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

- Rogue Medic

More on Lasix in EMS

Some people may think that I am crazy for claiming that we should not use Lasix (furosemide). For a slightly different perspective, here is an emergency physician describing the appropriate treatment of unstable hypertensive acute pulmonary edema patients.

EMCrit is an excellent podcast blog with nice short podcasts. More important than being nice and short, the podcasts are science-based and address many of the issues that EMS treats. The first podcast from EMCrit is 10:33.

How important is furosemide?

Is the furosemide drug shortage important?

So, the first thing you do is get your Lasix . . .

Only

1:50

into

the

podcast.

OK,

maybe

I

was

thinking

of

a

different

podcast.

Maybe

I

was

wrong.

So, the first thing you do is get your Lasix and you throw it in the trash.

No.

I was right.

This is the podcast for me.

It’s not going to help you and it’s very potentially going to hurt you. No Lasix in these patients. Now, I’m sure your EMS providers have already given it. Well, that’s just fine, but you don’t have to exacerbate the problem. Most of these patients will end up volume depleted, not volume overloaded when you look at their intravascular space. You’re probably going to end up giving fluid to these patients, not trying to diurese them. The problem is not fluid overload.

Most of these patients will end up volume depleted,

Go listen.

10 minutes 33 seconds of somebody who understands CHF(Congestive Heart Failure)/ADHF (Acute Decompensated Heart Failure). And he isn’t subtle. 🙂

PS – Dr. Weingart, why not try to get those of us in EMS to improve our care of these patients, too?

High-dose NTG and CPAP are also treatments that can be given by EMS. In some places, these are given by EMS.

With sublingual NTG (NiTroGlycerine) we probably cannot give too much to these patients.

We should be using NTG by IV in EMS. In Pennsylvania, IV NTG is an optional drug for 911 services.

EMCrit’s page of references supporting this aggressive approach.

Updated 02/08/11 to reflect the new blog address for EMCrit. http://emcrit.org/ The old links did not redirect appropriately.

.

Comments

  1. I could listen to Dr. Weingart all day, and this is a hot-button topic for me. Just last week, EMS brought us an elderly patient SOB with rales up to the clavicles, and everyone (including the treating doc) was sure it was pulmonary edema. Load em up with Lasix and nitro, get the stat CXR, and whoops, giant pleural effusion. Nitro got turned off with no harm done, but the lack of urine production even after Lasix probably didn’t bode well for the patient’s kidneys.

    One of his more recent posts on cardiac arrest management that pretty much nails everything you’ve been saying on your blog over the past couple years I’ve been following. It must be a good sign that you keep such good company. http://emcrit.org/podcasts/intra-arrest/

  2. I argue against your point with many providers. I believe that your statement should be amended to say “don’t reach for lasix right away…listen to the patient’s history”

    Lasix still has its place in the management of CHF…even prehospitally.

    This is also coming from a prehospital provider that uses IV NTG for CHF patients…so I am all on board with using afterload* reducing doses of nitro. That is at least 80mcg/min IV…for the appropriate patient population.

    Third spacing of fluid comes from different mechanisms: oncotic, hydrostatic, and inflammatory.

    The hydrostatic overload occurs in the patients in SCAPE…but not every CHF patient is in sympathetic induced cardiogenic pulmonary edema. These patients are either euvolemic or hypovolemic…I agree.

    What of the patient that is halving their daily dose of lasix due to financial reasons? Ran out of their medicine entirely and cannot afford a refill? I recall one patient recently that obtained her meds through her husband, a VA patient that was prescribed a lower dose than what she normally takes. He would take his medicine every other day so she could double up. The patient that has had a worsening progression of symptoms over the past few weeks with increased peripheral edema? That is the hypervolemic patient. Yes, nitroglycerin plays a large role and the mainstay of cardiogenic pulmonary edema should be aimed at reducing afterload NOW…but these patients have an underlying problem that is not corrected by nitro. That only relieves the symptoms.

    I urge for more judicious use of loop diuretics…not abolishment of their practice all together. As it goes for anything in EMS, one drug is not the solution to all problems.

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  1. […] This post was mentioned on Twitter by Dispatch Demon, Shelly Wilcoxson, { Rebecca }, { Rebecca }, EMS Blogs and others. EMS Blogs said: From #RogueMedic: More on Lasix in EMS http://bit.ly/9cyFYx #EMS #Blogs […]

  2. […] is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be […]

  3. […] is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be […]

  4. […] have also covered these drug shortages here, here, here, here, here, here, here, and […]

  5. […] first wrote about EMCrit a few months ago in More on Lasix in EMS. Dr. Weingart understands about continuity of care and combines ICU and ED (Emergency Department) […]

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