“Two Liters in Two Miles”- The Role of Pre-Hospital Rapid IV Fluids in Alexandria, Part 2

In part 1 we introduced Alexandria’s Fire Department and discussed their emphasis on early recognition and treatment of shock and hypotension.  Specifically, we discussed the important role that IV fluids can play, and we heard about a recent sepsis case.  Tim Jaffry, NREMT-P described how he and his partner were called to a nursing home and picked up a man who showed multiple signs of sepsis, including fever, tachycardia, diaphoresis and altered mental status.  Using LifeFlow, they were able to rapidly infuse 2 liters of IV fluid during the short trip to the hospital.  On arrival to the ED the patient’s heart rate had decreased from the 150’s to the 90’s and his SBP had increased from 100 to 130.

In part 2 of this blog, Tim describes a second case in which the diagnosis wasn’t as obvious, but the treatment was similarly effective…

Case # 2: A Man On A Date Who Lost Consciousness

We got a call from a restaurant that there was an unconscious man in his 40’s.  He was apparently on a date.  When we arrived, we found him lying supine in the bar area, he was awake, and his vital signs were in normal limits.   We got him into the truck, and suddenly he became extremely pale.  He was diaphoretic, and his blood pressure had dropped to 66/40.  We weren’t sure what was going on with him; this is a huge drop in blood pressure even for a vagal response.  His heart rate went from about 60 down to 40.  He then started losing consciousness and became confused; he was going in and out on us.

We got an 18 gauge IV in him, and, using LifeFlow, we were able to rapidly infuse about 2 liters of fluid.  His systolic blood pressure doubled, his heart rate came back into the 80’s, and his mental status completely changed!  He was no longer diaphoretic.   All of this occurred in less than 10 minutes – it was amazing.  We had been prepared to give him pressors and pace him, but none of that was needed.  He was back to normal before he arrived at the ED. (They never learned the patient’s final diagnosis).

Initially a Skeptic

Tim explains that when Alexandria Fire Department first stocked LifeFlow, he was a skeptic. “We see so many devices and so many gimmicks in this business.  But once I actually used LifeFlow on a patient, and saw what it did for the patient, I was convinced.”

Barbara Tharpe, NREMT-P, another Alexandria Paramedic, is responsible for stocking the EMS supplies and orienting the team to any new supplies or equipment. Barbara reiterated the initial skepticism that many medics have to new devices, including LifeFlow. “Initially, some folks were hesitant to use it. They have been using other methods such as the pressure bag or the push/pull method for such a long time and are super-comfortable with them.  They may not see the value in the LifeFlow until they actually use it”.  But Barbara explains that as the team hears stories such as Tim’s, and as they are trained on and get more exposure to the LifeFlow rapid infuser device, this barrier becomes less of an issue.  In fact, now that folks are seeing first-hand the benefit of early and rapid fluids for patients with hypotension, they are quickly becoming believers.

Barbara adds that LifeFlow has come with some advantages that even she didn’t expect.   She explains that when using an alternative device such as pressure bag or gravity for rapid fluid infusion you are more likely to hang it and kind-of forget about it.  “With pressure bags you are just checking for the green and red indicators periodically…but with LifeFlow you stay on top of it and are more aware of the patient’s status, you aren’t as distracted by other things.”  Being more tuned in to the patient and to their response to treatment is always a good thing.

Regardless of the underlying etiology, shock is a time-dependent medical emergency with high morbidity and mortality. In patients with sepsis, a MAP< 65 mmHg on admission significantly correlates with mortality, and patients with a single episode of non-sustained hypotension (SBP < 100) have 3-fold increased risk of mortality. 1, 2 Similarly, in trauma patients, even brief episodes of hypotension are associated with increased mortality, which further increases with longer duration of hypotension.3

We all know that shock and hypotension are emergencies, but how quickly we act and what we do is up to us. 

References

  1. Varpula M, Tallgren M, Saukkonen K, et al. Hemodynamic variables related to outcome in septic shock. Intensive Care Med. 2005;31:1066-1071.
  2. Marchick, Michael R., Jeffrey A. Kline, and Alan E. Jones. “The significance of non-sustained hypotension in emergency department patients with sepsis.” Intensive care medicine 35.7 (2009): 1261-1264.
  3. Zenati MS, Billiar TR, Townsend RN, et al. A brief episode of hypotension increases mortality in critically ill trauma patients. J Trauma. 2002;53:232-236; discussion 236-237.