Inappropriate LASIX use in the field???

[AZCEP]

emt322632

Let's think about what Albuterol does. Hmmmm...bronchodilates? Yes, but what else, more simplified. Hmmmm...stimulates beta 2 receptors? Right, and that will cause what to happen, not just in the bronchi? Hmmmmm...smooth muscle relaxant?

Bingo!

Now, where is there smooth muscle that will be responsive to beta stimulation? And how will those areas respond to the relaxation?

Focusing a minute on the vasculature, which vessels will be most affected by beta stimulated smooth muscle relaxation? Arterioles... right-o! Now with this reduction in afterload, what will happen to cardiac output? We would expect it to....increase, right again. With the increase in cardiac output, what will happen to preload, or the volume of blood left in the left ventricle when it is done contracting? We should expect it to increase as well, due in part to our not increasing the venous capacity. This blood has to go somewhere, right?

So, now that we have increased preload, momentarily, how will the heart respond? See how easy this is?! The heart will not be able to compensate for the increased volume for a short period, and the CHF will?...get worse. The patient becomes more short of breath, blood pressure increases from sympathetic influences, heart rate increases, the sick heart gets sicker.

Luckily this doesn't happen to every patient that Albuterol is given to with CHF as the problem. When you do this the first time, and your pucker factor rockets off the chart, you won't do it again. :shock:

[Ace844]

emt322632

Let's think about what Albuterol does. Hmmmm...bronchodilates? Yes, but what else, more simplified. Hmmmm...stimulates beta 2 receptors? Right, and that will cause what to happen, not just in the bronchi? Hmmmmm...smooth muscle relaxant?

Bingo!

Now, where is there smooth muscle that will be responsive to beta stimulation? And how will those areas respond to the relaxation?

Focusing a minute on the vasculature, which vessels will be most affected by beta stimulated smooth muscle relaxation? Arterioles... right-o! Now with this reduction in afterload, what will happen to cardiac output? We would expect it to....increase, right again. With the increase in cardiac output, what will happen to preload, or the volume of blood left in the left ventricle when it is done contracting? We should expect it to increase as well, due in part to our not increasing the venous capacity. This blood has to go somewhere, right?

So, now that we have increased preload, momentarily, how will the heart respond? See how easy this is?! The heart will not be able to compensate for the increased volume for a short period, and the CHF will?...get worse. The patient becomes more short of breath, blood pressure increases from sympathetic influences, heart rate increases, the sick heart gets sicker.

Luckily this doesn't happen to every patient that Albuterol is given to with CHF as the problem. When you do this the first time, and your pucker factor rockets off the chart, you won't do it again. :shock:

Great Post "AZCEP,"... If you would like more information I also suggest you do the following which will also give you good info.

1.) Do a search on CHF and Albuterol, as well as the various teaching posts here.

2.) Check out the links and info below

3.) Any further questions..Just ASK!!!

http://www.emtcity.com/phpBB2/viewtopic.php?t=846

http://www.emtcity.com/phpBB2/viewtopic.php?t=4089

http://www.emtcity.com/phpBB2/viewtopic.php?t=3794

http://www.emtcity.com/phpBB2/viewtopic.php?t=4010

http://www.emtcity.com/phpBB2/viewtopic.php?t=2402

http://www.emtcity.com/phpBB2/viewtopic.php?t=2459

http://www.emtcity.com/phpBB2/viewtopic.php?t=2401

http://www.emtcity.com/phpBB2/viewtopic.php?t=1432

http://www.emtcity.com/phpBB2/viewtopic.php?t=1661

http://www.geocities.com/ricks_rcp_resources/Albuterol.html

http://www.postgradmed.com/issues/2002/08_02/krieger.htm

http://www.emedicine.com/emerg/topic108.htm

http://www.uhmc.sunysb.edu/emed/paramedic/.../1996/1199.html

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://taylorandfrancis.metapress.com/link...56383ge34ywxqjv

http://www.guideline.gov/summary/summary.a...17&nbr=4184

Here's a link to a related teaching post here:::

http://www.emtcity.com/phpBB2/viewtopic.php?t=2496

(Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 10, Number 1 / January-March 2006

Pages: 41 - 45

URL: Linking Options

DOI: 10.1080/10903120500366938

Do Medications Affect Vital Signs in the Prehospital Treatment of Acute Decompensated Heart Failure?

Karl A. Sporer A1, A2, Jeff A. Tabas A1, A2, Roland K. Tam A4, Karen L. Sellers A1, A2, Jon Rosenson A1, Chris W. Barton A1, A2, Mark J. Pletcher A1, A3

A1 Department of Medicine, University of California, San Francisco, San Francisco, California

A2 Department of Emergency Services, San Francisco General Hospital, San Francisco, California

A3 Department of Epidemiology and Biostatistics, Albert Einstein School of Medicine, New York, New York

A4 Albert Einstein School of Medicine, New York, New York)

Abstract:

Introduction. Prehospital treatment of patients with acute decompensated heart failure (ADHF) has been shown to decrease mortality and morbidity. Vital sign changes have been proposed as clinical endpoints in the evaluation of prehospital treatment for this condition. Objective. To examine the effect of prehospital treatments on vital signs among patients with ADHF. Methods. Records of an urban emergency medical services system from September 1, 2002, through September 1, 2003, were queried for patients who had a paramedic impression of shortness of breath or respiratory distress and had received nitroglycerin and/or furosemide. Demographics, initial and repeat vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation), and medications and doses were collected. Results. Three hundred nineteen patients were included; the average age was 77 (±12) years and 47% were male. Treatments administered to these patients included nitroglycerin, 296 (93%); furosemide, 194 (61%); albuterol, 189 (59%); aspirin, 57 (18%); morphine, 20 (6%); and prehospital intubation, 15 (5%). Patients were initially hypertensive [mean ± standard deviation of systolic blood pressure (SBP) was 167 ±37 mm Hg], tachycardic (heart rate 106 ± 24 beats/min), tachypneic (respiratory rate 33 ± 7 breaths/min), and hypoxic (pulse oximetry 88% ± 9.5%). After treatment, mean changes included decreases (95% confidence interval) in (SBP), -10.6 mm Hg (-14.1 to -7.1), heart rate, -2.3 beats/min (-4.0 to -0.7), and respiratory rate, -3.0 (-3.6 to -2.3), and an increase in oxygen saturation, +8.2 (7.1 to 9.3). Changes in blood pressure and oxygen saturation after treatment correlated with initial values. There was no independent association of either nitroglycerin, furosemide, albuterol, or morphine with improvement in vital signs. Conclusion. Prehospital patients with ADHF are a heterogeneous group of patients with significant variability in vital signs. The change in systolic blood pressure or oxygen saturation after treatment depends greatly on the patient's starting point. There was no association of either nitroglycerin or other medications with the improvement in vital signs.

Hope this Helps,

ACE844

[Ridryder 911]

That is why when I am teaching CHF vs. COPD vs. Pneumonia differential it is so essential that a thorough H & P be performed. Examine the med's; HTN med.'s such as Lisinopril, CHTZ, Ace inhibitors, Diuretics, Look at the onset, the skin temp., the adventitious lung sounds, the incidence of hepatojugular reflex, JVD, and one that is essential EtC02.

Although, one may have a COPD/CHF patient even with pneumonia and as weird as this it occurs a lot, one needs to be very careful o the med.'s we administer. As AZCEP has posted we may be giving [/font:35e10c74b8]Beta [/font:35e10c74b8] we also remember these may also have some alpha effects as well. As Albuterol is simplistic, and easy to use, may actually increase an infarct size as well. Again, that why I strongly suggest EtCo2 noting the implication of obstruction, with the shark fin wave form. Basically, if they don't have it..... they don't get Beta's for COPD.

R/r 911

[emt322632]

Thanks guys, learnin alot here that I already knew but didn't know I knew...if that makes sense...basically, I just needed a little review lol...those articles are great by the way, thanks...

[AZCEP]

Most times, that is what learning is. Figuring out that you know what you know. Even more often, understanding that you know how to apply what you know is more difficult.

[Spock]

We have had significant problems with inappropriate administration of lasix in my area such that we now need an order from the physician before giving lasix. I disagreed with this because I thought is was more appropriate to educate the people giving lasix wrongly but I lost. Just another reason why I dislike the command system my service has.

The diagnosis of CHF versus pneumonia is not simple and requires a thorough physical exam which has been noted. What do you guys think about giving morphine for CHF?

Live long and prosper.

Spock

[jaronik]

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

[tniuqs]

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

Respected Sir:

I find your post most interesting, although I do not practice routinely in the US of A it was noted by myself that while on a visit to Baton Rouge and through discussions with Acadian Ambulance training staff under the direction of DR. R. Judice. He has implmented, a "patch before admin" Lasix standing order as well, I was uncertain as to rational of this but with your post I am more enlightened. In Canada we have a touch more latitude in practice most possible due to geography moreover, frankly I have not personally observed the inappropriate use of Lasix in a mis dx pnemonia, granted not to say that it does not occur.

If you be so kind could you please provide a link to the study Hoffman et al many providers here could benefit I am certain as previous posts are making me a bit dizzy, you demonstrate clarity. A further point may be was that this study was available to ILCOR when reviewing literature and while in preparation of NEW CPR and ACLS guidelines... still waiting for the printers to get that out in Canada...sheesh. Has the AHA modified its views in guidelines as of this time with the suggested use of lasix?

With some experience in the Critical Care setting quite frequently (in decompensated CFH patients) the use of Inotropes has been advocated by Cardiologists, granted this does present some difficulties in posing a study to be certain but is does make some sense to raise MAP resulting in increase renal perfusion, therefore improving the efficacy of some diuretics.

Comments on the use of BIPAP: as CPAP stand alone I must totally agree will increase WOB! This is why in some ER's the pressure supported levels are implemented, unfortunately initial application of base (PEEP levels more correctly) and PIP have never really been studied to the best of my knowledgde. Anecdotal success in application can be the dependent on the experience of the clinician, granted not every REMT-P out there has expertise of an RRT nor should that be an expectation.

And additional request would be for the less knowledgeable to please explain BNP in a bit more detail thanks.

I am forget my manners, greetings and a big WELCOME to EMT city!

cheers

[jaronik]

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

[flight-lp]

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

I find it interesting to say that there is no evidence of positive outcomes from diuretic treatment pre-hospital. Personally, I do not have enough fingers or toes to count the many patients I have witnessed first hand improving from the use of various diuretic agents. I am sorry to say this, but your study is indicative of what many ED physicians do...........blame the pre-hospital folks for patients gone bad. Removing Lasix is not the answer and most of us do not have any urge to give something just because we can, again, typical ED physician's false belief. A proficient examination utilizing adjuncts available to all medics (i.e eyes, hands, ears, thermometer, stethoscope, etc.) WILL reveal the difference between CHF and Pneumonia. Citing half assed points and creating it into a study will work for some, but for the rest of us who actually know what we are doing, this is just another "study" that will fizzle off into the wind. Now using Morphine on the other hand, well that is a whole different thread..........................