Category Archives: Intravenous and Fluid Therapy

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

Question: The IV Therapy Medical Directive lists hypotension as a required indication for a fluid bolus. In pediatric medicine, blood pressure is rarely used alone as an indication of perfusion and tends more to rely on looking at the overall presentation including: level of awareness/activity, heart rate, capillary refill etc.

If presented with a child who is: irritable, tachycardic (or bradycardic for that matter), with delayed cap refill, and decreased urine output, but is not hypotensive (<5th percentile), is it permissible to administer a fluid bolus?

Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Question: When administering a fluid bolus, are we to give the full bolus amount (i.e. 1000ml for a 50kg patient) reassessing for fluid overload or return to TKVO when the BP reaches 100mmHg or greater? Given so much fluid shifts, administering the full bolus when no fluid overload is present (either 10 or 20ml/kg), particularly with the septic or preload dependent patient would be beneficial.

Question: My question is regarding fluid bolus for DKA. There seems to be varying belief on whether or not a DKA patient must be hypotensive to administer a bolus. There is no specific language that I can find addressing bolus protocol for DKA other than the mandatory BHP patch point if the suspected DKA pt is 2-12yrs old, but this is listed under the NaCl fluid bolus protocol where hypotension is a condition for treatment. Just looking for a little clarification on the entire DKA bolus protocol.

Question: There was a question posted on Sep 23, 2014 in regards to a fluid bolus on a transfer between facilities. As I agree that there should have been an RN escort for this patient, the paramedic was certified in IV fluid therapy including boluses. Your answer has me perplexed however. If a physician gave the paramedic a fluid bolus order how would that differ from getting a similar order from a BHP through phone patch. It is in the scope of practice for the paramedic to administer NaCl 0.9% as a bolus, the volume was prescribed by the physician(s) in charge of this patient's care. Would any paramedic be wrong in following the order given by the physician?

Question: I'm a PCP with autonomous IV. It states that a contraindication for a fluid bolus is "signs of fluid overload". I realize the obvious one is pulmonary edema as that is the example that is always brought up in this scenario. What about a pt that has a clear chest with no fluid accumulation in the lungs, but has peripheral edema in the legs or abdomen? I've also had pt's with hypotension that are on dialysis and have stated that they cannot receive large amounts of fluid due to kidney failure. Do we just document their condition? I've heard different answers from everyone and would appreciate some clarification.

Question: I am a PCP-IV medic who recently transferred a patient between facilities - from county hospital to trauma centre. On arrival I was told by the attending physician that the patient was to be spinal immobilized as a precaution as instructed by the trauma centre. The physician also informed me that the trauma centre requested that the patient receive 1000ml NaCl prior to arrival at the LTC. I inquired about the patient's vitals and assessed the patient as normotensive with no indications of poor perfusion. I told the physician that my protocols did not permit me to fluid bolus the patient with up to 1000ml enroute unless the patient was hypotensive and remained hypotensive. Moreover the sending facility was not sending an escort on this long CODE 4 STAT transfer. I called my Duty Manager for advice and was told to abide by my directives and follow the BLS standard for IV monitoring - 200ml/hr max pending patient presentation enroute. This is the direction I proceeded with.

My question is - was I correct in my course of action and was it advisable to press the physician for an escort based on the requirements of the LTC?

Question: On a recent ischemic chest pain call with an approximately 60 year old female patient, conscious and alert, 2 nitro sprays prior to arrival. The 12 lead was normal and I gave ASA, but decided to withhold nitro as I had difficulty obtaining a BP on scene. The patient had no palpable radial or brachial pulses bilaterally. My partner and I made 4 NiBP attempts on scene with no reading on either arm and manual BP attempts bilat with no sound on auscultation or deflection of the needle. I was unable to also confirm the HR that showed on the monitor as she was uncooperative while attempting a carotid (although present). After extricating the patient on a stair chair, I decided to continue my care with an IV TKVO in the truck. I did not want to delay scene time any further. While in the truck I continued to attempt NiBPs which was now displaying a reading of hypertension, yet no pulses other than carotid were palpable. Although the monitor was always showing vitals within my parameters to administer nitro, I withheld it, as I was treating the findings with the patient, not the monitor. She had stated her pulses were usually weak. She remained conscious and alert with no signs of hypotension other than weak/absent pulses. My question is… was I ever justified to administer a bolus to this patient?

Question: What is the reason why IV certified PCPs cannot bolus PEA patients?

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