Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Corrections of Misleading Charts

Also posted over at Paramedicine 101, which is now at EMS Blogs. Go check out the excellent material there.

Back in September, I wrote Furosemide and Drug Shortages 2. I was just looking at the charts I made and realized that they were not at all helpful at explaining the information.

When I look at my own charts and have trouble figuring out what I was trying to explain, then I have completely failed.

I have edited the charts to do a better job of presenting the information I was trying to make clear.

Click on charts to make them larger.

When looking at the problems with the use of furosemide (Lasix), one import point to remember is that the authors only looked at the primary diagnosis. This is an important shortcoming of the study.

How many of the patients had a secondary diagnosis of CHF?

We don’t know.

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question,[1]

Another problem is that the authors seem to think that nitro is only for ACS (Acute Coronary Syndromes – essentially heart attacks). NTG (NiTroGlycerin) is the most effective medication for hypertensive CHF.

Only 43 out of 60 patients with a primary diagnosis of CHF received NTG – this needs to be studied.

Were these 17 patients not treated with NTG because they were hypotensive?

In the ED, it is much safer to give normotensive CHF patients NTG, because of IV (IntraVenous) NTG. EMS is usually limited to SL (SubLingual) NTG.

SL NTG is not what is best for patients, unless we feel that it is important to treat patients with NTG before starting an IV.

If we have IV access, we should be giving NTG the safer and more titratable way – IV NTG. (This sentence added 11:50 02/07/11)

This chart was just to show how little difference it would make to add in the patients who did not have a diagnosis.

This chart compares the deaths between the patients treated with furosemide by EMS and receiving a primary diagnosis of CHF and those not receiving a primary diagnosis of CHF.

Due to the shortcomings of this study, it should be replicated with the secondary diagnoses included. This is essential.


[1] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF



  1. So, I’m assuming you mean to say that we can actually give unlimited NTG to hypertensive CHF patients? What?!?! But, the NTG will surely bottom out their pressure. We can’t give that. The risks are too great. We need to leave the BP where it is and certainly we’re too stupid to know when it’s hypertension, much less CHF vs pneumonia vs ACS……….but in all seriousness, why is there such a resistance to giving multiple nitros? The most I’ve seen has been 6, but they usually want you to stop at 3 and switch to morphine……..but wait, don’t they also freak out about hypotension with that………..hmmm


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