IV Lasix of IV Nitro for CHF

[ABMedic]

Interested in your thoughts on utilizing IV nitro infusions instead of Lasix? Should prehosipital treatment follow the shift in the paradigm in the treatment of acute heart failure (AHF)? Is the utilization of IV nitro not only safer (less chance of hypokalemia and corresponding dysrhythmias) and is it more effective in treating the predominant underlying cause (ischemia)?

Thoughts?

ABMedic

[hageremtp]

Maybe call me wrong but I dont ever think Nitro should be use in place of lasix. I think each is equally important in the treatment of CHF. I would agree that IV Nitro (Nitro Drips) are much safer to use than Nitro Sl. Why?? Look at a does of Nitro SL, you give 0.4 mg (400 mcg) when you do a nitro drip, we usually start 5 mcg. THis is much less than the dose of SL nitro, which in my mind makes the chances of 'bottoming' a persons BP much less. But again I think both are needed in this instance in order to provide proper treatment. Call me wrong but thats my thought!

[DaSharkie]

I think the lasix is the better option supplemented, if the patient is hemodynamically stable, by the nitro.

Your first step is to try and implement a measure that will aleviate the built up fluid in the lungs and the body. The lasix preforms this by its loop diureses effect. Granted it can take up to 20 minutes to take effect, it will still begin to perform its function effectively. In addition to this though the pressure must be above 100 (using my protocols) it will take much longer to lower a pateints pressure than the NTG will. I am not saying that as an absolute, but as a rule I feel it is true.

Now, the NTG will only dilate the blood vessels allowing for a larger "container" to hold the blood and fluid, thereby reducing the blood pressure. It does little by way of aiding in the elimination of interstitial fluid other than by pressure gradients. The Lasix on the other hand, not only begins a diuresis effect of eliminating excess fluids, it causes the same pressure gradient movement as NTG, albeit at a slower rate, and also causes the movement of fluid through diffusion because the fluid loss forcing fluid to move out of the lungs.

I just feel that the benefits of lasix are multifold and have a better overall effect. Whereas the NTG will require additional doses, if used SL, the Lasix has a prolonged effect of hours. Granted you asked about the use of IV infusions, many services do not carry pumps, not required in my state for emergency units, so there is a problem caused by ensuring appropriate doses are administered.

[tom2003]

I am an EMT-B/RN student. In my area they have taken Lasix away from the medics, they did this because the medics were givining Lasix to just about anyone in acute dyspnea with rales or ronchi. It did not appear they were looking at the entire picture, hot or warm skin, pale or flushes(CHF vs Pneumonia). They now give .4 NTG SL for chest pain, and .8 NTG SL for dyspnea with pulmonary edema. The .8NTG clears them of fast, but its not a definative TX, its a "good enough for now" TX. I would rather they kept the Lasix and retrained the medics on CHF vs Pneumonia.

[RemptyP]

Our protocol for CHF includes Nitro, Lasix, Morphine, and CPAP. A have read a couple of studies from some years ago that compared the effectiveness of SL Nitro and Lasix to SL Nitro and Morphine for CHF, and the combination of Ntg and Lasix was more effective.

If you want to give IV Ntg, you need an IV pump. We don't normally carry them in the field - we only use them on interfacility transfers. If you don't like the relatively large dose of SL Ntg, consider Nitro ointment - a lower dose, and longer lasting.

[kghemtp]

Ditto here on the CHF protocol (minus CPAP). We have SL Nitro as well as spray (never used the spray). I have a fear that 1 spray won't "look" like enough and eventually someone will pump it 3 or 4 times! Like M&M's or potato chips, one just isn't enough! You know when someone puts a simpler product out there, someone will find a way to screw it up!


Cautiously using SL NTG....

KGHEMTP
--^v--^v--^v--

[tom2003]

All we have now is the spray. We have has 0 problems with people giving more than 1 at a time.

[PuffyNPFD]

Agree with Da Sharkie, NTG only shifts the fluid while Lasix rids the body of it. In RI, protocol is Albuterol first line for CHF!!?? Basically to rule out. I personnally feel that taching a pt. out while opening their aveoli further will do more harm than good. But what do I know, I am a medic not a Cardi-hac.

[Weruj1]

same protocol as kgh .........CPAP huh ? in the field .........that could be the S&%t !!!!!

[Toering]

I'm no doctor but I feel that you need a diuretic in a CHF case. The nitro spray is a great way to move some oxygenated blood. Who really has time to set up a nitro gtt in the feild? Show me some facts and perhaps I may think different.

[hageremtp]

I would like to go back and hit on the post by PuffyNPFD. Let’s look at the use of Albuterol as a first line treatment for CHF. The big picture problem of CHF is the build up of 'extra' fluids, which by the laws of osmosis will settle in the lungs and the alveoli. Now there are two ways to look at it. One- you open up the alveoli with albuterol, give the nitro to open up the veins, and then the lasix to eliminate the fluids in the long run. This is our line of treatment (here) and it works great. Think of it this way, the alveoli will recognize the fluids as a foreign material, just like in asthma pts, in the lungs and start to constrict. By giving the albuterol to the pt, you open up the alveoli to the size of what it was prior to the constriction of when the fluids were recognized in the lungs. Although its stated that albuterol will increase heart rate, you need to once again look back at the whole picture. The heart is over-worked because of the build up of the fluids. If you open the alveoli to the widest it could be, it will allow 'more' fluids to move into the lungs, Thus decreasing the work load of the heart. However, this fluid can settle further into the lungs because the alveoli are now 'more' open. That’s the reason for albuterol, but you cannot just give this alone. With that you need to give the nitro. This allows the veins and arteries to open up to a wider than normal state, thus allowing fluid to shift, again. The fluid can then be eliminated out of the body only by a diuretic of some nature, such as lasix. Also never forget how well positive pressure ventilations work for these patients after the albuterol, Nitro, Lasix treatments.
The second way to look at it is your way.....the idea that the heart is already over worked, so why make it beat faster....but I think that if you look at the top picture, discuss it with 'most' MD’s they will paint for you a similar picture as what I just did.

I hope that wasn’t too confusing for everyone, its harder to explain on paper, with out the ability to do some drawings.

Toering - we carry and often use NTG Drips. We carry mini-med pumps that are simple to use. When we talk about 65 mile transports, you have plenty of time to set up a nitro drip!

[ABMedic]

A good thread with lots of input generated. I asked the question to see what the current clinical practice and thoughts on CHF. Notwithstanding the conventional treatment with bronchodilators, the question was restricted to a comparison of IV Lasix with that of IV Nitro. In cases of fulmenting pulmonary edema, I would think that using both IV Lasix and IV Nitro would be utilized. However, IV nitro infusion in a dose dependent fashion is both a preload and afterload reducer. Since most cases of Acute Heart Failure, the basis of the initial event is ischemia, and left ventricular dysfunction, would not the hemodynamics and the myocardial oxygen demand of the left ventricle be improved by reducing preload and afterload? In a comparison, IV Nitro titrated rapidly upwards has made dramatic clinical improvement in AHF, in a number of cases preventing the need for intubation and mechanical support both in the hospital and prehospital environments. Lasix essential has two phases in its action; firstly, as a venodilator and then in approximately 30 minutes to increase diuresis. Initial improvement of AHF when utilizing Lasix is due to the venodilation and the decrease in preload thereby reducing the end-diastolic volume and improving left ventricular pump function. I agree with some of the responders and evidence in the literature, that Lasix is often misused, as all crackles is not AHF; therefore, incurring all the risks of Lasix and no therapeutic benefit. CPAP as a treatment option is currently being investigated for a role in prehospital care, and as a Respiratory Therapist, I can attest to its value in the hospital setting; however, clinical trials will assess its clinical utility within our environment. IV Nitro is a safe drug, perhaps safer than SL administration in some situations, if one considers the initial dosing and ability to titrate the dose to clinical endpoints. Thoughts?

ABMedic

[hageremtp]

the question was restricted to a comparison of IV Lasix with that of IV Nitro
Ok, that one was a bit over-board. You gotta understand that many regions treat things with a little different thought. There is no such thing as restricting questions on here. If we get off on a tangent (which often happens) we may need to be reminded to return to the question. I do believe that the Treatment of CHF has many aspects of which each was being talked of.

IV Nitro is a safe drug, perhaps safer than SL administration in some situations, if one considers the initial dosing and ability to titrate the dose to clinical endpoints.
I would agree with it being safer, but it can also get one into as much trouble as SL nitro. Many services do not carry IV pumps in their ambulances, there is just not enough use to justify the cost. With out a pump, it is hard to manage a nitro drip....dont get me wrong it can be done, and I have done it...I just wanna say its hard to do.

A good thread with lots of input generated. I asked the question to see what the current clinical practice and thoughts on CHF.
So tell me where the quesion was restricted, I missed that part and so did you. First you say its restricted to the discussion of "IV Lasix of IV Nitro for CHF", then you go on to say the above line about learning of the current clinical practices. Further more I want to remind you to stay on topic, as you brought in SL Nitro, which unless I cannot see anymore, is no place in your "restricted" original question.

Notwithstanding the conventional treatment with bronchodilators
As I understand there are still many area of the world that do not use bronchodilators as a first line treatment of CHF. There are many people that perscribe to the "second" school of thought that I posted above. I think that the debate on Bronchodilators is justified just as the original question on IV Nitro and Lasix.

Now whats your thoughts on IV Lasix of IV Nitro for CHF ?? (hey thats how you typed it)

[ALSfirefighter]

Let's look at an even bigger picture, unless there is something else, all I've ever seen NTG drip in is glass bottles. That can cause a huge problem for transport. Also does it have to be refridgerated?
Now on my tangent:
Nothing aggravates me more then when a medication or a skill gets yanked because of "problems." The real problem is that they don't do refresher or remedial training to fix the problem. Instead lets just pull it. Real nice. "problems with administering it at the wrong times, ie pneumonia." Says something about either the assessment training they got, or the continuing ed they still are suppose to get. Acute onset is acute onset, and if it is somewhat of a progressing problem, more then likely they will have some other history to back it up, ie HTN, already on a diuretic, etc. Or how about a fever? productive or even non productive cough? Any abnormal pain with routine movement? So now instead of giving a little lasix which will open up their old loop of henle's, they now will have a whopping heading because they still will want to deliver SL NTG for rales. I haven't heard to many people dropping dead from a little lasix given.

We do not have bronchodilators in our protocol for CHF either, and I partly understand why and I know of medics who use it for the "rule out" method. I don't need to do that and guess I'm still on the debate that occurs that it could still cause more harm by opening up the lower airways and alveoli even more. But I'm not an MD so I'll drop that.
Hypokalemia? With one dose of Lasix? Even at 100mg, yes it is potassium depleting, however, that is more of a larger concern for those who take lasix chronically. Even more so if you gave lasix, your potassium level should be drawn with routine blood work anyhow. For us its SL, Lasix 40-80, up to a 100 with med ctrl, paste and MS. I often call for the extra 20 to equal a hundred :rolleyes: because we only have 80 for standing orders. But mostly I use and tell newer medics when they ask how do you know how much. First experience will tell you, and then I often tell them: rales in the: bases=40mg, half full=60...full and drowing=80-100. and if they get 60 or more of lasix they get paste.

[hageremtp]

ALS you are right, that Nitro in a drip form comes in a glass bottle. This is not that big of a problem, as most of the IV 'hangers' I have seen have a somesort of wrap to secure a bag to it, thus you just need to wrap the IV nitro so it dont bounce either. I will often inflate a BP cuff around the bottle and then hang it........
Secondly, no nitro in the drip form does not have to be kept in the fridge. It is the same as the other nitro products in its storage. Lasts up to 2 years before it will expire.

[ALSfirefighter]

Hager thanks for the info, but I still have to say as a expierienced field provider, those bottles can add weight, and weight is my enemy with all the other crap I carry, unless it would be kept in the bus.
I'll stick to lasix.

[ffemt1361]

Here is the Maryland Protocol for the treatment of CHF/Pulmonary Edema:Pts who use NTG or have a hx of using NTG it can be admin @ 0.4mg SL. Can be repeated if symptoms persist and BP is > than 90mm Hg and HR is > than 60 bpm max dose is 1.2mg. For pts that dont have their own NTG or do not have a hx of using it IV of LR must be started. Rhythm must be identified and treated accordingly to the appropriate algorithm. After that the following meds may be considered: Additional NTG 0.4mg SL, Albuterol Neb @ 2.5mg in 3.0ml of normal saline, Furosemide @ 0.5-1.0mg/kg slow IVP, Morphine 2-10mg slow IVP, and Dopamine 2-20mcg/kg/min titrated to systolic BP of 100mm Hg or medical consultation directed BP. CPAP in Maryland is a Pilot Program.

When I was the driver on a CCT unit I was responsible for helping the nurse and paramedic set up the drips. We carried NTG in drip form also know as Tridil. The glass bottles do add weight and sometimes didnt play well with the other drips.
Take care and stay safe.

[ABMedic]

Interestingly, systems with relatively short transport times 20 to 30 minutes to an acute care facility have been using Nitro infusions for some time, some carry it in 100 ml premixed glass bottles whereas others carry Nitro in a large ampule and mix it in a normal plastic IV bag before running it on a pump. One would think that this would violate all common sense regarding Nitro infusions, due to the absorption of Nitro into the PVC bag. Not the case for short transport times of less than 60 minutes. The kinetics of PVC absorption are not instantaneous, and there has been no difficulties with dosing rates upon switching over at the ER.

IV Nitro started in the prehospital environment is not labor intensive, and considering that ER's are generally crowded means that therapy initiated in the field is maintained over the "potential" gap that occurs in busy ER departments.

Furthermore, it's been interesting to see the shift to the early use of IV Nitro earlier in the treatment of Acute Heart Failure (AHF). This does not mean that Lasix is not used; but rather, that the acute episode of failure and underlying ischemia is treated earlier and more aggressively, especially since most of these patients with the exception of those in cardiogenic shock with pulmonary edema (Killip Class 4) are hypertensive.

Bronchodilators improve the ventilation-perfusion mismatching that occurs in failure, although no drug is without adverse effects, significant increase in the heart rate is usually not a complicating factor. Interestingly, the wheeze in failure is due to interstitial edema that not only mechanically narrows the small airways but also induces bronchospasm by the NonAdrenergic-NonCholinergic (NANC) pathway. Bronchodilators antagonize this inducement of bronchoconstriction, improving ventilation-perfusion mismatch, whereas Nitro and Lasix, improve the degree of shunting by improving the function of the left ventricle.

PS - I was in error in trying to restrict the question; however at the time I thought with the many aspects of AHF management that focusing on one aspect would be reasonable, but even I have trouble not travelling down tangents (laughing)

Thoughts?

ABMedic

[firemedic14]

Just remember in CHF treatment is Nitro, lasix, morphine... Chest pain SL nitro, morphine, nitro drip if your department has it...

Some CHF patients also need albuterol nebulized if they have some wheezing... But don't forget about the other treatments... If you give a pt a breathing treatment, and nitro you may open things up too much and basicly drown them.... Lasix is supposed to work in 5-15 min, "I would say you should start seeing more effect in the 10-15 min area...." If your pressure is low you may be looking at more of a pump problem, that might be causing Pulmonary edema... Consider Dop.. and Lasix in these pts, but becareful of a fluid bolus and nitro...

[ABMedic]

Responding to the post by firemedic14


If you give a pt a breathing treatment, and nitro you may open things up too much and basicly drown them....

I don't understanding this statement?? Could you explain?? The pathophysiology and subsequent management does not work this way. The reduction in preload and afterload will result in improved left ventricle performance and thereby help resolve the pulmonary edema!

ABMedic

[hageremtp]

ABMEDIC Glad the floor is open to discuss the treatment of CHF in all aspects of the world....

Just remember in CHF treatment is Nitro, lasix, morphine... Chest pain SL nitro, morphine, nitro drip if your department has it...

You may think this is the treatment, and it might be the treatment in your area......BUT here its: CHF-Oxygen, Nitro SL and/or Drip, Lasix, Neb, Morphine...Chest Pain is Nitro SL and/or Paste and/or Drip, Oxygen, ASA, and Morphine. Both get 4 and 12 leads done on them. And if there is ST elevation in 3 leads (that go together) we can call in to use TNKase....hows that for a feild drug? Thats right my friends TNKASE in the feild. Now who has a long transport time??

firemedic14
Please remember that your service only represents a fraction of all the services in the Country. Remember that the national standard is set as just that, and some services choose to go beyond the standard as the direction of the Medical Director. Your service might have a 30 min transport time, but other areas of the world transport times can be hours in lenght. Things that I do here are no where what you might do there....WHY?? I have a great medical director that is proactive.......and we have 45-65 min transport times in area that I serve. SO just because you treat something one way (and it works for short times your with the pt) remember that there are those of us that are with our pts longer times that provide care to our pts (your pts get this care in house) in the feild.

[ABMedic]

Glad you brought up TNKase, we have been using TNK for the past number of years as part of ASSENT 3Plus - International Prehospital Thrombolytic Trial. The trial recently was completed (credit given to my coworkers - and as a result of comprehensive screening of even possible atypical ischemic presentations, resulted in our center having the highest enrollment worldwide) Currently a couple of new trials in different areas of prehospital research are being set up.

But back to the topic - Acute Heart Failure:

I agree with you that all the drugs mentioned in your post are used in the management of acute heart failure. However, management of medical conditions do change as our understanding of the pathophysiology improves ... the thought of IV Nitro in CHF is not my original thought; but rather, from the peer reviewed literature and clinical practices of both the ER and Cardiology services. I am glad that this topic has generated lots of dialogue. Perhaps we should now select a different topic to debate?

ABMedic

[hageremtp]

Let's Just Bump this one too!

[YuccaP]

Originally posted by ABMedic
Perhaps we should now select a different topic to debate?

Well, I'd like to add my point of view to this thread.

First, pulmonary edema is symptom of something. At least one should record ECG to find out possible iscemia or AMI. Furosemide can be helpful if there is clear signs of periferic edema (pitting etc.) but it is not primary medication. Nitro comes first. Well, CPAP comes even before that...

Many acute pulmonary edema patients are actually hypovolemic and sometimes even need extra iv-fluids. The reason of pump failure is often AMI or ischemia. Nitro via infusion pump gives pretty easy way to handle blood pressure and decrease both pre- and afterload, but why to give diuretics if there is no extra fluid?

On the other hand sick and dilated hearth needs enough preload to pump effectly, so pushing water out from circulation can drop blood pressure. Furosemide effects after 20-30 mins. and patient is in many cases in hospital. Possible side-effects don't show up before that.

IMHO threating CHF is maybe most complicated situations in EMS. In fact I don't believe that it is possible to create clear and simple protocol to handle all these cases well.

What comes to pre-hospital nitro infusion, infusion pump makes it pretty easy. Of course it takes some time, but threating these patients takes usually 30-45 minutes anyway.

[911WACKER]

Keep It Simple Stupid - Nitro only buys you time when treating CHF, no matter what form you use. Lasix is still an important part of the treatment regiment, and works well along with nitro.

I don't know abpout any of you but SL or spary NTG is much easier to use when you have an acute case of CHF going on, drips need careful, acurate attention to manage and therefore could be potential pittfalls in the treatment process. I am not agianst this idea, but practicality is a big factor, especially when you are the only person in the back of the bus treating one of these acute cases. The IV NTG is more practical for the less acute cases, but then you really don't need it so bad then!!!!

Then agian, we are all entitled to the opinion!!!!!

[hageremtp]

But IV Nitro can deliver a small dose over a longer time.....SL give a much larger dose at one time! Just rememeber that.........and your going to need an IV anyways!

[FiremedicNV]

Per our protocol, Nitro can be given 1.6 SL (4 sprays) if diastolic is >100. Research (both read and practiced) shows, though that through creative documentation, and reduced dosages, that 0.8 can be just as effective, without bottoming a pressure (obviously patient to patient, presentation and hemodynamic dependant). I love the Albuterol too. Granted it floods them, but its better to open up the alveoli, fill them with fluid, than force air on bronchoconstriction. Bag-in neb's, fluid bolus ready...When in doubt, Mac 3 and 7.5..... But Id rather overtreat and correct, than show up and tube....

[emt161]

And this thread was exhumed.... why?

though that through creative documentation,

Translation: we lie on our run reports.

I love the Albuterol too. Granted it floods them, but its better to open up the alveoli, fill them with fluid, than force air on bronchoconstriction.

Bag-in neb's, fluid bolus ready...

Dude where the @#$% did YOU go to school!

[biggravy]

For all the folks that in 2003 were thumbsdown on nitro and thumbsup on lasix, have your treatments changed now in 2007?

[DAN911]

Here we can only use Nitro if the patient have chest pain, if the patient is able to have good respiratory amplitude, we give 5mg of Salbutamol, if he have chest pain AND good respiratory amplitude, we give both and if not able to breath by imself: CPAP.

[bonedog]

I would suppose that with the studies showing the increase in mortality with morphine, lasix and intubation, people's outlook will have changed.

CPAP, high dose NTG, beta agonists only if COPD is truly a component, as most probably have figured out by this time that "cardiac asthma" is a result of airway compression and hydrostatic pressure, as opposed to bronchospasm.

Once the vasoconstriction/shock state is dealt with the kidneys perfuse better and lasix isn't needed....but we could get into the lasix vs. ethacrynic acid debate, any interns care to jump on board?

[LasVegasEMS]

And this thread was exhumed.... why?



Translation: we lie on our run reports.





Dude where the @#$% did YOU go to school!

Completely agree with you. For the record, this is not how the majority of medics practice medicine here. From the protocol he stated I assume he is in Clark County, which hits even closer to home.

This is one of the reasons that most of the privates cancel fire as soon as they can, because fire, for the most part, has NO idea what they're doing. Hopefully he didn't go to one of the schools here because I know they teach'em better then that.

[DAN911]

Our medical control is working on new protocol that can allow us to give nitro SL for patient in CHF without chest pain but for now we can't.

[emt161]

Here we can only use Nitro if the patient have chest pain, if the patient is able to have good respiratory amplitude, we give 5mg of Salbutamol, if he have chest pain AND good respiratory amplitude, we give both and if not able to breath by imself: CPAP.

Cripes. And here I thought Canadian EMS was more advanced than the US due to the education requirements for their providers.

[medic563]

For any moderate to sever CHF:

1. Medical supportive care
2. NTG 0.4 mg SL once every minute to a total of three NTG as long as systolic BP above 140
3. Iniate CPAP if airway intact and currently not having ST changes. (If either of those most likely intubate)
4. IV NTG, 2nd IV, IV lasix
5. Dopamine as appropriate

[ChiefSquirrel]

Anyone thought of using NTG paste?

Our system allows for CPAP if available (it's not for us) or 1 inch of paste AND 0.4 mg SL. Lasix is next and then morphine if the patient's BP is maintaining and other treatments aren't working.

[armymedic571]

PA state protocol 5002, CHF

Pt assessment
manage airway
High flow oxygen, consider CPAP, titrate above 90% SpO2
ECG and pulse-ox

Intiate IV, if B/P is above 100 systolic
1-3 doses(0.4 mg NTG SL) every 3-5 minutes
(3 sprays or tabs for SBP >180)
(2 sprays or tabs for SBP 140-180)
(1 spray or tab for SBP 100-140)

1-2 inchs of NTG paste for pts on CPAP

may repeat SL NTG as long as SBP is above 100.

lasix 40-100mg for pts who currently have a prescription, or by command.

Bronchodilators if wheezing or to rule out cardiac wheeze.

thats a paraphrase. Goto www.sehsc.org for an official look.

[medic563]

I've used paste before and the only benefits I see is that you only need one line on the patient and its quicker to put on. Its absorbition is so variable as for as amount and time that it isnt my personal favorite. I'd rather take the time to get another IV on my patient and have my first line as NTG. Once on the drip more control and can titrate your dose better.

[armymedic571]

That would be great, if we were allowed to give NTG IV.

[DAN911]

Cripes. And here I thought Canadian EMS was more advanced than the US due to the education requirements for their providers.

All the Canadian EMS except for the Province of Quebec, we are all primary care paramedic and we don't have ALS except for a few in Montreal (around 15 advance care paramedics).

[Azurri111]

Cripes. And here I thought Canadian EMS was more advanced than the US due to the education requirements for their providers.

Quebec's system is VERY FAR behind the rest of Canada. They are catching up though which is great. I heard they had the Dr.'s in cars method. I have heard rumours they only approved ACP's in the past couple years in Montreal.

In Saskatchewan we go with :

Nebs for bronchospasm,
Obtain 12 lead prior to nitro (rule out RVI)
NTG x 3 doses,
IV Lasix - double their daily pill dose to 200 mg max (rarely give more then 120)
Morphine: Contraindicated- Resp depression worries - Hospital rarely uses.
CPAP is being approved as we speak
I use BVM assisted resps quite a bit in flash edema and it works great.

There was talk about IV Push nitro at one time too. Still in the hospitals occass but seems to be not used near as much as before.

BTW Are services using CPAP - single pressure settings or BIPAP in EMS?

[bonedog]

Azurri111, here in BC the CCP's can use the LTV for CPAP, the pressure 10 above peep is what I use, however if transport time is short it is much easier to hand bag them, many patients who have had it before actually will reach for the mask.

Personally I prefer SL NTG as it is high dose immediately, with severe HTN I have used from upwards of 30-60 sprays until the afterload is dealt with, I watch for a 10% drop in pressure then back off either on timing or dosage and titrate to half life. ( When your using high dosing the 10% will save your bacon, many of these patients who have had long term NTG therapy become attenuated to it, at any rate one must tx each patient according to how they present and respond) Also it saves me setting up the infusion and getting out a pump.

As I stated before, once the vaso constriction is dealt with the kidneys will perfuse so the Lasix isn't really needed. We used to do the shot gun with NTG/Morph/Lasix but after a high dose NTG study found that worked best, at least where the tired old pump is working against the severe back pressure.
The other advantage, once you have gained back on the excessive stretch is the added bonus of better coronary perfusion.

We also used to use the double daily dose, used 240 on one occaision, with CPAP, to keep from intubating, as there were no vents, an hour later we were able to transport on face mask, another obese pt who didn't get the PVC challenge.

When I suspect a RVI a 15 lead is usually done.

[medic563]

The problem with contiuned SL in conjuction with CPAP is you have to keep breaking your mask seal. I think its alot better to front load them with SL while CPAP is getting sat up, then immediately switch to your drip. Our pumps are three channels with NTG always preprogrammed into one. I think its important though that people not be shy with uping the NTG drip rate. If you give a SL every 5 minutes your already giving 80 mcg/min, starting at 5 mcg/min on the pump you need to be prepared to increase your dose rather quickly.

CPAP/nitrates are the way to go with your prehospital CHF care. Morphine has already been shown to increase mortality in your CHF patients. Lasix is good if you're certian your dealing with CHF but unless you have extended transport times you probably will not be seeing much of the results in the ambo.

Of course with an evolving MI your better off to intubate then you are to CPAP the patient.

[FireLtParaM]

My modality of treatment would not include morphine for CHF patients with acute flash pulmonary edema due to the fact that Morphine as any other analgesic will in turn cause respiratory depression which battles against everything you're trying to accomplish.

As for administering Nitro with CPAP, I would not personally recommend it. As stated above the whole process of CPAP will be ruined by the constant removal of the Positive Pressure environment in the patients lungs. This is why many EMS providers will consult with their hospital to find out the make/model of their CPAP unit so as to get the same one for compatibility and continuity of care.

[medic563]

As for administering Nitro with CPAP, I would not personally recommend it. As stated above the whole process of CPAP will be ruined by the constant removal of the Positive Pressure environment in the patients lungs. This is why many EMS providers will consult with their hospital to find out the make/model of their CPAP unit so as to get the same one for compatibility and continuity of care.

Or go spend a little money on NTG paste or alot of money for pumps and NTG drip (high intial startup costs, then fairly cheap) That way you can have the best of both worlds.

[BCALS11]

MS:

- Decreases preload through histamine mediated pathways
- Decreases profound sympathetic tone by promoting anxiolysis and analgesia
- Can certainly cause respiratory depression, especially when administered too rapidly or in inappropriate doses for a given patient presentation (e.g. 1-2 mg might be more than enough when used in this situation) .....that being said, is this really a bad thing when you are taking over their respiratory efforts through use of a BVM, positive pressure ventilation with a vent, or CPAP?? Quite frankly, I prefer a patient who is compliant with my airway management efforts compared to one who is combative and whose ineffective efforts produce unnecessary complications when I attempt to improve both the patient's oxygenation and ventilation status. If you are truly afraid of the respiratory depression associated with opiates in this setting and for some reason don't want to include the other positive results of of MS administration when faced with a truly sick cardiogenic pulmonary edema patient, a touch of Midazolam will go a long ways towards improving your attempts to manage this challenging airway issue. "Chill" is a good thing when you are drowning in your own fluids even if it is limited only to the sedative effects of a benzodiazapine - as described above, MS has other collateral effects that I believe make it a superior drug in this situation.

I'm not saying that MS is the Holy Grail for the treatment of cardiogenic pulmonary edema, the astute posters above have already detailed appropriate initial treatments in the pre-hospital setting and certainly MS is not appropriate for every patient. That being said, excluding MS when used in judiscious amounts and when clinically indicated may limit the positive effect that we can have on these patients before they reach the hospital. As with appropriate pre-hospital administration of Lasix, MS has a place in the pre-hospital treatment of CHF complicated by pulmonary edema.

[medic563]

Unfortunately research does not support your thoughts on MS as it has been shown to increase the mortality of pulmonary edema patients. I personally believe that this is probably due more to the histamine effect than the resp depression but that is still yet to be determined. I believe it will very quickly become standard practice to use either fentanyl, which does not have the histamine release, or a benzo for these patients. The true benefit of these drugs is in their ability to calm the patient, not the mild vasodilation that MS typically causes.

[mitllesmertz1]

Unfortunately research does not support your thoughts on MS as it has been shown to increase the mortality of pulmonary edema patients

Since I have read this quote a few times, it makes me wonder if there is another cause for the increased mortality.
For example, many "algorythms" I have seen for Acute Pulmonary Edema go something like this:
O2,IV access,ECG/12lead
NTG
Lasix
Morphine
RSI

So if you look at it like this, the pts that end up receiving MS are the ones that don't respond well to the earlier treatments.
Same thing for pts that were intubated prehospital.

Therefore, the pts that receive MS were possibly "more sick" than those that didn't receive it.
Some systems make restocking narcs a lengthy procedure, and medics are rather hesitant to pull it out of the box.
Does anyone's protocols call for giving MS as the initial treatment for APE?

In this study that is often mentioned, I would ask if the groups that received/didn't receive MS were looked at to see if the initial presentation was any different. Were the initial sats, or resp rate/perceived excertion, BP, etc, all similar between the 2 groups?

My theory is that the pts who receive MS or RSI were "sicker" overall than the pts that didn't receive these treatments, and the overall increased mortality is not an end result of receiving MS.
It's an end result of them being in greater distress at the initial presentation.

Anyone else thinking about this?

[biggravy]

The major study that "proved" Morphine increases M&M was a chart review basically, not a double blind. The point that sicker patients are the one's getting the MS has been discussed alot since then. I think the jury may be out on morphine in small doses, but only second line to CPAP and Ntg, and then only really to decrease agitation, etc. where a benzo could do the trick anyway.

0.02

[medic563]

Mittle,
To some of your points I agree. The sicker patients were probably more likely to get MS. However I believe a large volume of the research based on the findings for MS use in both ACS and pulm. edema came from retrospective hospital reviews so that might not be as skewed as if it were based solely on prehospital data. You are totally correct about most medics treating CHF with MS farther down the algorythmn so if that would definetly skew data if based on EMS care.

Trust me I think about items like that all the time, but you also have to look at any evidence out there. Unfortunately I seriously doubt (if anyone knows if one is going on I'd love to hear it) a double blind randomized trial to compare MS to no-MS or MS vs another drug. Unfortunately none of the drugs we are talking about are new meds so there is no real money to be made off of proving one is better. Because of this I would doubt a study of this complexity and cost would be untertaken because no drug company has a huge profit to make.

So why do we give MS to CHF?

Personally it usually is for anxiety control and help to tolerate the CPAP mask and not because I think I need further vasodilation past what the NTG has already given me.

[DaSharkie]

The vasodilatory effects of Morphine Sulfate are nowhere near what they were thought to be.

And if anyone in medicince totally alters their practice based upon 1 study they are out of their freaking mind. The only possible exception to this (in my own feeble little mind) is the NEXUS study - Some 20,000 patients in academic to community hospitals in various levels of experience and education.

Back to the point, the Morphine Sulfate for the post part is for analgesic relief and, as mentioned, to help reduce the anxiety component that exists when one is drowning in their own fluids.

There are few, if any providers that I work with that have changed their practice on this study.

As with any study in medicine - there are contrary studies produced frequently so one must careful to make the aforementioned alterations in ones' practice.

[medic563]

I dont think its just the one study that is going to alter what people are doing, I think the study plays a role, but as knowledge as to why were giving MS change (I know when I was in medic school it was drilled in because it was a vasodilator, I think much differently now) along with meds that should have less side effects becoming more common place in prehospital and emergency medicine I think there is going to be a shift in the meds we are using to treat some varying problems.

[jjones1418]

I don't think that there is a way to accurately say, "This one is better than the other." As they are different medications. NTG being a nitrate, vasodilates. Lasix, a loop diuretic, diureses. But we can look at the two separately and see that using them in concert is sometimes effective, and maybe talk about a few other drugs.

I think YuccaP's post was very accurate. He stated that diuretics were not the so-called "first-line" treatment, rather that Nitroglycerin was before that. He also made a point that just because someone has APE, it doesn't mean they need a diuretic. Lasix does, however, push fluid from the vasculature. This, OVER TIME, reduces preload on the left side of the heart, causing increased efficiency. It works, or we wouldn't be using it. I think that it has been taken away from some EMS crews as they are relying on it over NTG in patients that needed a reduction in preload, like, yesterday... It does have it's place though.

Nitroglycerin works much faster to vasodilate and decrease preload on the heart. Some places initiate drips starting at 50-100 mcg/min for these critical CHF patients. It's easy to titrate, much more accurately dosed than SL and TD NTG. SL NTG is a good quick fix for us prehospital, and it's going to be continued usually in the hospital. Initiating an NTG infusion is a good idea, if you have the capability.

More in the critical care scenario than in the prehospital arena, you see the use of Nipride or Natrecor to reduce afterload as well. Nipride works well in CHF and cardiogenic shock. It works to decrease both preload and afterload, resulting in increased pumping effectiveness. In Cardiogenic Shock, where they have a decreased pumping effectiveness AND hypotension, it works to decrease both preload and afterload, which results in increased cardiac output. It seems weird to give a vasodilator in hypotension, but think of it as increasing the size of the fire hose to decrease friction loss. There's not a volume problem, but a pump problem. The fact that there is increased SVR makes the pump work a lot harder than it needs to, and by increasing the size of the "fire hose" we allow the "pump" to work more effectively. Also, we know that BNP is released when the heart does not pump effectively. BNP is measured to determine the severity of the heart failure, but the body doesn't just release it to say, "AHH I'm in heart failure." It actually functions to decrease the afterload, hence why the worse the failure, the more BNP is released to help the heart out. Natrecor or Nesitiride is basically synthetic BNP.

Also used in the management of CHF are ACE inhibitors. Angiotensin I is converted to Angiotensin II, which is one of the most potent vasoconstrictors in the body. Angiotensin II causes all kinds of issues. It causes increased release of ADH, causes the adrenal cortex to release aldosterone (causes kidneys to retain Na+ and H20), and it's thought to cause hypertrophy. ACE Inhibitors prohibit the body from converting Angiotensin I into Angiotensin II, or "vasoconstrictor." It leaves the inactive Angiotensin I floating around in there. If the APE is due to an acute MI, ACE inhibitors limit the ventricular remodeling, which causes restrictive cardiomyopathy. So, ACE inhibitors seem to work...


Sooooo,

All of these together are useful in the treatment of CHF. It's really hard to say one is better than another one, because they all do different things.


And for those who take themselves wayyy to seriously, I'll insert a sarcasm tag....

-- sarcasm

Personally, I would just mix all the drugs up in one BIG 60cc syringe, and SLAM it. Who needs an infusion pump?

-- end sarcasm


--- J.Jones

[algoma44]

I agree with jjones.. I think the larger issue involved here is not what meds are better. Each of these procedures/meds is effective in certain, but not every, situation. I think the problem is that people are always wrapped up in fixing the problem at hand.

The first issue is to define the problem - which is second spacing of fluids - obviously somehow fluid is in places where it isn't supposed to be. Acute vs Chronic, Fluid Volume Overload vs Pump problem, mere postural changes, new MI, simple non-compliance with low sodium diet; whatever caused this problem is a whole different animal and is not usually ours to decide. Ultimately the objective is to treat the underlying cause, which we generally don't have enough time to figure out in the back of our squads.

So, what is our job in the field and what should we be doing? Keep it simple stupid! Go back to the basics and try not to over do it. Good medics.. good nurses.. good doctors are great at one thing: Assessment! There isn't a magic potion of meds that will create an effective response with every patient, every time. As a society, we are always trying to develop one set of standards that we can apply to every patient in every situation, when in reality, we know that every situation and every patient are different! So why do we continue to try to develop one set treatment for such a diverse problem? Cant help ya! If you can ansewr that question you deserve a nobel prize.

In my opinion, the one thing we are trying to prevent is intubation. How aggressively you need to treat your patient to do this should be on a case-by-case basis. Because we dont' always know the cause, sometimes this may involve a little trial and error with medications. In other words.. rely on your critical thinking and judgement. A lot of medics get so charged up to use those critical care skills they aquire in school when really they shouldn't have to... There's a time and a place to bust out those skills, aggressive is not always better!!

[emt161]

I think that it has been taken away from some EMS crews as they are relying on it over NTG in patients that needed a reduction in preload, like, yesterday... It does have it's place though.

The fact that EMS is only 40% accurate at correctly diagnosing CHF may also have something to do with it.