncmedic309]

If he's got a good pressure and isn't showing signs of inadequate perfusion then there's no benefit to the patient by overloading him with fluids. If his systolic was less than 80 mmHg it would be a different story, but even then I would likely start with a 500 mL bolus and then reassess. It's still not necessary to dump an entire liter of fluid or more just because you can.

[AZCEP]

The addition of fluid to a compromised container is not going to be much help. Sure, running some fluids in then reassessing is a reasonable thing to do, and that should have been the stance the good Dr. took. Unfortunately you are working under his rules, and there will be more than a few instances where you walk out of a meeting scratching your head about what you were just told.

If you would like details, PM away.

[Eydawn]

Was there something else going on with this patient that might have necessitated fluid bolus? Or are we just operating on the theory that he needed fluids because he lost fluids?

Losing blood like that, I agree, turning his fluid into cherry kool-aid is not helpful, and I would challenge the idea that he needed an entire liter pre-hospital unless it was a very long transport time and the last set of vitals was under 90 systolic... then he could have definitely used more than he got. But an entire liter? Even two? I'm not sure.

Paramedics, this is more in your court... from what I'm thinking, I say no, the MD is fulluvit, but I might be missing something really important.

Wendy

CO EMT-B

[firedoc5]

I would have kept in mind his initial BP. Take into consideration of his size. I would hang 1 L of LR and give fluid challenge of 500 ml and recheck BP. If no change, continue LR, but not necessarily wide open. If he had two IV's, I've had orders to hang a liter of NS. Some would argue D5W, but NS was our PMD's choice.

Constantly monitor BP and hear monitor. Check for edema regularly. O2 @ 6L per NC.

GI bleeds such as this can be difficult to manage. If the have a BM or vomited coffee ground emesis, definitely run IV's WO. On the contrary, unless there is so much blood loss that it appears to be "kool aid", then there's not much hope for that patient.

I've actually had this scenario a time or two, for real.

[Arizonaffcep]

I would say permissive hypotension is not called for here. It is geared more towards acute bleeds that are traumatic in origin, although there are other applications. I would guess that as a truck driver, he's probably on HTN meds, which is why his HR is only high 90's. I'm thinking he's probably pale, cool, and possibly diaphoretic. This type of GI bleed is more chronic than acute...as it's digested, meaning it's been in his guts for a while. I would treat with NS and LR, with at least a litter bolus (or w/o and get in as much as you can without pressure bag by the time you get to the hospital). Remember, with a hemoglobin like that, he's got perfusion issues...1 because there are not the normal amount of RBC's to take the O2 around, and 2 is because of lack of fluid, which we CAN replace. Hope this helps!

[Eydawn]

That does make more sense.

Wendy

CO EMT-B

[firedoc5]

So, yes, push all the fluids you can.

[crotchitymedic1986]

WIthout all of the information, its hard to say. Were orthostatics taken -- the patient may have had a much lower b/p standing (especially with the H&H you stated --- which may be why the doctor was upset, because they did do orthos and found a much lower number). Was the patient average truck-driver size or a tiny fellow ? I probably would have bolused with 500-1000cc and then rechecked v/s. Either way, he needs a transfusion more than he needs fluid, so they should have been happy that he had 2 IV sites.