2. WHY HOLD THE
LASIX?
AMR 713 Victorville
85 y/o male SOB x 1 day
3-4 word dyspnea
Warm to touch
Cough
Pedal edema
2
3. Acute SOB
66 y/o man presents with acute sob developing over
the last 8 hours
History of HTN, and tobacco use
Diaphoretic, normal mental status
Afebrile, HR 110, BP 180/110, RR30, pulse ox. 86%
Lungs crackles, JVD, pedal edema
3
4. Acute SOB
What is the optimal treatment in the next 5-10
minutes?
! A. morphine
! B. Lasix
! C. Morphine + lasix
4
5. Acute SOB
What is the optimal treatment in the next 5-10
minutes?
! A.
! B.
! C.
5
9. Morphine as Preload
Reducer
Disadvantges
May increase catecholimines
Respiratory depression
Direct myocardial depressant…decreased SV
No good evidence that it is a central preload
reducer
9
11. Lasix
Increased catecholine output… activates
renin..angiotensin system early on
Dieuresis is delayed…at least 90 minutes
Decrease stroke volume and cardiac output drop
Increases afterload
11
12. Nitroglyercin
Better than morphine or lasix for preload
reduction
Safer than morphine or lasix
Rapid effective iniation of treatment
12
13. Ace Inhibitors
Reduces afterload & some preload benefits
Works within 15 minutes
Decreases intubation and ICU admission rates
Combined ith NTG exceeds benefit of either
alone
13
14. WHY HOLD THE
LASIX?
Top Articles in 2006
Evaluation of Prehospital use of Furosemide in
patients with Respiratory Distress
Use of Lasix prior to adequate preload and
afterload reduction can be harmful
Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197
14
15. WHY HOLD THE LASIX?
Lasix given improperly up to 30%
of the time
Patients that received lasix and/or
morphine had increased mortality
2.2 to 22%
Use of NTG not associated with
worse outcome even if given
inappropriately
! ! Wuerz (Ann Emerg Med 1992)
16. What about CPAP or
BIPAP?
Non-Invasive Positive Pressure Ventilation
In an Austrialian meta-analysis 23 trials were reviewed
They found that when either CPAP or BiPAP were used
there was decreased mortality
Decreased need for mechanical ventilation
Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163
16
17. SOB & Funny looking
T-Waves
AMR 145
40 y/o female CC- general weakness & SOB
DM, HTN, ESRD on dialysis 3x wk.
Sinus rhythm with peaked T-waves
17
18. Acute SOB & Renal
Failure
Medic 314
57 y/o female w/ acute resp distress
Unable to speak
Retractions, JVD, no pedal edema
ESRD
Bp 250/150 HR 140 RR 30’s SATS 80-90’s
18
19. Case #1
37 y/o man presents in respiratory distress
History of HTN
Missed last 2 dialysis sessions
Exam is consistent with pulmonary edema,
severe hypoxia (pulse ox 80%)
Initial EKG…
19
25. Ventricular Tachycardia
Wide complex regular rhythm
No obvious pqrs association
Heart Rate must be >= 120
If HR < 120 BPM, consider
Hyperkalemia
Type IA medication toxicity (incl. TCA &
Cocaine toxicity
Reperfusion arrhythmias (AIVR)
25
26. Ventricular
Tachycardia
What’s the problem why don’t just go ahead and treat
with lidocaine, procainimide, amniodarone…
V- Tach Mimics
Treatment of slow “VT” may induce asystole
Mclean, et al (Ann Emerg Med, 2000)
WCT due to hyperkalemia misdiagnosed
as VT
26
51. 100. 26 year-old woman with history
renal failure, reports nausea and
generalized weakness
52.
53. V Tach Mimics-
Summary
Beware Slow V Tach HR < 120 BPM
Consider hyperkalemia, TCA OD, AIVR
Avoid Lidocaine and other antidysrhythmics
When in doubt try HCO3
53
Time for a case discussion. \nThink about what your response to this patient will be. \n\nCheck if they know ambulance codes.\n(note: change of modes to maintain interest)\n
