RTs intubating...

[thegenius]

I'm sort of aware of this argument, but I have been unclear as to when diuretics should be given (in an EBM setting)? Also, I feel like this is similar to Kayexalate. If you have pulmonary edema, the hospitalist will give diuretics and usually demand that they are given prior to admission. It seems like an uphill battle.

Thoughts?

I agree. I give lasix. There is not some profound harm giving it at hour 2 vs hour 4….I give it and move on. What’s the difference if I don’t give it, and then the Hospitalist orders it 5 mins later and the pt gets it 30 mins later? That the order came from the Hospitalist and not the ER doc?

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[The Knife & Gun Club]

Sounds like a solid EM resident who's been keeping up with the EM literature.

Most recent studies have shown that lasix is harmful in acute heart failure.

I had a tough case just like this recently. CHF, bad AKI, huge pleural effusions but no tamponade on pocus, but also a BUN of 160, clinically bone dry, and BP of 80/40. Like all the fluid was just stuck in the wrong compartments.

We could not figure out which diuretics would push them and ultimately called called ICU and Nephro who settled on albumin and Lasix at the same time.

 

[Zebra Hunter]

Link with the relevant studies: http://www.emdocs.net/furosemide

That is some incredibly low quality literature on the subject. Also, emdocs is written by a bunch of residents looking to get their "research" requirement and frequently find low quality articles or controversial opinions (not being stated as such) stated there with above being one example. The argument that lasix in APE is harmful is spurious at best, and laughable at worst. The discussion regarding whether APE patients are volume overloaded is a legitimate one, but I don't think this discussion is relevant in a patient with 4+ pitting edema along with significant pulmonary edema.

 

[Jabbed]

That emdocs article is a little suspect in that it seems to paint all decompensated heart failure patients with one brush.

Yes, acute pulmonary edema with 230/170 should be BiPAP/nitro first and may not even need lasix. But the chronic dilated cardiomyopathy patient who is 20 lbs over their dry weight definitely does. And some like @The Knife & Gun Club actually need fluid/pressors/isotopes. It's a pretty heterogeneous disease process.

With that said 20 mg of lasix never hurt (or saved) anyone...

 

[RustedFox]

That emdocs article is a little suspect in that it seems to paint all decompensated heart failure patients with one brush.

Yes, acute pulmonary edema with 230/170 should be BiPAP/nitro first and may not even need lasix. But the chronic dilated cardiomyopathy patient who is 20 lbs over their dry weight definitely does. And some like @The Knife & Gun Club actually need fluid/pressors/isotopes. It's a pretty heterogeneous disease process.

With that said 20 mg of lasix never hurt (or saved) anyone...

Great post.

 

[alpinism]

I'm sort of aware of this argument, but I have been unclear as to when diuretics should be given (in an EBM setting)? Also, I feel like this is similar to Kayexalate. If you have pulmonary edema, the hospitalist will give diuretics and usually demand that they are given prior to admission. It seems like an uphill battle.

Thoughts?

I don't give lasix during the initial resuscitation but will administer their home dose before admission.

In my experience giving lasix immediately upon arrival does nothing for acutely decompensated patients.

 

[alpinism]

Sorry, I must have missed the day in statistical analysis class where case reports were equivalent to "current literature." Also not sure how the link relates at all to the clinical presentation described where it was explicitly mentioned that the patient had not only pulmonary edema but "4+ pitting edema"; the patient was clearly volume overloaded in that case. If your contention is that BiPAP and afterload reduction aren't utilized more, well, I can't argue with you there based on my experience. The conclusion that diuretics are actually harmful when a) the patient in question in the above scenario is not what is being described (ie pulmonary edema without overt volume overload), and b) the studies that make said assertion were either small or didn't actually describe clinical outcomes is spurious at best. And c), when was 2014 considered "current" in today's world?

So you'd rather give a drug that's never been supported by any high quality clinical trials over the past fifty years?

Case reports aren't great but they're better than expert opinion which is what guidelines for lasix are based on currently.

 

[greatnt249]

So you'd rather give a drug that's never been supported by any high quality clinical trials over the past fifty years?

Case reports aren't great but they're better than expert opinion which is what guidelines for lasix are based on currently.

I don't exactly need a "high quality" clinical trial to know that a markedly volume overloaded patient will benefit from diuresis. And when what you're quoting as evidence states that it's harmful, yeah, I'm going to question that conclusion.

Bad evidence is worse than no evidence.

 

[thegenius]

I don't give lasix during the initial resuscitation but will administer their home dose before admission.

In my experience giving lasix immediately upon arrival does nothing for acutely decompensated patients.

That’s my general approach as well. Lasix is given when I can safely walk away and never go back into the room. I give nitrates and bipap first.

There are some that don’t look all that bad to begin with, and probably don’t need to be in the ED anyway…and I’ll give 40-80 lasix up front to see how they diurese. But I’m not giving these bipap or nitrates anyway…or maybe I give a little nitrates or something if they have a meth induced 210/135 high BP.

 

[Radetzky]

I had a tough case just like this recently. CHF, bad AKI, huge pleural effusions but no tamponade on pocus, but also a BUN of 160, clinically bone dry, and BP of 80/40. Like all the fluid was just stuck in the wrong compartments.

We could not figure out which diuretics would push them and ultimately called called ICU and Nephro who settled on albumin and Lasix at the same time.

What was the clinical evidence for being “dry”? Heart failure with fluid stuck extra vascular is one of those made up pathologies that doesn’t exist, unless you have coexisting severe sepsis or pancreatitis or something.

 

[Jabbed]

The ones that I have seen were cardiac cirrhotics with albumin 1.x.

 

[thegenius]

What was the clinical evidence for being “dry”? Heart failure with fluid stuck extra vascular is one of those made up pathologies that doesn’t exist, unless you have coexisting severe sepsis or pancreatitis or something.

??

Isn’t HF with pitting edema extra vascular fluid?

 

[Radetzky]

??

Isn’t HF with pitting edema extra vascular fluid?

As in extravascularly overloaded but intravascularly dry doesn’t exist unless you have coexistence severe sepsis, sorry didn’t make myself very clear.

I just see a lot of pts be described in this way based off things like a high urea or hypotension or some other bogus clinical exam finding when in fact they’re just shocked and overloaded and need inotropic support

 

[GassYous]

what does any of this have to do with rts intubating? Are they giving lasix too or something

 

[thegenius]

Ironically, I’ve actually been questioned by an RT as to why I was giving lasix. In the same breath she demanded I get a chest X ray before she does CPT.

The baby boomers really gave us a giant pile of ****

It’s because RTs have a unique ability to see mucus on a chest xray?

 

[dadaddadaBATMAN]

Link with the relevant studies: http://www.emdocs.net/furosemide

Removed my original reply.Noted everyone else said what I said better and it’s off topic.

 

[The Knife & Gun Club]

What was the clinical evidence for being “dry”? Heart failure with fluid stuck extra vascular is one of those made up pathologies that doesn’t exist, unless you have coexisting severe sepsis or pancreatitis or something.

As in extravascularly overloaded but intravascularly dry doesn’t exist unless you have coexistence severe sepsis, sorry didn’t make myself very clear.

I just see a lot of pts be described in this way based off things like a high urea or hypotension or some other bogus clinical exam finding when in fact they’re just shocked and overloaded and need inotropic support

You’re exactly right. Bad sepsis + CHF + ARF

 

[OptionOffense]

I recently took a per-diem gig at a hospital that historically staffed their ED with a lot of FM and IM trained guys. RTs did most tubes, and I was told they were "good"

Last night, had a patient that needed to be tubed (urgently, but non-emergently) so I asked the nurse to page RT to bring a vent. I find a COW to go throw in some orders for RSI meds and a post-tube CXR and I turn around 5 mins later and this RT is hacking away at my patient's oropharynx, no suction set up, patient malpositioned, sats in the 80s.

I ask him to pull out the laryngoscope and start bagging before the patient desats any further and I see a bloody Mac 3. At this point I ask RT to step aside, bag the patient back up, grab a bougie and suction and tube the patient myself, no issues.

This AM I get an email saying that the RT complained I was "unprofessional" - even though I never said anything untoward against him and he performed an invasive procedure on my patient without telling me and was failing at it. I called the vice chair for the site and gave my side and he seemed to be pretty understanding but is it worth it to even keep this job if this is the culture at this institution? Has anyone worked in a shop where RT did airways and had issues^

I'm a new grad and can use the extra money towards loans and saving towards a house but the signouts I've gotten from these FM guys have been mostly hot trash and now with this incident I'm wondering if I should just cut ties and try to just pick up extra shifts at my main gig instead.

It is NOT unreasonable to resign immediately. It is also not unreasonable to need to pay your loans off. Ancillary staff have Zero respect for physicians or medical care. They have been empowered by the culture of midlevel BS so everyone is basically practicing medicine without a license. They are imposters. 30 years ago criminal charges would be brought against that RT. Now its the new normal. Get used to it, get paid and get the f*** out.